The Common Vein Copyright 2008
Alok Anand
Definition
Cholelithiasis or gallstones are the result of a metabolic disorder of bile metabolism caused by an increase in the insoluble portions of bile relative to the solutes which keep them in solution, and resulting in precipitated solutes of biliary secretions in the gallbladder. Gallstones are more common in women, and are associated with diseases relating to cholesterol metabolism, diabetes, mellitus., heolytic anemai, cirrhosis.
The resulting concretions are common in the Western world, (8% in the population at large and 10-15% in ages 40-60)) and more commonly than not of no clincial significance. However occasionally they may impact in the neck, cystic duct or common bile duct, causing obstruction in the biliary tract. The obstruction progresses to inflammation and acute cholecystitis, or cholangitis may result.
There are three forms of stones:
Cholesterol
Pigment
Mixed
The most common stones are cholesterol stones, which account for 75-80% of cases. The next are pigment stones, which account for approximately 15% of all cases. The remainder of cases are mixed stones, representing a combination of the previous two. An aberration of cholesterol metabolism causes an imbalance between cholesterol and the bile acids, phospholipids and lecithin which keeps the cholesterol in solution. Similarly, increased bilirubin metabolism from the breakdown of hemoglobin, usually due to hemolysis, causes in increased excretion of bile pigments, leading to stone precipitation. These are called black pigment stones. An additional type of pigment stone is the brown pigment stone. This is associated with intra-hepatic infection, and is seen mostly in Asian populations.
Structurally, cholelithiasis is characterized by the presence of rock-like crystals in the dependent portion of the gallbladder. There is no characteristic change in the size or shape of the gallbladder unless an obstruction occurs. The stones vary from small crystals in the submms range to very large stones which may occupy the whole gallbladder. They be round, oval, or faceted. Calcification may be dense, or minimal, diffuse, laminated, or heterogeneous
Although there is no functional change with the presence of stones in the gallbladder itself, in later phases obstruction can impair excretion of bile salts and digestion. Aberrations in metabolism of cholesterol and hemoglobin predispose to the formation of gallstones.
Clinical presentation of patients varies with the staging of disease:
Asymptomatic: stones are merely present in the gallbladder and may be incidental findings on abdominal imaging.
Symptomatic: patients may have colicky RUQ pain, often radiating to the right shoulder (transient impaction without inflammation)
Complicated: RUQ pain, fever/leukocytosis (impaction with inflammation)
The symptomatic stage is characterized by 1-5 hour bouts of pain, usually after meals, and may recur. It may progress to complicated stage, where pain is of longer duration and accompanied by symptoms of infection.
Diagnosis is easily detected by ultrasound, (95%), but are seen by CT as well. (80-85%),. The stomes that are not seen by CT are usually cholesterol stones which are isodense with bile and very small non calcified stones. In the absence of obstruction, scintillography with HIDA scan provides little information, though in patients who have progressed to symptomatic and complicated stages, it is the most specific study for the diagnosis of an impacted stone in the neck or cystic duct.
Treatment depends on the staging. If asymptomatic and found incidentally, patients may be followed. If symptomatic, patients may have elective cholecystectectomy. In the complicated stage, patients are hospitalized, with IV antibiotics. Elective cholecystectomy is perfgormed after a “cool-down” period.
Types of Stones |
This photograph shows examples of the three types of pure gallstones. The multiple small green-black stones are pure bilirubinate – “pigment stones”. The egg-shaped stone and two smaller halves on cut surface are pure cholesterol stones. These are clear and crystalline, like quartz. The single round, opaque chalky-tan stone is pure calcium carbonate, like limestone. Gallstones of pure composition occur about 10% of the time.
gallbladder dx cholelithiasis grosspathology Courtesy Barbara Banner MD 11918.83s |
Cholesterol Stones |
This is a photograph of a pure cholesterol gallstone cut in half to show its crystalline beauty.
gallbladder dx cholelithiasis grosspathology Courtesy Barbara Banner MD 11919.81s |
Types of Stones |
This photograph shows examples of the most common gallstones, which are a mixture of bilirubin, cholesterol, calcium carbonate and other components. They are usually multiple, multifaceted, and about 0.5 –1.0 cm on a side. Note the small stone cut across which has a yellow rim and a dark green center. This is a combined stone with a bilirubinate center and a cholesterol-containing rim.
11920b03s gallbladder dx cholelithiasis grosspathology Courtesy Barbara Banner MD |
Micrsoscopic Appearance of a Stone |
This is a medium –power photomicrograph of a tiny gallstone which was present in a gallbladder and was included in the microscopic section of that gallbladder. The yellow color is the natural color of the stone, and there appears to be some linear or crystalline structure. Only the gallstone is present in the picture, no gallbladder tissue can be seen.
11921s gallbladder dx cholelithiasis histology Courtesy Barbara Banner MD |
00404b01.800 gallbladder gallstones cystic duct cholelithiasis greenpepper banana Davidoff Art Davidoff MD |
Imaging Stones
Size
Small Floaters
Cholesterol floaters76356 gallbladder stones floaters crystaline tiny cholelithiasis ring down artifact floating USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 |
Small Sinkers
41164 Courtesy Ashley Davidoff MD code pancreas pancreatic calcifications code gallbladder calcified stones dx cholelithiasis dx chronic pancreatitis imaging radiology CTscan chronic inflammation metabolic |
Ill Defined Small Floaters
25306.8s small cholesterol crystals stones floaters hyperemic wall chronic cholecytitis gas air cholelithiasis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Well Defined Small Floaters
04730 gallbladder floating small filling defect cholesterol stones cholelithiasis OCG oral cholecystogram imaging radiology historical |
Small Floaters That may Not Be Small Floaters
45092 45092b02 gallbladder fx cholelithiasiscompletely occupying gallbladder lumen CTscan Courtesy Ashley Davidoff MD |
Moderate Size Gall Stones
13456 liver normal anatomy gallbladder stones cholelithiasis grosspathology |
70026 gallbladder stones shadowing forces reflection transmission dx cholelithiasis USscan Davidoff MD |
04672 gallbladder multiple small stones cholelithiasis OCG oral cholecystogram imaging radiology |
82167.8s gallbladder multiple stones cholelithiaisis dependant mobile CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
18261.8s gallbladder shape phrygian cap distended enlarged courtesy Ashley Davidoff MD copyright 2008 |
04407 gallbladder filling defect stones cholelithiasis OCG oral cholecystogram imaging radiology historical
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Large Stones
Large stones can occupy the entire gallbladder lumen and in general are less likely to cause obstruction of the neck. In general the larger the stone the less likely it will result in other significant disease. Large stones can uncommonly erode the wall and evolve into a gallstone ileus, but this is a rare entity.
abo82151.8s 51f obesea gallbladder stone large calcified lamellated cholelithiasis CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
82166c01s 27F gallbladder stone cholelithiasis WES sign wall = pink line echo = white line = front anterior echo of the stone black shadow = shadow of the large stone shadow USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 Courtesy Ashley Davidoff MD Copyright 2008 |
04733 gallbladder filling defects stones cholelithiasis WES sign USscan imaging radiology |
Applied Biology
77625.8s gallbladder stones cholelithiasis cholesterol floaters pregnancy fetus gravid uterus deforming gallbladder USscan Ultrasound Courtesy Ashley Davidoff MD copyright 2008 |
70269c02 gallbladder air methane nitrogen gas cholesterol stone isodense with bile fat subtle change CTscan |
16141c01s.8 gallbladder stones cholelithiasis hyperemic wall edematous wall small filling defects in dependant position in the infundibulum distended gall bladder edema in the wall fluid in the gallbladder fossa gbf normal bile duct MRI T1 weighted image with gadolinium and fat saturation T2 weighted MRCP normal pancreatic duct Courtesy Ashley Davidoff MD copyright 2008 |
78305.8s gallstone large stone cholelithiasis impacted in the infundibulum does not move with decubitus fluid in the gallbladder fossa acute cholecystitis USscan ultrasound Courtesy Ashley Davidoff Md copyright 2008 |
gallbladder stone cholelithiasis cholecystitis bile duct obstruction Mirizzi’s syndrome USscan ultrasound CTscan CourtesyAshley Davidoff MD copyright 2008 82342c.8s |
Shape
11930.81s gallbladder chronic cholecystitis grosspathology Courtesy Barbara Banner MD
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Position
Dependant Position and Mobile
11921.8b05b018.8s gallbladder cystic duct gallstones cholelithiasis Davidoff Art copyright 2008 |
46462c01s gallbladder moderaste size shadowing mobile stones cholelithiasis USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 |
Applied Biology
Stuck in the Neck
11921.8b05b019.8s gallbladder cystic duct gallstones cholelithiasis stone impacted in the cystic duct distended enlarged Davidoff Art copyright 2008 |
78305.8s gallstone large stone cholelithiasis impacted in the infundibulum does not move with decubitus fluid in the gallbladder fossa acute cholecystitis USscan ultrasound Courtesy Ashley Davidoff Md copyright 2008 |
Stuck in the Cystic Duct
04766b05b04.35k.8s gallbladder cystic duct stone impacted obstruction enlarged gallbladder acute calculous cholecystitis Davidoff art copyright 2008 |
Character
Calcification
Dense “Hard” Calcification |
77728c01.8s gallbladder edematous wall distended gall bladder edema in the wall fluid in the fat surrounding the gallbladder indurated fat acute cholecystitis calcified stones cholelithiasis stones visible on CT scan CTscan Courtesy Ashley Davidoff MD copyright 2008 |
00136 gallbladder stone large shadowing cholelithiasis imaging radiology USscan |
26073.8s gallbladder stones moderate calcification soft calcification gallstone pancreatitis dx cholelithiasis Courtesy Ashley Davidoff MD copyright 2008 |
76040b01 gallbladder stones cholelithiasis bile duct normal portal vein liver vein USscan Courtesy Ashley DAvidoff MD |
30836.8s gallbladder calcified cacalcification varied size stones cholelithiasis complex stones chronic cholecystitis CTscan Courtesy Ashley DAvidoff Md copyright 2008 |
82151.8s 51f obesea gallbladder stone large calcified lamellated cholelithiasis CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
Fat
82205.8s 82206.8s 54 female mildly enlarged non tender gallbladder no abnormality seen on CTscan but large stone seen on USscan consistent with cholesterol stone isodense on CT shadowing on ultrasound atony obese Courtesy Ashley Davidoff MD Copyright 2008 |
25055 Courtesy Ashley Davidoff MD code pancreas fx cyst gallbladder + fx filling defect + fx floating + dx cholesterol cholelithiasis + imaging radiology CTscan C+ |
Mixed
1994H5~1.8s gallbladder stones cholelithiasis hypoechoic centre harmonic sonoCT normal wall Courtesy Philips Medical Systems copyright 2008 |
Air
26540 gallbladder + fx filling defects + fx air + fx floating + dx cholelithiasis + imaging radiology CTscan C- |
70269c02 gallbladder air methane nitrogen gas cholesterol stone isodense with bile fat subtle change CTscan |
Applied Biology
The Trouble Stones Cause
Complication of Gall Stone Disease
Acute Cholecystitis
00401.1cs 67Male right upper quadrant pain RUQ pain positive Murphy’s sign gallbladder gallbladder fossa thickened linear lacy thickening gall stones calculi calculous large stone in the infundibulum shadowing multiple small stones cholelithiasis cholecystitis acute cholecystitis acute calculous cholecystitis USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 |
77744c01.8s gallbladder distended enlarged pericholecystic fluid fluid in the gallbladder fossa wall thickened hyperemic almost completely filled with stones shadowing cholellithiasis hypervascular gbf acute cholecystitis USscan ultrasound color flow doppler Courtesy Ashley Davidoff MD copyright 2008 |
Complications
Chronic Cholecystitis
11930.81s gallbladder chronic cholecystitis grosspathology Courtesy Barbara Banner MD |
30701.8s stone cholelithiasis hyperemic wall small contracted chronic cholecytitis stomach gastrostomy redundant mucosa CTscan Courtesy Ashley Davidoff MD copyright 2008 chronic cholecytitis |
16239c.8s gallbladder stone cholelithiasis wall thickened thick wall enhancing wall dx chronic cholecystitis bile duct cholangiocarcinoma MRI with and without contrast |
11530.81s gallbladder shape deformity filling defect figure of eight defect cholelithiasis chronic cholecystitis oral cholecystogram historical Courtesy Ashley DAvidoff MD copyright 2008 |
Gallstone Pancreatitis
05265 Courtesy Ashley Davidoff MD code pancreas fx air fx fluid cystic fx mass dx necrotizing pancreatitis code gallbladder fx stones dx cholelithiasis code lung pleura fx effusion dx sympathetic effusion dx gallstone pancreatitis complicated by gangrene necrosis possible infection imaging radiology CTscan code acute inflammation |
Porcelain Gallbladder
76225c01 gallbladder wall calcification calcified porcelain gallbladder premalignant CTscan Courtesy Ashley Davidoff MD |
Gallstone Ileus
31127c01.8s gallbladder stones air adherent to duodenum small bowel dilatation calcification stone gallstone ileus CTscan Courtesy Ashley DAvidoff copyright 2008 |
Gallstone Ileus |
31127c02.8s gallbladder stones air adherent to duodenum small bowel dilatation calcification stone gallstone ileus CTscan Courtesy Ashley DAvidoff copyright 2008 |
Gallbladder Carcinoma
Local Invasion and Separate Liver Mestastasis |
17280c02b01.8s gallbladder liver mass local invasion cholelithiasis metastasis carcinoma primary gallbladder gallbladder fossa Courtesy Ashley Davidoff MD copyright 2008 |
Local Invasion Bile Duct Obstruction Peritoneal Involvement |
17280c03.8s gallbladder liver mass local invasion cholelithiasis metastasis carcinoma primary gallbladder gallbladder fossa invasion into gastrohepatic ligament bile ducts obstructed ascites Courtesy Ashley Davidoff MD copyright 2008 |
References
Aspinall By Richard J. Aspinall, Simon D. Taylor-Robinson, Joanna Cameron Mosby’s Color Atlas and Text of Gastroenterology and Liver Disease Published by Elsevier Health Sciences, 2001
Rosenthal Principles and practice of geriatric surgery Ronnie A. Rosenthal, Michael E. Zenilman, Mark R. Katlic Published by Springer, 2001
Faye Maryann Lee, MD e Medicine Cholellithiasis Last updated June 2006