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

I. Definitions, Types and Pathomechanism

Definitions

• Gallstones = solid concretions formed from bile components
• Cholecystolithiasis = gallstones in the gallbladder
• Choledocholithiasis = gallstones in the common bile duct (CBD)
• Gallstones are most commonly in the gallbladder
• Most gallstones remain asymptomatic

Types of Gallstones

1. Cholesterol Stones

• Most common type in Western countries
• Usually yellow, cholesterol-rich stones
• Classical risk factors: 4F

• Female
• Fat
• Forty
• Fertile

• Additional risk factors:

• Pregnancy and estrogen therapy
• Rapid weight loss / bariatric surgery
• Diabetes mellitus and metabolic syndrome
• Family history
• Ileal disease or resection → disturbed bile salt circulation

2. Pigment Stones

• Bilirubin-rich stones
• Black pigment stones:

• Associated with chronic hemolysis
• Cirrhosis

• Brown pigment stones:

• Associated with biliary infection and bile stasis
• More common in bile ducts
• Can be associated with biliary strictures or parasites in endemic areas

Pathomechanism

• Cholesterol supersaturation of bile
• Crystal nucleation and stone growth
• Gallbladder hypomotility / bile stasis
• Impaired enterohepatic circulation of bile acids
• Mucin hypersecretion promotes crystal trapping
• Biliary infection favors brown pigment stones

II. Symptoms and Clinical Presentation

Asymptomatic Gallstones

• Gallstones found incidentally on imaging
• No biliary colic
• No jaundice, fever or inflammatory signs
• Most patients do not need treatment

Symptomatic Cholecystolithiasis: Biliary Colic

• Intermittent obstruction of cystic duct by stone
• Episodic right upper quadrant or epigastric pain
• Often after fatty meal
• Radiates to right scapula, shoulder or back
• Sharp, cramping or steady pain
• Usually lasts 30 min to a few hours, then resolves
• Nausea and vomiting common
• No fever and no persistent inflammatory signs in uncomplicated biliary colic
• No jaundice unless CBD obstruction is present

Choledocholithiasis Symptoms

• Stone in common bile duct
• May be asymptomatic or cause intermittent obstruction
• Right upper quadrant or epigastric pain
• Jaundice
• Dark urine
• Pale / acholic stool
• Pruritus
• Nausea and vomiting
• Fever suggests cholangitis, not simple uncomplicated choledocholithiasis

Red Flags for Complication

• Persistent RUQ pain > 6 hours → acute cholecystitis
• Fever, chills → cholecystitis or cholangitis
• Jaundice → CBD obstruction
• Hypotension/confusion → severe cholangitis/sepsis
• Epigastric pain radiating to back + vomiting → gallstone pancreatitis

III. Diagnostics

Laboratory Tests

Uncomplicated Gallbladder Stones

• Often normal laboratory findings
• No leukocytosis, no CRP rise, no cholestasis pattern

Suspected CBD Stone / Obstruction

• Total and direct bilirubin increased
• ALP and GGT increased
• GOT/AST and GPT/ALT can increase, sometimes markedly early in obstruction
• CBC/CRP if inflammatory complication suspected
• Amylase/lipase if pancreatitis suspected

Ultrasound

• First-line imaging for suspected gallstones
• Gallstones: echogenic mobile structures with posterior acoustic shadowing
• Sludge can be seen as low-level echoes without clear shadow
• Signs of acute cholecystitis:

• Gallbladder wall thickening
• Pericholecystic fluid
• Distended gallbladder
• Sonographic Murphy sign

• CBD dilation suggests choledocholithiasis or distal obstruction
• CBD stones are not always visible on transabdominal ultrasound

MRCP

• Magnetic resonance cholangiopancreatography
• Non-invasive imaging of biliary tree and pancreatic duct
• Excellent for suspected CBD stones when probability is intermediate
• No therapeutic intervention possible

Endoscopic Ultrasound (EUS)

• Very sensitive for small CBD stones and microlithiasis
• Useful when MRCP is negative but suspicion remains
• Can triage need for ERCP

ERCP

• Endoscopic retrograde cholangiopancreatography
• Diagnostic and therapeutic for CBD stones
• Findings: filling defect in contrast-enhanced duct
• Therapy:

• Sphincterotomy
• Balloon/basket stone extraction
• Biliary stent if drainage needed or stone cannot be removed immediately

• Because ERCP has complications, it is mainly used when therapeutic intervention is likely

Other Imaging

• CT:

• Not first-line for simple gallstones
• Useful for complications, malignancy suspicion or atypical abdominal pain

• HIDA scan / cholescintigraphy:

• Used when ultrasound is inconclusive and acute cholecystitis is still suspected
• Non-visualized gallbladder suggests cystic duct obstruction

IV. Treatment

Asymptomatic Cholecystolithiasis

• Usually no treatment
• Patient education: seek care if biliary colic, fever or jaundice develops
• Prophylactic cholecystectomy can be considered if increased risk of complications or cancer:

• Porcelain gallbladder with significant calcification pattern / cancer concern
• Large gallbladder polyp or suspicious polyp
• Very large stones
• Hemolytic disease such as sickle cell disease
• Candidate for organ transplantation or long-term immunosuppression in selected protocols
• Planned bariatric/abdominal surgery only if local indication exists; not automatic for everyone

Symptomatic Gallbladder Stones / Biliary Colic

• Analgesia:

• NSAID such as diclofenac if no contraindication
• Opioid if severe pain or NSAID contraindicated

• Definitive treatment: elective laparoscopic cholecystectomy
• Timing: after first typical symptomatic episode is reasonable because recurrence is common
• Dietary fat reduction can reduce attacks but does not remove stones
• Ursodeoxycholic acid:

• Limited role
• Only for small radiolucent cholesterol stones with functioning gallbladder when surgery is unsuitable
• Slow effect and recurrence common

Choledocholithiasis

• High probability CBD stone or obstructive jaundice → ERCP with sphincterotomy and stone extraction
• After CBD clearance, perform laparoscopic cholecystectomy if gallbladder still present
• If ERCP fails:

• Repeat ERCP in expert center
• Percutaneous transhepatic drainage/intervention in selected cases
• Laparoscopic or open common bile duct exploration

• Cholecystectomy alone after failed ERCP does not clear a retained CBD stone unless bile duct exploration is performed

Laparoscopic Cholecystectomy

• Surgical removal of the gallbladder
• Gold standard for symptomatic gallbladder stones
• Open cholecystectomy mainly if laparoscopy is unsafe, severe inflammation, conversion, malignancy suspicion or complex anatomy

Basic Procedure

1. Place laparoscopic ports, or Kocher right subcostal incision for open surgery
2. Expose gallbladder and hepatocystic triangle
3. Obtain critical view of safety before clipping/dividing structures
4. Clip and divide cystic duct and cystic artery
5. Separate gallbladder from liver bed
6. Remove gallbladder, usually through umbilical or epigastric port

Calot / Hepatocystic Triangle

• Classical Calot triangle: cystic duct, common hepatic duct, cystic artery
• Modern hepatocystic triangle: cystic duct, common hepatic duct and inferior liver edge
• Correct identification prevents common bile duct injury

Complications

• Bile duct injury
• Bile leak from cystic duct stump or accessory duct
• Bleeding from cystic artery or liver bed
• Right hepatic artery injury
• Duodenal or colonic injury
• Retained CBD stone
• Wound infection, abscess