The term gallstones (also called gallstones or cholelithiasis) means the presence, in various locations, of stones in the biliary tree. This condition can lead to the development of various pathologies, such as:
- Cholecystitis, or inflammation of the gallbladder, can present acutely, with sudden symptoms, or chronically, through the slow and progressive development of stones that worsen the inflammatory picture over time.
- choledocholithiasis, that is, the presence of stones inside the common bile duct, the part of the extrahepatic bile duct that connects the cystic duct (of the gallbladder) with the common bile duct (leaving the liver);
- Intrahepatic lithiasis occurs when stones are present in the branches of the bile ducts inside the liver.
CHRONIC LITHIASIC CHOLECYSTITIS
It is a persistent and recurrent inflammatory phenomenon of the gallbladder. In more than 90% of patients, the cause of this phenomenon is the presence of stones that condition the recurrence of episodes of obstruction of the cystic duct with the consequent appearance of biliary pain or colic (biliary colic). Over time, the repetition of these inflammatory episodes can lead to scarring that forms narrowings within the cystic duct, leading to functional exclusion of the gallbladder.
Clinic presentation
Obstruction of the cystic duct causes a progressive increase in pressure within the gallbladder. The wall is stretched and causes pain, which is constant in most patients. The main symptom is therefore biliary colic, characterized by localized pain generally at the level of the upper right abdominal quadrant, although it can affect the stomach (sometimes it can arise only in this area) and frequently radiates to the back, in the direction of the right shoulder blade or between the two shoulder blades. The pain is usually severe enough to require medical attention for most patients, at least for the first episode. Colic usually lasts 1–5 hours, rarely more than 24 hours or less than an hour.
If the pain persists for more than 24 hours, it should be assumed that acute cholecystitis has started.
Accompanying symptoms are nausea and vomiting, which add to each episode of biliary colic in 60–70% of cases. Abdominal distension and belching are present in half of the patients. The appearance of fever and jaundice is less frequently associated with simple biliary colic.
Obstruction of the cystic duct causes a progressive increase in pressure within the gallbladder. The wall is stretched and causes pain, which is constant in most patients. The main symptom is therefore biliary colic, characterized by localized pain generally at the level of the right upper abdominal quadrant, although it can affect the stomach (sometimes it can arise only in this area) and frequently radiates to the right back. upwards, in the direction of the right shoulder blade, or between the two shoulder blades. The pain is usually severe enough to require medical attention for most patients, at least for the first episode. Colic usually lasts 1–5 hours, rarely more than 24 hours or less than an hour.
Diagnosis
In the presence of uncomplicated chronic cholecystitis, laboratory tests are usually normal. The diagnosis requires the presence of abdominal pain (with the typical characteristics of biliary colic) and the radiological finding of cholelithiasis.
In asymptomatic patients, which are approximately two-thirds of carriers of cholelithiasis, symptoms appear rarely and complications even more rarely. Therefore, no therapy will be necessary for the majority of these patients.
The differential diagnosis includes other conditions that cause acute upper abdominal pain, such as gastroesophageal reflux, acute pancreatitis, gastric ulcers, and irritable bowel syndrome.
TREATMENT
Laparoscopic cholecystectomy is the treatment of choice for patients with chronic lithiasis or symptomatic cholecystitis. Today, only cases complicated by gallbladder perforation require a conventional ("open") surgical approach, i.e., through the classic surgical incision.
ACUTE LITHIASIC CHOLECYSTITIS
Acute cholecystitis is caused by the presence of stones in 90–95% of cases. Obstruction of the cystic duct by a stone causes pain, known as biliary colic, which causes distension of the gallbladder with consequent edema, swelling, and inflammation. In most cases, the stone moves on its own, and the inflammatory picture gradually resolves. Less commonly, the stone causes ischemia and necrosis of the gallbladder wall (5–10% of cases).
Clinic
The main symptom is pain, located in the upper right quadrant of the abdomen, which may recall episodes of biliary colic already experienced by the patient. However, this symptom persists longer than uncomplicated colic, for a few hours or even a few days. Other common symptoms are nausea, vomiting, and fever. Sometimes a mass can be seen under the right rib due to distension of the gallbladder.
Blood tests often show a moderate increase in white blood cells, sometimes accompanied by a slight increase in bilirubin and liver indices. However, in most cases, blood tests alone serve as a corollary to the diagnosis of cholecystitis.
Diagnosis
The most useful diagnostic test in the diagnosis of acute cholecystitis is ultrasound. Pressure from the ultrasound probe on the area of interest can trigger abdominal guarding due to direct compression on the gallbladder.
Treatment
Once the diagnosis is established, it is necessary to stop taking fluids and food by mouth and start the intravenous infusion with antibiotic coverage and adequate anti-inflammatory and analgesic therapy. Surgery is almost always curative; in most patients with acute cholecystitis, laparoscopic cholecystectomy is performed once the diagnosis is established (within 24–48 hours).
Complications
Acute cholecystitis can progress to empyema of the gallbladder, emphysematous cholecystitis, and perforation despite antibiotic therapy. Sepsis may occur with a high fever and increased white blood cells. In any case, in the face of these complications, emergency cholecystectomy is essential, which can sometimes be performed with the traditional technique.
ACUTE ACALTIC CHOLECYSTITIS
The clinical presentation of acute acalculous cholecystitis is similar to that of acute calculous cholecystitis, with right upper quadrant pain, fever, and leukocytosis. Findings on radiological investigations are those of acute calculous cholecystitis with thickening of the gallbladder wall and the presence of a free collection of perivesicular fluid, but there is an absence of stones.
choledocholithiasis
This type of stone can occur in association with cholelithiasis or independently of it. In the vast majority of cases, it derives from stones that have formed in the gallbladder and migrated through the cystic duct. In a minority of cases, gallbladder stones are primary, that is, caused by stone formation directly within the main bile duct. This is more common when there is biliary stricture (narrowing), stenosis of the duodenal papilla (the structure that connects the main bile duct to the duodenum), or dysfunction of the sphincter of Oddi, which maintains continence of the papilla by preventing reflux of duodenal material towards its interior.
Choledocholithiasis causes bile stasis with a biliary tract infection.
Clinic
Often, stone obstruction is transient, and blood tests may be normal. Elevated levels of bilirubin and liver indices are often found, although all of these abnormalities are of no diagnostic value by themselves.
When choledocholithiasis causes biliary obstruction, symptoms consist of biliary colic and jaundice, with the appearance of dark urine and pale stools. When an infection occurs, cholangitis occurs, which is manifested by the appearance of a fever accompanied by chills. Preoperative ultrasonography is the primary radiological examination to reveal the presence of stones in the main bile duct. Endoscopic retrograde cholangiography (ERCP) is another reference method in preoperative diagnosis and can also constitute a therapeutic act (LINK ERCP).
Treatment
When ERCP alone is not feasible or ineffective, the surgery of choice is laparoscopic exploration of the main bile duct. This procedure is called rendezvous (from French, "crossing", "encounter") and consists of an ERCP with an associated laparoscopic cholecystectomy.
In more complex cases, when attempts to extract the stone(s) prove difficult, a flexible choledochoscope is inserted. It is continued into the main bile duct and, thanks to a small camera placed at its end, allows direct vision of the bile duct. The choledochoscope can be used to push the stone into the duodenal papilla, engaging it with a basket-shaped catheter. If a complete release of the main bile duct is achieved through the cystic, it will not be necessary to place an external biliary drain (T-shaped, according to Kehr).
If, on the other hand, an anterior choledochotomy is required (i.e., laparoscopic incision of the common bile duct with surgical removal of the stones), placement of the Kehr drain will be appropriate.
In the rare cases where endoscopic or laparoscopic techniques fail or are unavailable or impractical due to specific situations, open exploration of the main bile duct is required, with longitudinal choledochotomy with cholangiography demonstrating successful duct release. Main biliary exploration can sometimes be performed through a dilated cystic duct, avoiding choledochotomy and the placement of a biliary drain.
Multiple bile duct lithiasis, primary choledocholithiasis, and intrahepatic lithiasis will require a biliary drainage operation (RRoux-en-Y hepatic-jejunoanastomosis, transduodenal sphincteroplasty, or choledochoduodenoanastomosis).
INTRAHEPATIC LITHIASIS
Intrahepatic lithiasis consists of the presence of gallstones in the intrahepatic branches of the bile duct. It is associated with more common biliary diseases, such as benign strictures of the main bile duct, primary sclerosing cholangitis, choledochal cysts, and bile duct tumorsign strictures of the main bile duct, primary sclerosing cholangitis, choledochal cysts, and bile duct tumors. Predisposing factors for intrahepatic stone formation are bile stasis and bile duct infections.
Clinic
The classic and most common symptom is cholangitis (67%), that is, a biliary tract infection accompanied by fever with chills and pain in the right upper quadrant (63%). Jaundice (39%) and pruritus (6%) are associated but less frequent symptoms. The diagnosis is confirmed by ultrasound and endoscopic, percutaneous, or MRI cholangiography.
Treatment
The goal of treatment is the correction of the underlying biliary disease as well as the release of all calculi from the hepatic ducts. Often, achieving this goal requires repeated approaches. Surgical options include cholecystectomy, resection of extrahepatic bile duct strictures, neoplasms, and cysts, followed by choledochoscopy and removal of all intrahepatic stones.
Since some of these methods require resection of the extrahepatic bile duct, continuity between the common hepatic duct and the duodenum is restored by performing a biliodigestive anastomosis, which consists of surgical union between the remaining bile ducts and a jejunal loop (except Roux Y), with or without placement of transhepatic drainage or a hepatic-cutaneous catheter through a jejunostomy.
Liver resection may be necessary in the presence of prolonged biliary obstruction or segmental parenchymal atrophy. In about 50% of cases, additional combined procedures (percutaneous choledochoscopy with pneumatic dilation) are required to clear the intrahepatic bile ducts and treat residual persistent biliary strictures.