Gall Stone Disease

Symptoms of Gall Stone Disease:

-Asymptomatic in 80% cases

– Biliary colic 20-25%

– Biliary Colic results from obstruction of cystic duct/ common bile duct by stone by distending the viscus causing severe pain, steady ache or fullness in epigastrium or right hypochondrium ,frequently radiating to interscapular area, right scapula or shoulder

– Biliary colic usually starts suddenly and may persist for 15 minutes to 5 hour subsiding gradually or rapidly

-Biliary colic is steady rather than intermittent. that’s why it is a misnomer

-Pain aggravates by fatty meal, some have pain not related to eating

  • 10% patient’s first manifestation of gall stone is cholecystitis, obstructive jaundice or pancreatitis
  • After the first manifestation of biliary colic 30% patients do not have another episode
  • If there are no further episode of biliary colic within 5 year after the first attack, the natural history of the patient may be regarded as that of asymptomatic gall stone disease

Complicated gall stone disease:

If an episode of biliary pain persist beyond 5 hours and clinical, laboratory findings consists with acute cholecystitis

Uncomplicated gall stone disease:

If biliary pain persist for less than 5 hour

Chronic cholecystitis:

  • Chronic inflammation of the gall bladder wall that results from repeated attacks of acute and subacute cholecystitis or mechanical irritation of the gall bladder mucosa by gall stone. It progress from asymptomatic to symptomatic

Treatment options of Gall Stone disease

  1. Surgical treatment
  2. Non-surgical treatment

Surgical Treatment

  1. Asymptomatic gall stones:
  • Treatment is not indicated with some exception as the risk of biliary colic, complications and cancer is low
  • 60-80% asymptomatic gall stone patient asymptomatic over a follow up period of 25 years
  • Probability of developing symptoms within 5 year after diagnosis is 2-5% per year and 1-2% thereafter

Indications of prophylactic cholecystectomy

  • High risk for GB cancer
  • Poreceline GB
  • Native American
  • Small gall stone ( <5mm on size) and preserved GB motility
  • Children who will be exposed to the risk of stone for a long time
  • Gall stone + GB polyp >1 cm irrespective of symptoms
  • Polyp <1cm and age >50 years should undergo cholecystectomy
  • Patients undergoing surgery for morbid obesity

** Early intervention should be taken in symptomatic diabetic patients because these patient are at risk of developing gangrenous cholecystitis

  1. Symptomatic patients
  • Laparoscopic cholecystectomy is the standard method

Non-surgical Treatment

  1. Oral bile acid dissolution therapy
  2. Extracorporeal shock wave lithotripsy
  3. Medical prophylaxis of cholesterol gall stone disease
  4. Symptomatic treatment of biliary colic

 

1.Oral bile acid dissolution therapy (UDCA)

Selection criteria for UDCA:

  • Gall stone without complications
  • Mild, infrequent biliary pain
  • Normal gall bladder function test (patent cystic duct, normal GB emptying
  • Radiolucent stone of <10 mm (<6mm optimal) : Dissolution occur in 50% patients
  • Stone: Isodense/hypodense to bile and absence of calcification on CT

Duration of treatment:

– Continue until stone dissolution is documented by 2 consecutive negative USG at least 1 month apart

Treatment should be stopped

  • If the patient does not tolerate the drug
  • Patient experience a complication of gall stone during therapy
  • If stone fail to dissolve after 6 months
  • If stone dissolve only partially after 6 months with lack of progression to complete dissolution by 2 year

Dose of UDCA: 10-15 mg/kg/day

* Stone>15 mm rarely dissolve

*Pigment stone is not responsive to UDCA

*Recurrence occur 10-30% patients in 3-5 year

    2.Extracorporeal shock wave lithotripsy

– Abandoned

– Limited role in treatment of bile duct stone resistant to endoscopic extraction

3.Medical prophylaxis of cholesterol gall stone disease by UDCA

-For obese patients during rapid weight loss

4.Symptomatic treatment of biliary colic

                     -NPO

                     -Parenteral nutrition

                    -Analgesic: NSAID (diclofenac, Indomethacin), Pethidine, Buprenorphine

                    -Spasmolytic

 


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