Name
CHOLELETHIASIS
DESCRIPTION
DETAIL
CAUSES β’ Production of bile supersaturated with cholesterol β’ Decrease in bile content of either phospholipids or bile acids β’ Biliary stasis β’ Hemolytic diseases β’ Biliary infection -------------------------------------------------------------------------- D.D. : - ACALCULOUS CHOLECYSTITIS - BILE DUCT STRICTURES - BILIARY COLIC - BILIARY DISEASE - BILIARY OBSTRUCTION - CHOLEDOCHOLITHIASIS - CHOLELITHIASIS - DUODENAL ULCER - GALL BLADDER CANCER - GASTRIC ULCER - GASTRITIS, ACUTE - GASTRITIS, CHRONIC - HELICOBACTER PYLORI INFECTION - HEPATITIS, VIRAL - IRRITABLE BOWEL SYNDROME - PANCREATITIS, ACUTE - PANCREATITIS, CHRONICSPECIAL TESTS : Hepatobiliary radionuclide scan IMAGING: β’ Ultrasound (best technique to diagnose gallstones) β’ Oral cholecystogram β’ CT scan (no advantage over ultrasound)
TYPENOTES
RISK FACTORS: Short gut syndrome, IBS, Multiparity, Long term total parenteral nutrition, Cirrhosis (for pigment stones), Hemolytic disorders, Prosthetic cardiac valves, Biliary parasites, Rapid weight loss, Childhood malignancyGENERAL MEASURES : β’ Treat only symptomatic gallstones β’ Advise patient of presence of stones β’ Observe asymptomatic stones β’ Oral dissolution - only if surgery option not available (less than 25% of all patients eligible) SURGICAL MEASURES: β’ Laparoscopic cholecystectomy β’ Open cholecystectomy β’ Direct contact dissolution - only for a small subset of patients - high recurrence rate β’ Extracorporeal shock wave lithotripsy - role of this modality unclear and currently under study - not FDA approved β’ Percutaneous cholecystostomy in high risk patients DRUG(S) OF CHOICE: β’ Analgesic for symptom relief β’ Ursodiol (ursodeoxycholic acid, Actigall) 8-10 mg/kg/day bid-tid - for up to two years - oral dissolution β’ Chenodiol (Chenix) 250 mg bid for 2 weeks; then increase by 250 mg increments until a dose of 13-16 mg/kg daily is reached or intolerance develops - oral dissolution β’ Methyl tert-butyl ether - contact dissolution CONTRAINDICATIONS: β’ Known allergy β’ Acute cholecystitis - dissolution agents β’ Severe abnormal liver function tests β’ Non-functioning gallbladder β’ Calcified (radiopaque) stones - relative β’ Multiple stones β’ Stones greater than 2 cm β’ Stones that donβt fl oat on oral cholecystogram PRECAUTIONS: β’ Monitor liver enzymes - may rise in up to 30% of patients β’ Monitor serum cholesterol β’ Methyl tert-butyl ether should only be used by one experienced with this contact dissolution method β’ Observe for severe diarrhea Significant possible interactions: N/A ALTERNATIVE DRUGS : NSAIDs may have a role in pain relief since prostaglandins are important in the development of pain Note: β’ Oral dissolution only effective for radiolucent (cholesterol) stones β’ Ursodiol probably preferred over chenodiol as it has a lower incidence of adverse effects PATIENT MONITORING β’ Medical attention if asymptomatic stones become symptomatic β’ Patients on oral dissolution agents should be followed with liver enzymes, serum cholesterol and imaging studies PREVENTION/AVOIDANCE Use of ursodiol (Actigall) with rapid weight loss prevents stone formation POSSIBLE COMPLICATIONS β’ Acute cholecystitis (90-95% secondary to gallstones) β’ Gallstone pancreatitis β’ Acute cholangitis β’ Common bile duct stones with obstructive jaundice β’ Gallstone ileus β’ Liver abscess β’ Biliary-enteric fi stula β’ Peritonitis β’ Gallbladder cancer EXPECTED COURSE/PROGNOSIS β’ Less than half of patients with gallstones will become symptomatic β’ Cholecystectomy - mortality 0.5% elective, 3-5% emergency, morbidity less than 10% elective, 30-40% emergency β’ 10-15% will have associated choledocholithiasis β’ After cholecystostomy, stones may recur in bile duct AGE-RELATED FACTORS: Pediatric: β’ Uncommon before 10 years of age β’ Associated with blood dyscrasia Geriatric: β’ Incidence increases with age β’ Age alone should not alter therapy plan
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
ULTRA SOUND WHOLE ABDOMEN - MALE, COMPLETE BLOOD COUNT, CT SCAN ABDOMEN, MRI, LIVER FUNCTION TEST