Cholelithiasis and Cholecystitis

The Gallstone Elimination Report

Gallstone Natural Solutions by David Smith

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Gallstones are exceedingly common among women and men of all ages, affecting approximately 20% of Americans during their lifetime. Population-based studies reveal a prevalence of gallbladder disease in women age 20 to 55 of 5% to 20%, increasing to 25% to 30% after age 50. By age 75, an estimated 35% of women and 20% of men will develop either symptomatic or asymptomatic gallstones (Attili et al., 1995). The prevalence for men is approximately one-third to one-half that for women in any given age group. The traditional clinical picture of a patient likely to have gallstones is an obese woman over 40 years of age (The four F's: female, "fat", 40, and fertile). Prevalence is also increased in patients with cystic fibrosis with pancreatic insufficiency, diabetes mellitus, or family history of biliary colic; pregnancy; rapid weight loss; Native American Pima Indian or Scandinavian descent; patients taking estrogens, progestins, or ceftriaxone; and those requiring total parenteral nutrition (TPN).

The Rome Group for the Epidemiology and Prevention of Cholelithiasis (GREPCO, 1984) found that the overall cumulative probability of developing biliary colic over time was 11.9% at 2 years, 16.5% at 4 years, and 25.8% at 10 years, with a cumulative probability of 3% of developing complications at 10 years. The incidence of the development of biliary complications as the presenting complaint of gallstone disease is rare, ranging from zero to 5.5%. Based on these data, evidence from well-designed cohort and case-control studies summarized by GREPCO favors expectant treatment of asymptomatic gallstones.

In the approach to the patient with symptomatic gallstones, clinicians should effectively rule out other potential causes of RUQ and epigastric abdominal pain, distinguishing biliary from nonbiliary etiologies as the primary source of disease (see Table 38-1). A gallstone blocking the cystic duct or common bile duct (CBD; choledocholithiasis) results in acute biliary colic, which can evolve into acute suppu-rative cholecystitis or cholangitis. The onset of pain from biliary colic is rarely related to meals or the type of food consumed, contrary to popular opinion. Many patients with postprandial abdominal pain believe that they have gallbladder disease, but many of them suffer from dyspepsia or GERD. One meta-analysis found that heartburn, flatulence, regurgitation, and fatty food intolerance were not associated with gallstones, but that epigastric pain, nausea, and vomiting were associated with a higher odds ratio of having gallstones (Kragg et al., 1995).

In cases of acute cholecystitis, laboratory tests frequently lack adequate predictive value in making an accurate diagnosis. A complete blood count (CBC) usually reveals a moderate leukocytosis, often with a "bandemia" in cases of ascending cholangitis. Serum amylase and lipase values are usually normal but may be elevated if there is associated pancreatitis. Serum alkaline phosphatase (ALP), liver transaminases, and bilirubin levels are rarely elevated except when CBD stones are causing obstruction. Patients with choledocholithiasis often present similar to those with cholelithiasis, although they may also have obstructive jaundice, cholangitis, and pancreatitis.

The evaluation of gallstones using abdominal ultrasound is currently the best screening modality, with sensitivity and specificity above 90%. When calculi, gallbladder wall thickening, and gallbladder sludge are found, the diagnosis of acute cholecystitis is almost certain, yet the presence of stones by itself does not ensure the diagnosis of acute cholecystitis. Only 10% to 15% of gallstones are visible on plain radiographs (Fig. 38-10). A CT scan of the upper abdomen is more sensitive than conventional radiography but may miss a significant amount of cholesterol gallstones and biliary sludge readily seen on US (Fig. 38-11). Biliary scintigraphy (HIDA scan) uses technetium 99m (99mTc)-labeled derivatives of excreted bile acids to determine CBD obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and/or sphincterotomy is useful

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Figure 38-10 Radiographs of gallstones. (Courtesy Dr. PerryPernicano.)

in identifying and treating CBD stones, but is invasive, expensive, and often fraught with complications, including iatrogenic pancreatitis (Fig. 38-12).

Endoscopic ultrasound is a widely used, noninvasive method with excellent sensitivity and specificity for detecting and evaluating CBD stones. Magnetic resonance cholangiopancreatography (MRCP) is another noninvasive modality for identifying gallstones and CBD stones, but it often has lower sensitivity and specificity than ultrasound and is more costly (Browning and Sreenarasimhaiah, 2006). The natural history of CBD stones suggests that 70% will pass safely into the duodenum and will not require ERCP for stone extraction.

Most surgeons advocate expectant management in patients with asymptomatic gallstones. Nonsurgical treatments include pain relief with narcotic analgesics, excluding morphine and its derivatives (which may precipitate sphincter of Oddi spasm and worsen symptoms) extracorporeal shockwave lithotripsy, and gallstone dissolution using oral bile acid therapy and contact solvents such as MTBE). Numerous RCTs have confirmed the adoption of laparoscopic cholecys-tectomy as the gold standard for the treatment of gallstone disease over the open procedure (Glasgow and Mulvihill, 2006).

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