Gall bladder disease (specifically gall stones) is the most common abdominal complaint causing hospital admission in the developed world. In the UK, 5.5 million people have gall stones and 50 000 cholecystectomies are performed each year.
Gall stones are 2-3 times more common in women than in men at post-mortem. Obesity is the strongest independent risk factor for their development in women. The increased incidence in women is most likely caused by the effect of oestrogen, which promotes the transfer of cholesterol from the blood to the liver.
Gall stones are found in up to 20% of adult females.
Gall stone disease presents a spectrum of pathology, ranging from asymptomatic gall stones, to acute cholecystitis and ascending cholangitis.
The position of the stone within the gastrointestinal tract relates to the clinical problems that are produced:
- It can pass freely (asymptomatic gall stone)
- It can get intermittently stuck in the biliary tract (biliary colic/chronic cholecystitis)
- It can get stuck for a more prolonged period (acute cholecystitis, ascending cholangitis, acute pancreatitis, gall bladder perforation and empyema)
- The gall stone may also get stuck outside the biliary tract (gall stone ileus). However, 70% of gall stones are asymptomatic, with a yearly risk of developing pain of 1-4%.
Gall stones are precipitates of bile that form in the gall bladder.
When fasting, 50% of bile produced is released into the duodenum, and 50% (up to 50 ml) is stored within the gall bladder
Acalculous cholecystitis occurs in 5-10% of cases of acute cholecystitis and tends to be more severe. It is more common in the elderly and those with diabetes mellitus. It may occur as a complication of burns or multiple trauma, and patients are very ill on presentation.
7 in 10 patients with gall stones are likely to be asymptomatic.
Types of Gallstones
Gall stones are found in the following forms:
- White or mixed (pure or mainly cholesterol): 80% of UK gall stones occur when bile is super-saturated with cholesterol. This is the most common!
- Brown: <5% in the UK, due to stasis and infection within the biliary tree
- Black (bile predominant): seen in haemolytic disease (sickle cell, thalassaemia, G6PDHase deficiency and hereditary spherocytosis) and cirrhosis
Risk Factors for Gallstones
There are many risk factors for the production of cholesterol gall stones, which points to why cholesterol gall stones are so common worldwide. Risk factors associated with formation of cholesterol gall stones are as follows:
- Increasing age
- Female sex
- Familial predisposition
- Bile salt loss (ileal disease, resection, clofibrate drugs)
- Diabetes mellitus, cystic fibrosis
- Total parenteral nutrition
- Prolonged fasting
Presentation of Gallstone Disease
The patient may be flushed, jaundiced, dehydrated, tachycardic and hypotensive, all depending on the stage of gall stone disease continuum. They may have epigastric and/or RUQ tenderness, or diffuse abdominal tenderness (more likely to be gall stone pancreatitis).
Murphy’s sign is demonstrated by asking the patient to inspire while the examiner palpates deeply in the right subcostal region. A sharp increase in pain is felt as the inflamed gall bladder touches the examiner’s hand: this can cause inspiratory arrest.
Isolated rebound tenderness in the RUQ reflects localised peritoneal irritation secondary to leakage of inflammatory fluid (acute cholecystitis) or gall bladder contents (gall bladder perforation contained locally within the omentum). Generalised rigidity and peritonism is rare and reflects leakage of gall bladder contents from a gall bladder rupture into the peritoneal cavity.
There may be a reduction in bowel sounds and distension due to a secondary ileus.
Murphy’s sign is about 97% sensitive for acute cholecystitis.
If the bile duct does become completely or partially obstructed, the patient will also develop pale stools and dark urine (since bilirubin can no longer pass into the gut in the normal way). The offending stone will usually be found in the common bile duct, but can be found in the neck of the gall bladder or the cystic duct, where it can compress the common hepatic duct causing blockage of bilirubin passage into the gut (Mirizzi’s syndrome)
Ascending cholangitis is a life-threatening emergency, with an untreated mortality near 100%. The Charcot triad of fever, RUQ pain and jaundice is noted in only 25% of patients with ascending cholangitis
Surgical Management of Gallstones Disease
Surgery is not indicated in asymptomatic patients, except in some select groups (e.g. sickle cell disease). Surgical treatment choices are based on the patient’s clinical condition: less radical surgical procedures such as endoscopic retrograde cholangiopancreatography (ERCP) are done emergently in sick patients with ascending cholangitis or gall stone pancreatitis.
Comparing laparoscopic and open cholecystectomy, there is no difference between mortality, operating time or complication rate, but there is an extension of hospital stay with open cholecystectomy. Other surgical options include percutaneous cholecystostomy for biliary sepsis in patients with high surgical risk.