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GS46 General Surgery and Thoracic Surgery Biliary Tract Toronto Notes 2019 Biliary Tract
Risk Factors for Cholesterol Stones
4Fs Fat Female Fertile Forties
Cholelithiasis
Definition
• thepresenceofgallstones
Pathogenesis
• imbalanceofcholesterolanditssolubilizingagents(bilesaltsandlecithin)
• excesshepaticcholesterolsecretionrelativetobilesaltsandlecithin→supersaturatedcholesterolwhich
precipitates as gallstones
• NorthAmerica:cholesterolstones(80%),pigmentstones(20%)
Risk Factors
• cholesterolstones ■ obesity
■ age <50
■ estrogens: female, multiparity, OCPs
■ ethnicity: First Nations heritage (especially Pima Indians) > Caucasian > Black ■ terminal ileal resection or disease (e.g. Crohn’s disease)
■ impaired gallbladder emptying: starvation, TPN, DM
■ rapid weight loss: rapid cholesterol mobilization and biliary stasis
• pigmentstones(containcalciumbilirubinate) ■ cirrhosis
■ chronic hemolysis
■ biliary stasis (strictures, dilation, biliary infection)
■ protective factors: statins, vitamin C, coffee, exercise
Common hepatic duct Cystic duct Gallbladder CBD
Sphincter of Oddi Ampulla of Vater
© Merry Shiyu Wang 2012
Figure 25. Gallstone disease
Clinical Presentation
Ligament of Treitz Pancreas
Pancreatic duct
Duodenum
Cholelithiasis/Cholecystitis
Choledocholithiasis/Cholangitis
Cholecystoenteric fistula may lead to gallstone ileus
Summary of Biliary Tract Conditions
• asymptomatic(80%):foundincidentally
■ 18% risk of progression to symptomatic gallstone disease within 20 yr
■ most do NOT require treatment
■ consider cholecystectomy if: increased risk of malignancy (choledochal cysts, Caroli’s disease,
porcelain or calcified gallbladder), sickle cell disease, pediatric patient, bariatric surgery, and
immunosuppression
• biliarycolic(10-25%)
• cholecystitis
• choledocholithiasis(8-15%)
• cholangitis
• gallstonepancreatitis(seeAcutePancreatitis,GS51)
• gallstoneileus(0.3-0.5%)
• other:empyemaofthegallbladder,liverabscess,andgallbladderperforationwithbileperitonitis
Gall Bladder
Cholelithiasis Biliary Colic Cholecystitis
Common Bile Duct
Choledocholithiasis Cholangitis
Asymptomatic
Pain Only
Infection + Pain
✓
Infection + Pain
✓(majority)
✓(majority)
✓
Asymptomatic
✓(majority)
Pain Only
✓