| Risk-factors of cholelithiasis and chronic cholecystitis during pregnancy. Georgian
Med News. 2007 Jun;(147):37-40.
The peak of cholelithiasis formation in women concurs with
reproductive period and physiological pregnancy serves as a starter of
pathological processes in bile-excreting system. The aim of
investigation was to reveal the risk-factors of cholelithiasis and
cholecystitis during pregnancy. Investigation was a case-control type.
A main group consisted of 30 cases. 2-4 pregnant patients in control
group were corresponding with each case from main group. Basic
significant prognostic factors of cholelithiasis and cholecystitis
were determined. They are: fat-rich diet (OR=5.00), feeding
irregularity (OR=5.78), visceral obesity (OR=2.67), artificial
abortion (OR=3.25); among notable abdominal symptoms during pregnancy
are heaviness sensation in right lateral region (OR=406.0), dull ache
sensation in right lateral region (OR=196.0) and heartburn sensation
(OR=14.50). Thus, revealing the anamnestic risk-factors related with
pregnancy and delivery on any stage of pregnancy will be very useful
for prevention of cholelithiasis and chronic cholecystitis. The
results need to be confirmed by further investigations.
Inflammatory diseases of the gall
bladder and biliary system. I. Imaging--cholelithasis--inflammation of
the gall bladder. Radiologe.
2005 May;45(5): 479-90; quiz 491.
Cholelithiasis is the most common affliction of the gallbladder and
biliary tract. Including its complications, gallstone disease
represents the basis for cholecystitis and cholangitis in the majority
of cases. Inflammatory diseases of the biliary system are divided into
acute and chronic forms originating from the gallbladder as well as
from the biliary tract. Although acute calculous cholecystitis is the
most common form, gangrenous, and emphysematous inflammation of the
gallbladder as well as gallbladder empyema are included in this group
of diseases. In the chronic forms, calculous and acalculous
inflammation is also differentiated. Recent developments in
cross-sectional imaging in sonography, computed tomography, and
magnetic resonance imaging offer numerous tools for depicting the
biliary system with high diagnostic accuracy. Invasive imaging
modalities of the biliary system are mainly used for therapeutic
aspects.
Cholelithiasis and cholecystitis.
J Long Term Eff Med Implants. 2005;15 (3): 329-38.
Gallstone disease remains one of the most common
medical problems leading to surgical intervention. Every year,
approximately 500,000 cholecystectomies are performed in the US.
Cholelithiasis affects approximately 10% of the adult population in
the United States. It has been well demonstrated that the presence of
gallstones increases with age. An estimated 20% of adults over 40
years of age and 30% of those over age 70 have biliary calculi. During
the reproductive years, the female-to-male ratio is about 4:1, with
the sex discrepancy narrowing in the older population to near
equality. The risk factors predisposing to gallstone formation include
obesity, diabetes mellitus, estrogen and pregnancy, hemolytic
diseases, and cirrhosis. A study of the natural history of
cholelithiasis demonstrates that approximately 35% of patients
initially diagnosed with having, but not treated for, gallstones later
developed complications or recurrent symptoms leading to
cholecystectomy. During the last two decades, the general principles
of gallstone management have not notably changed. However, methods of
treatment have been dramatically altered. Today, laparoscopic
cholecystectomy, laparoscopic common bile duct exploration, and
endoscopic retrograde management of common bile duct (CBD) stones play
important roles in the treatment of gallstones. These technological
advances in the management of biliary tract disease are not
infrequently accomplished by a multidisciplinary team of physicians,
including surgeons trained in laparoscopic techniques, interventional
gastroenterologists, and interventional radiologists. With the
evolution of laparoscopic cholecystectomy, there has been a global
reeducation and retraining program of surgeons. However, the treatment
of choice for gallstones remains cholecystectomy. In recognition of
the revolutionary advances in the treatment of cholelithiasis, it is
the purpose of this collective review to describe recent information
on the following topics: types of gallstones, asymptomatic gallstones,
symptomatic gallstones, chronic cholecystitis, acute cholecystitis,
and other complications of gallstones. Gross and compositional
analysis of gallstones allows them to be classified as cholesterol,
mixed, and pigment gallstones. When asymptomatic gallstones are
detected during the evaluation of a patient, a prophylactic
cholecystectomy is normally not indicated because of several factors.
Only about 30% of patients with asymptomatic cholelithiasis will
warrant surgery during their lifetime, suggesting that cholelithiasis
can be a relatively benign condition in some people. However, there
are certain factors that predict a more serious course in patients
with asymptomatic gallstones and warrant a prophylactic
cholecystectomy when they are present. These factors include patients
with large (>2.5 cm) gallstones, patients with congenital hemolytic
anemia or nonfunctioning gallbladders, or during bariatric surgery or
colectomy. Epigastric and right upper quadrant pain occurring 30-60
minutes after meals is frequently associated with gallstone disease.
The diagnosis of chronic cholecystitis is made by the presence of
biliary colic with evidence of gallstones on an imaging study.
Ultrasonography is the diagnostic test of choice, being 90-95%
sensitive. The surgical literature suggests that 3-10% of patients
undergoing cholecystectomy will have CBD stones. Intraoperative
laparoscopic ultrasonography has recently replaced cholangiography as
the method of choice for detecting CBD stones. Ultrasonography and
radionuclide cholescintigraphy (HIDA scan) are useful in establishing
a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy
should also be used in the treatment of acute cholecystitis.
Laparoscopic cholecystectomy is more likely to be successful when
performed within 3 days of the onset of symptoms. It is important to
remember that gallstones can lead to a variety of other complications
including choledocholithiasis, gallstone ileus, and acute gallstone
pancreatitis.
Gallbladder wall inflammatory cells in pediatric
patients with biliary dyskinesia and cholelithiasis: a pilot study.J
Pediatr Surg. 2006 Sep;41(9): 1545-8.
BACKGROUND/PURPOSE: Inflammation has been
implicated in functional gastrointestinal disorders, including
functional dyspepsia and irritable bowel syndrome. This study was
undertaken to evaluate gallbladder wall inflammatory cells in children
with abdominal pain related to gallstones and biliary dyskinesia to
determine the candidate cell types that may be contributing to the
pathophysiology of these entities. METHODS: Gallbladder specimens from
20 patients with cholelithiasis, 20 biliary patients with dyskinesia,
and 12 autopsy controls were evaluated in a blinded fashion.
Eosinophil, tryptase-positive, and CD3+ cell densities were determined
for the lamina propria and muscularis mucosa layers and compared
between groups. RESULTS: Patients with biliary dyskinesia and
cholelithiasis had a 9- to 12-fold increase in mean and peak mast cell
densities, respectively, in both layers as compared with controls.
Peak (13.7 vs 8.4) and mean (9.2 vs 5.2) CD3+ cell densities were
increased in the muscularis mucosae of cholelithiasis specimens as
compared with biliary dyskinesia specimens. CONCLUSION: Gallbladder
wall inflammatory cell densities, particularly mast cells, differ
between children with cholelithiasis, children with biliary dyskinesia,
and controls. Future studies are warranted to define the roles for
specific inflammatory cell types.
Silent gallstones: a
therapeutic dilemma.Trop
Gastroenterol. 2004 Apr-Jun;25(2):65-8.
Asymptomatic gall stones are defined as stones
that have not caused biliary colic or other biliary symptoms. Nearly
two-third of patients with gall stones are asymptomatic. Studies of
the natural history of asymptomatic gall stones suggest that the
cumulative probability of developing biliary colic after 10 years
ranges from 15% to 25%. The incidence of other complications is much
less. The operative mortality of elective cholecystectomy is <0.5% but
increased mortality is seen in elderly persons (>60 year of age),
particularly in those with complications such as acute cholecystitis.
Most decision analysis studies do not favour prophylactic
cholecystectomy for asymptomatic cholelithiasis. Nonetheless, many
studies have listed certain criteria for carrying out elective
cholecystectomy in asymptomatic patients. The authors, from their own
experience and after reviewing the literature, propose the following
criteria for cholecystectomy: life expectancy >20 years, calculi >3 cm
in diameter, particularly in individuals in geographical regions with
a high prevalence of gall bladder cancer or calculi <3 mm, chronically
obliterated cystic duct, non-functioning gallbladder and calcified
(porcelain) gallbladder. The widespread use of diagnostic abdominal
ultrasonography has led to the increasing detection of clinically
unsuspected gall stones. This, in turn, has given rise to a great deal
of controversy regarding the optimal management of asymptomatic or
'silent' gall stones. While cholecystectomy is the undisputed gold
standard treatment for symptomatic gall stones, the natural history of
silent gall stones is not known well enough to recommend a definitive
therapeutic strategy for such patients. The treatment options for
asymptomatic or silent gall stones range from no treatment to
selective cholecystectomy in at-risk group to elective cholecystectomy
in all patients. There are a large number of proponents for each of
these options so that each merits careful consideration. In this
article, the authors examine the evidence for and against treating
silent gall stones with the aim of providing more specific guidelines
for the management of patients found to have asymptomatic gall stones.
Histopathological changes in
gallbladder mucosa in cholelithiasis: correlation with chemical
composition of gallstones.Trop
Gastroenterol. 2002 Jan-Mar;23(1):25-7
BACKGROUND: Cholelithiasis produces diverse
histopathological changes in gallbladder mucosa namely acute
inflammation, chronic inflammation, glandular hyperplasia,
granulomatous inflammation, cholesterosis, dysplasia, and carcinoma.
Gallstones have different chemical composition. They may be
cholesterol, pigment or mixed stones. The aim of this prospective
study was to see if any correlation existed between the chemistry of
gallstones and any particular histopathologic picture. METHODS:
Between May 1997 and December 1997 we diagnosed and operated on 40
patients with cholelithiasis. Diagnosis was established by ultrasound.
After operation gallstones were sent for chemical analysis to detect
presence of calcium bilirubinate and cholesterol. Serial sections of
gallbladder from fundus to neck were stained by haematoxylin and
eosin, and studied. RESULTS: Out of 40 patients (n = 40) 29 were
females and 11 were males. The mean age of our patients was 38 +/- 21
years with a median of 40 years. Median age of males was 48 years
compared to 38 years for females. Twenty-eight patients had mixed
stones, 8 had pigment stones and 4 had cholesterol stones. Out of 28
patients with mixed stones 14 had histological picture of chronic
cholecystitis, 8 had granulomatous cholecystitis, 4 had adenomatous
hyperplasia, 1 had dysplasia and 1 had carcinoma. All 8 patients
having pigment gallstones had chronic cholecystitis. Out of 4 patients
with cholesterol gallstones, 2 had chronic cholecystitis, 1 had
adenomatous hyperplasia and 1 had cholesterosis. Gallbladder having
pigment stones were devoid of Rokitansky-Aschoff sinuses. CONCLUSION:
Adenomatous hyperplasia and Rokitansky-Aschoff sinuses were not seen
in gallbladder containing pigment stones but seen in gallbladders
containing mixed and cholesterol stones in our study. Cholesterol may
be a more potent stimulus for glandular hyperplasia or glandular
hyperplasia may responsible for formation of cholesterol rich stones.
Neoplasms and
dysplasias of the gallbladder and their relationship with lithiasis. A
case-control clinicopathological study.Rev
Gastroenterol Mex. 1998 Apr-Jun;63(2):82-8.
BACKGROUND: A strong association has been reported
between gallbladder carcinoma, premalignant epithelial or metaplasic
inflammatory lesions and cholelithiasis, varying the incidence among
different ethnic groups. PURPOSE: To determine the frequency of
association between such lesions and gallbladder lithiasis. MATERIAL
AND METHODS: We examined histopathologic changes in 1,367
cholecystectomy specimens with (1,096) or without (271) lithiasis and
established its frequency of association, correlating with main
clinical data. RESULTS: Overall, 80% had lithiasis. In this group,
pseudopyloric metaplasia (50%), intestinal metaplasia (16%), low grade
dysplasia (40%), high grade dysplasia (16%), carcinoma in situ (1.5%)
and invasive carcinoma (2.6%) were observed compared to 25%, 2%, 17%,
2%, 0%, and 0% in the control group. The findings of 80% with
lithiasis, 65% with carcinoma in situ and 90% of invasive carcinoma,
all were in women. Median age of patients with low and high grade
dysplasia, carcinoma in situ and invasive carcinoma was 42, 48, 53 and
61 years, respectively. CONCLUSIONS: Acute and xanthogranulomatous
cholecystitis, adenomyomatosis, pseudopyloric and intestinal
metaplasia, hyperplastic polyps, low and high grade dysplasia, tubular
adenomas, carcinoma in situ and invasive carcinoma were more frequent
when cholelithiasis was present (p < .05) than in cases without
lithiasis.
Cholelithiasis in Taiwan. Gallstone characteristics, surgical
incidence, bile lipid composition, and role of beta-glucuronidase.Dig
Dis Sci. 1995 Sep;40(9):1963-73.
The nature and occurrence of gallstones in Taiwan
and their etiologic factors might not be the same as in Western
countries and warranted a systematic investigation. Gallbladder biles
and gallstones were obtained at surgery from 100 and 74 patients,
respectively. Common duct bile and stones were either drained through
an indwelling common duct T-tube or aspirated through a nasobiliary
catheter in 108 patients. Gallstones were analyzed for bilirubin,
cholesterol, bile acid, calcium, and residue, and biles for bile acid,
cholesterol, phospholipid, bilirubin, and beta-glucuronidase. There
were four major kinds of gallstones in Taiwan: cholesterol/mixed
stones, high-residue black formed pigment stones, low-residue brown
formed pigment stones, and muddy pigment stones. The surgical
incidence of all types of stones increased steadily during the past
four decades. During the past 15 years the relative frequencies for
mixed, formed pigment, and muddy pigment stones had been roughly 40,
40, and 20%, respectively, with a further increase in the mixed stones
and a decrease in the muddy pigment stones in recent years.
Improvement of nutritional status and living standards might
contribute to such changes. Cholesterol content in the common duct and
gallbladder biles was higher in the mixed stone group than in other
groups. Bacterial beta-glucuronidase activity was detected in 53% of
patients with muddy pigment stones. Endogenous beta-glucuronidase
activity and concentration were also highest in this group,
intermediate in the formed pigment and mixed stone group, and lowest
in the control. We concluded that hypercholesterobilia was responsible
for increasing incidence of mixed stones during the past two decades,
while both bacterial and human beta-glucuronidase might contribute to
pigment cholelithiasis.
Pathogenesis of gallstones. Recenti
Prog Med. 1992 Jul-Aug;83(7-8):379-91.
Gallstones are composed principally of cholesterol
monohydrate crystals (cholesterol stones) or the acid salt of calcium
bilirubinate (pigment stones). Cholesterol stones and the black
variety of pigment gallstones form in sterile gallbladder bile whereas
brown pigment gallstones form in infected bile. Biliary
supersaturation is the principal pathophysiological defect and is
hepatic in origin. Supersaturation results from excessive secretion of
cholesterol or bilirubin conjugates, the precursors of unconjugated
bilirubin, and/or, deficient secretion of bile salt and lecithin, the
solubilizers of these otherwise insoluble lipids. As has now being
clarified for cholesterol stones, an imbalance in pro- and
antinucleating biliary proteins, hypersecretion of gallbladder mucin
and gallbladder dysmotility possibly from cholesterol "toxicity" to
sarcolemma, all interact to promote nucleation. Crystallisation
results in suspension of cholesterol crystals or bilirubinate salts in
gallbladder mucin gel and is known as "biliary sludge". It is believed
today that this stage is essential for evolution of both cholesterol
and pigment stones. Brown pigment gallstones form principally in the
bile ducts. These stones result from infection of the biliary tree,
most commonly due to obstruction from migrating gallbladder stones.
Chemical compositions of brown and black pigment stones are different:
In black stones, calcium bilirubinate is polymerized and oxidatively
degraded but in brown stones, calcium bilirubinate is present as the
unpolymerised salt. Brown stones differ also from black stones in
containing calcium fatty acid soaps, a result of bacterial
phospholipase A1 hydrolysis of biliary lecithin. Both types of pigment
gallstones may contain crystalline inorganic calcium salts especially
carbonate (gallbladder stones) and phosphate (bile ducts stones).
Since a molecular understanding of the multiple defects that lead to
cholesterol and pigment gallstones is becoming a reality, the future
holds much promise for gallstone prevention.
Pathogenesis of gallstones. Am
J Surg. 1993 Apr;165(4):410-9.
Gallstones form as a result of many disorders.
Unphysiologic supersaturation, generally from hypersecretion of
cholesterol, is essential for the formation of cholesterol gallstones.
The other common abnormalities of the hepatobiliary system in
gallstone patients are accelerated nucleation, gallbladder
hypomotility, and the accumulation of mucin gel. An attempt is made
here to relate hypersecretion of cholesterol and biliary
supersaturation to the molecular basis of the associated phenomena.
Supersaturation of bile with calcium hydrogen bilirubinate, the acid
calcium salt of unconjugated bilirubin, is essential for pigment
gallstone formation, but its magnitude remains undefined in model
systems. Nucleation and the precipitation of calcium hydrogen
bilirubinate with the polymerization of the pigment in the
gallbladder, together with the deposition of the inorganic salts,
calcium carbonate and phosphate, result in black pigment gallstone
formation. On the basis of ex vivo muscle studies, gallbladder
hypomotility is unlikely in patients with black pigment stones but is
invariably present in patients with cholesterol stones. Pigment
supersaturation in the gallbladder is the result of hepatic
hypersecretion of bilirubin conjugates in hemolytic disorders and
possibly enterohepatic cycling of unconjugated bilirubin in
nonhemolytic states. Less common is bile salt hyposecretion from
impaired synthesis in constitutional disorders and cirrhosis, and
uncompensated interruption of the enterohepatic circulation in ileal
dysfunction syndromes. Bile salt deficiency causes incomplete
solubilization of unconjugated bilirubin and impaired binding of
calcium ions. Stasis and anaerobic bacterial infection are responsible
for brown pigment stones, which usually form in the bile ducts. In
addition to the precipitation of calcium hydrogen bilirubinate that
remains unpolymerized, there is also the deposition of the calcium
salts of saturated fatty acids and free bile acids, both of which are
the result of bacterial enzymatic hydrolysis of biliary lipids.
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