Gallstone Disease. PSH Clinical Guidelines Statement 2017

Transcription

1 PSH Clinical Guidelines Statement 2017 Gallstone Disease Dr. Muhammad Fayyaz Consultant Gastroenterologist Saidu Group of Teaching Hospitals, Saidu sharif Swat, Pakistan Abstract Gallstone disease is one of the most common gastrointestinal disorder worldwide with huge financial implication, the current article is broad review of the disease with special emphasis on clinical presentation and approach to management and a brief discussion on risk factors and pathogenesis of gallstones for the general practitioners involved in patient care. It will help the health care providers in proper and timely management of gallstone disease. Introduction Gallstones are common mostly cholesterol stones 75%, 20% black pigment stones and 4.5% brown pigment stones. The prevalence varies in various geographic regions more common in Europe and America followed by Asia and Africa. Most of the gallstones are silent only less than one third cases become symptomatic and may develop complications. Natural History The majority of gallstones are asymptomatic only 15-25% will become symptomatic during years of follow up. Billiary pain is usually the initial presentation of symptomatic Recurrent billiary pain occurs in 38-50% of patients with symptomatic gallstones in whom billiary complications are more likely. Patients with symptomatic gallstones will develop complication at 1-2% per year. Contrary to the previous belief in diabetics 15% become symptomatic and the mortality and morbidity are comparable to the non diabetic population, Epidemiology And Risk Factors Gallstone disease is a worldwide problem more common in women than men increasing with age. The first degree relatives are at 4.5% times more risk. In Pakistan the prevalence is roughly 4-14%. Risk Factors: There is large number of modifiable and non modifiable risk factors for cholesterol gallstones Age: Gallstones are more common in elderly population than children. Gender: Gallstones are more common in females than males. Genetic factors: first degree relatives are at 4.5 times more risk of gallstones and there is strong racial predilection Diet :western diet rich in cholestrol,saturated fatty acids, high number of calories and refined carbohydrate. Pregnancy and parity :Increases with the number of pregnancies. Rapid weight loss: Like in gastric bypass and intense dieting Total parental nutrition. Drugs :Like estrogen containing oral contraceptives,clofibrates,octreotide and ceftrioxone Systemic diseases like obesity,diabetes millitis and spinalcord injuries. Lipid abnormalities: increased triglycerides and decreased HDL

2 Pigment Stone Black pigment stones are formed in patients with hemolytic anemia s like thalassemia, hereditary spherocytosis,sickle cell disease and in liver cirrhosis. Brown pigment stones are associated with billiary infections (Ecoli, round worms and clonorchis sinences). Which are common in Asia. Pathogenesis Gallstones are mainly composed of cholesterol, bilirubin, and calcium salts, with smaller amounts of protein and other phospholipids. There are three types of (I)Pure cholesterol stones, which contain at least 90% cholesterol, (ii) pigment stones either brown or black, which contain at least 90% bilirubin and (iii) mixed composition stones, which contain varying proportions of cholesterol, bilirubin and other substances such as calcium carbonate, calcium phosphate and calcium palmitate. Brown pigment stones are mainly composed of calcium bilirubinate whereas black pigment stones contain bilirubin, calcium and/or tribasic phosphate. In Western societies and in Pakistan more than 70% of gallstones are composed primarily of cholesterol, either pure or mixed with pigment, mucoglycoprotein, and calcium carbonate. To simply understand the pathology, cholesterol gallstones form when the cholesterol concentration in bile exceeds the ability of bile to hold it in solution, so that crystals form and grow as stones. Cholesterol is not soluble in aqueous solution but the presence of bile salts and phospholipids make it soluble in the form of micelles. Cholesterol super-saturation is the essential requirement for cholesterol gallstone formation, might occur via excessive cholesterol biosynthesis,defective conversion of cholesterol to bile acids, due to a low or relatively low activity of cholesterol 7α hydroxylase, the rate limiting enzyme for bile acid biosynthesis and cholesterol elimination could result in excessive cholesterol secretion. Finally, interruption of the enterohepatic circulation of bile acids could increase bile saturation. Estrogen treatment also reduces the synthesis of bile acid in women. Pigment stones occur when there is excessive production of bilirubin like in hemolytic anemia s. Black pigment stones are more common in patients with cirrhosis, thalassemia, hereditary spherocytosis, and sickle cell disease, in which bilirubin excretion is increased. Primary bile-duct stones, defined as stones that originate in the bile ducts, are usually brown pigment stones associated with infection. High biliary protein and lipid concentrations are risk factors for the formation of Impaired motility of the gallbladder has been cited as important contributor to the formation of gallstones such as seen in patient with high spinal cord injury or with the use of somatostatin analogue octreotide. Intestinal hypomotility has been recently recognized as a primary factor in cholesterol lithogenesis. Fiber may protect against gallstone formation by speeding intestinal transit. Clinical Presentations, Diagnosis And Management Gallstones may present in the following manners and to be managed accordingly Incidental gallstones Incidental gallstones are diagnosed while investigating some other abdominal pathology with imaging studies. Ultrasonography is the principle modality for diagnosis of gallstones In patients with incidental gallstones treatment is expectant and prophylactic cholecystectomy is not indicated except in special populations at risk of gallbladder cancer like stone size more than 3cm. Symptomatic gallstones 78% of patients of symptomatic gallstones presents with billiary pain. The typical billiary

3 pain is intense poorly localized right hypochondrium discomfort which radiates to the shoulder blade associated with nausea and diaphoresis for at least 30 minutes and subsides within 6 hours. The laboratory investigation in uncomplicated billiary pain are usually normal. Treatment of the acute pain is with pain killers like diclofenac and ketorolec. Elective cholecystectomy is offered. Patient can be treated expectantly as 30% of cases will never experience another episode. Acute cholecystitis: Acute cholecystitis is the most common complication of gallstone. Right upper quadrant pain and tenderness, fever and leukocytosis is the hallmark of acute cholecystitis in the 90% of cases result from obstructions of the cystic duct by impaction of 75% of these patient report a prior attack of biliary pain. Laboratory investigations show mild increase in bilirubin and ALT. Total Leukocyte count is increase and if more than 15000/cmm suspect supporative cholecystitis. Treatment is hospitalization, intravenous fluids, injectable pain killers and antibiotics if patient is toxic. Surgical consultation is done for laparoscopic cholecystectomy. Choledochlothiasis 15% of patients with gallstones will have common bile duct stones which may have formed denovo or migrated from gallbladder and 95% of CBD stones patients will have Mostly CBD stones are silent but symptomatic stones need some sort of intervention. Patients present with pain,jaundice and pruritis. Laboratory investigation show increased ALT,ALP,and bilrubin. Ultrasongraphy is 50% sensitive in detecting CBD stones. Endoscopic ultrasound and ERCP has sensitivity and specificity of 98%. Symptomatic CBD stones warrants treatment with ERCP or laproscopy in all patients. Cholangitis: The most serious complication of gallstone results from embedded stones and bile stasis the usual organism are Ecoli,klebseilla and pseudomonas. Cholangitis is diagnosed with the help charcoal triad ( right upper quadrant pain,fever and juandice)in 70% of cases. Laboratory investigations shows increased bilirubin,alt, and ALP. Serum Amylase may be high and blood cultures usually positive Ultrasound,CT abdomen and ERCP are performed. Treatment is with hospitalization,intravenous fluids,intravenous antibiotics. Patients usually needs ERCP with stenting. Gallstone pancreatitis Billiary pancreatitis occurs when gallstones gets impacted at the ampulla of vater.the diagnosis is made on clinical features of pancreatitis like pain epigastrium,vomiting and epigastric tenderness with raised total leukocyte count raised serum amylase and ALT. Along with suggestive ultrasound features which show dilated CBD.Managment depend on severity of pancreatitis, mild disease usually resolve spontaneously and severe pancreatitis may need ERCP with stone extraction specially when there is cholangitis. Other complication of gallstones though rare are Mirizzi syndrome, gallbladder perforation and gallstone illius. Summary Gallstone disease is a common problem, most gallstones are asymptomatic. There is strong association with female gender, genetic background, increasing age, parity, estrogen exposure, diabetes, lipid abnormalities and rapid weight loss.billiary pain is the most

4 common presentation.laproscopic cholecystectomy is indicated in symptomatic disease. Complications are many and usually serious like cholecystitis,cholangitis, gallstone pancreatitis and needs hospitalization and timely intervention.

5 References sleisenger, & fordtrans. (2010). gastrointestinal and liver disease. sounders. Channa NA, Khand FD, Khand TU, Leghari MH, Memon AN. Analysis of human gallstone by fourier transform infrared (FTIR) Pak J Med Sci. 2007;23: GREENBURGER, N. N., & BLUMBERG, R. S. (2016). current dignosis and treatment. LANGE. Njeze, G. E. (2013). gallstone. nigerian journal of surgery, sleisenger, & fordtrans. (2010). gastrointestinal and liver disease. sounders. Berci G. Historical overview of surgical treatment of biliary stone disease. In: MacFadyen BV, Arregui M, Eubanks S, Olsen DO, Peters JH, Soper NJ, et al., editors. Laparoscopic Surgery of the Abdomen. New York: Springer; pp Tsai CJ, Leitzmann MF, Hu FB, Willett WC, Giovannucci EL. Frequent nut consumption and decreased risk of cholecystectomy in women. Am J Clin Nutr. 2004;80: [PubMed] Kurtin WE, Schwesinger WH, Diehl AK. Age-related changes in the chemical composition of Int J Surg Investig. 2000;2: Acalovschi M. Cholesterol gallstones: From epidemiology to prevention. Postgrad Med J. 2001;77: [PMC free article