Cholelithiasis

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Chapter 15 Cholelithiasis

INTRODUCTION

Description: Cholelithiasis is the formation of stones in the gallbladder or biliary collecting system. Most stones (80%) are the result of precipitation of supersaturated cholesterol. Women are three times more likely than men to form gallstones.

Prevalence: Ten percent of the population, 1 million cases per year.

Predominant Age: Seventy percent of patients older than 40.

Genetics: Ratio of women to men is 3 : 1; some races at greater risk (e.g., Pima Indians). (Pigment gallstones affect men and women equally.)

ETIOLOGY AND PATHOGENESIS

Causes: The metabolic alteration leading to cholesterol stones is thought to be a disruption in the balance between hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase and cholesterol 7α-hydroxylase. HMG-CoA controls cholesterol synthesis, whereas cholesterol 7α-hydroxylase controls the rate of bile acid formation. Patients who form cholesterol stones have elevated levels of HMG-CoA and depressed levels of cholesterol 7α-hydroxylase. This change in ratio increases the risk of precipitation of cholesterol as stones.

Risk Factors: Age, female gender, parity (75% of affected patients have had one or more pregnancies), obesity (15 to 20 pounds overweight 2-fold increase in risk, 50 to 75 pounds excess weight 6-fold increase in risk), estrogen use (oral), cirrhosis, diabetes, and Crohn’s disease. A family history of cholelithiasis in siblings or children results in a 2-fold increase in risk.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Asymptomatic (60% to 70%; 50% become symptomatic, 20% develop complications)

• Fatty food intolerance

• Variable right upper quadrant pain with radiation to the back or scapula

• Nausea or vomiting (often mistaken for “indigestion”)

• Fever usually associated with cholangitis

FOLLOW-UP

Patient Monitoring: Normal health maintenance

Prevention/Avoidance: Low-fat and low-cholesterol diet may delay symptoms. Oral prophylaxis during rapid weight loss has been advocated for those otherwise at risk.

Possible Complications: Acute cholecystitis, pancreatitis, ascending cholangitis, peritonitis, internal fistulization. Stones re-form in approximately 50% of patients treated with oral therapy, although the majority (85%) remain asymptomatic. Those who have recurrent symptoms respond to additional courses of oral therapy.

Expected Outcome: Generally good with either oral or surgical therapy. Oral therapy results in resolution of symptoms in 2 to 3 months. Despite this, gallstone disease is responsible for about 10,000 deaths per year in the United States.

MISCELLANEOUS

Pregnancy Considerations: Of pregnant patients, 3% to 4% experience gallstone symptoms. Women with increased parity and multifetal pregnancies are at greatest risk.

ICD-9-CM Codes: 574.2 (others based on obstruction or inflammation).

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