Special Surgery 9. Gallstones of the Gallbladder and the Biliary Tract: Symptomatics, Diagnostics, Treatments

I. Definitions, Types and Pathomechanism

Definitions

• Gallstones / cholelithiasis: Solid concretions formed from bile components
• Cholecystolithiasis: Gallstones in the gallbladder
• Choledocholithiasis: Gallstones in the common bile duct (CBD)
• Most gallstones are in the gallbladder and remain asymptomatic

Types of Gallstones

1. Cholesterol Stones

• Most common in Western countries
• Risk factors: 4F

• Female
• Fat
• Forty
• Fertile

• Other risks: pregnancy/estrogen, rapid weight loss, diabetes/metabolic syndrome, family history, ileal disease/resection

2. Pigment Stones

• Bilirubin-rich stones
• Black pigment stones: chronic hemolysis, cirrhosis
• Brown pigment stones: biliary infection, bile stasis, biliary stricture/stenosis

Pathomechanism

• Bile cholesterol supersaturation
• Crystal nucleation and stone growth
• Bile stasis / gallbladder hypomotility
• Impaired enterohepatic circulation of bile acids
• Biliary infection → brown pigment stone formation

II. Symptoms and Clinical Presentation

Asymptomatic Gallstones

• Incidental gallstones on imaging
• No biliary colic, fever, jaundice or inflammatory signs
• Usually no treatment

Biliary Colic: Symptomatic Cholecystolithiasis

• Intermittent cystic duct obstruction by gallstone
• Episodic RUQ or epigastric pain
• Often after fatty meal
• Radiates to right shoulder/scapula or back
• Nausea and vomiting
• Usually lasts 30 min to a few hours, then resolves
• No fever, no persistent inflammatory signs, no jaundice if uncomplicated

Choledocholithiasis Symptoms

• Stone in common bile duct
• RUQ/epigastric pain, nausea, vomiting
• Obstructive jaundice: direct bilirubin rises, dark urine, pale/acholic stool, pruritus
• Fever/chills → suspect ascending cholangitis

Red Flags for Complication

• Persistent RUQ pain > 6 h + fever/Murphy sign → acute cholecystitis
• Jaundice + fever + RUQ pain → ascending cholangitis
• Hypotension/confusion → severe cholangitis/sepsis
• Epigastric pain radiating to back + high lipase → gallstone pancreatitis

III. Diagnostics

Laboratory Tests

• Uncomplicated cholecystolithiasis: labs usually normal
• Acute cholecystitis/cholangitis: increased WBC, CRP ± procalcitonin
• CBD obstruction: increased direct/total bilirubin, ALP, GGT; AST/ALT can also increase
• Gallstone pancreatitis: increased amylase/lipase

Ultrasound

• First-line imaging
• Gallstones: echogenic mobile stones with posterior acoustic shadowing
• Acute cholecystitis signs: wall thickening, edema/pericholecystic fluid, distension, sonographic Murphy sign
• Dilated bile duct → suggests choledocholithiasis or distal obstruction
• CBD stones are not always visible on transabdominal US

Biliary Tree Imaging and ERCP

• MRCP: non-invasive biliary imaging; good for suspected CBD stones when probability is intermediate
• EUS: very sensitive for small CBD stones/microlithiasis
• ERCP: diagnostic and therapeutic when CBD intervention is likely

• Finding: filling defect in contrast-enhanced duct
• Therapy: sphincterotomy + balloon/basket stone extraction ± biliary stent

• CT: atypical presentation or complications
• HIDA scan: if US is inconclusive and acute cholecystitis remains suspected

IV. Treatment and Cholecystectomy

Asymptomatic Cholecystolithiasis

• Usually observation only
• Consider prophylactic cholecystectomy only with complications or increased cancer/complication risk:

• Porcelain gallbladder / suspicious calcification
• Large or suspicious gallbladder polyp
• Very large stones
• Hemolytic disease, e.g. sickle cell disease
• Selected immunosuppressed/transplant candidates according to local protocol

Symptomatic Gallbladder Stones

• Acute attack: analgesia, usually NSAID such as diclofenac if no contraindication
• Definitive treatment: elective laparoscopic cholecystectomy
• Dietary fat reduction may reduce attacks but does not remove stones
• Ursodeoxycholic acid: limited role; small radiolucent cholesterol stones + functioning gallbladder + surgery unsuitable

Choledocholithiasis

• High probability CBD stone / obstructive jaundice → ERCP with sphincterotomy and stone extraction
• After CBD clearance → laparoscopic cholecystectomy if gallbladder remains
• If ERCP fails: repeat expert ERCP, percutaneous drainage/intervention or surgical CBD exploration
• Cholecystectomy alone after failed ERCP does not clear retained CBD stone unless bile duct exploration is done

Laparoscopic Cholecystectomy

• Surgical removal of gallbladder
• Gold standard for symptomatic cholecystolithiasis
• Open operation: Kocher right subcostal incision; used if laparoscopy unsafe, severe inflammation/conversion, complex anatomy or malignancy suspicion

Procedure

1. Place laparoscopic ports
2. Expose hepatocystic / Calot triangle
3. Obtain critical view of safety
4. Clip and divide cystic duct and cystic artery
5. Separate gallbladder from liver bed
6. Remove gallbladder via umbilical/epigastric port

Important Anatomy and Complications

• Classical Calot triangle: cystic duct, common hepatic duct, cystic artery
• Modern hepatocystic triangle: cystic duct, common hepatic duct, inferior liver edge
• Complications: bile duct injury, cystic/right hepatic artery bleeding, bile leak, retained CBD stone, duodenum/colon injury, wound infection