Gall Stone Disease- EASL Guideline 2016

 

                                                               (EASL Guideline)

Composition of bile:

  • – Water
  • – Inorganic electrolytes
  • – Organic solutes
  •                 Bile acid
  •                 Bile pigments
  •                 Cholesterol
  •                 Phospholipid
  • Daily 500-600 ml bile is secreted by liver
  • Bile acids are predominantly absorbed by distal ileum

Function of Bile Acid:

  • – Induce bile flow
  • – Induce hepatic secretion of biliary lipids (Phospholipid + cholesterol)

Risk Factors for Gall Stone Disease:

  • – Age and gender (F>M) (older>younger)
  • – Diet: western diet consists of
  •                     • High total calories
  •                     Cholesterol
  •                     Saturated fatty acid
  •                     Refined carbohydrate
  •                     Protein and salt
  •                     Low fibre
  • – Pregnancy
  •                   Increased cholesterol secretion
  •                   Decreased gall bladder motility
  • – Rapid weight loss
  • – Total parenteral nutrition
  • – Biliary sludge
  • Drugs:
  •               Estrogen, Clofibrate, Octreotide, Ceftriaxone
  • – Lipid abnormalities :
  •               TG
  •               LDL, HDL  →  Not associated with GB stone
  • – Systemic disease:
  •                • Obesity and insulin resistance
  •                 DM
  •                • Disease of the ileum
  •                • Spinal cord injury

 

 Protective Factors for Gall Stone Disease:

  • – Statin
  • – Ascorbic acid
  • – Coffee

Pathogenesis of cholesterol Gall stone formation     

  • – Cholesterol in bile remains in solubilized state in association of bile acid and phospholipid
  • – Biliary lipoprotein also solubilizes cholesterol
  • – Cholesterol stone formation occur when
  •                       Excess cholesterol formation occur due to relative deficiency of bile acid (lithogenic bile)
  •                       Crystallization of lithogenic bile depends upon nucleation factors of bile
  •                      → Factors favoring nucleation
  •                                               Mucous
  •                                               Calcium
  •                                               Fatty acid
  •                                               Other proteins
  • – Anti-nucleating factor: Apolipoprotein

Pathogenesis of pigment stone formation

  • –  Bacterial/Parasitic infection of biliary tree
  • – Bacterial β-glucoronide hydrolyse conjugated bilirubin to its free form which then precipitate calcium bilirubinate
  • – Hemolysis

Natural History and Complications of Gall Stone Disease

  • – Asymptomatic (75%)
  • – Cholecystitis (10%)
  • – Mirizzi’s syndrome (0.1%)
  • – Stone impaction in distal bile duct and ascending cholangitis or acute biliary pancreatitis (5%)
  • – Cholecystoenteric fistula
  • – Gall bladder carcinoma
  • – Porcelain gall bladder
  • – Emphysematous cholecystitis
  • – Gall stone ileus (Stone >2.5 cm in size)

Investigations of Gall Stone Disease

  • – 50% of pigment stone and 20% of cholesterol stone contain enough calcium to be detected by plain X-ray abdomen
  • – CT, MRI, plain X-ray abdomen is usually done to detect complications of gall bladder disease, not to detect stone

USG findings of Gall stone:

  • – Echogenic substance casting acoustic shadow
  • – Stones are mobile and aggregates in the dependent part of the GB
  • – Modern US can detect even 2 mm stone
  • – Sensitivity and specificity of USG to detect GB stone >95%
  • – Only 50% choledocholithiasis is detected by USG

USG findings of acute cholecystitis:

  • – Pericholecystic fluid collection
  • – GB wall thickening (>4mm)
  • – Sonographic Murphy’s sign

 

Treatment of Gall stone during Pregnancy

  • – If indication is urgent: Laparoscopic cholecystectomy irrespective of trimester
  •   Asymptomatic stone  →   Not treated
  • Pregnancy is not a contraindication for cholecystectomy

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