Description
Gallbladder stones, or gallstones, are crystalline concretions formed within the gallbladder by accretion of bile components. These stones can vary in size from as small as a grain of sand to as large as a golf ball and are primarily composed of cholesterol, bilirubin, or a mix of both. The exact cause of gallstone formation is not fully understood, but risk factors include obesity, rapid weight loss, a diet high in fat and cholesterol, diabetes, and certain genetic predispositions. Gallstones can remain asymptomatic, but when they obstruct the bile ducts, they can cause severe pain known as biliary colic, typically felt in the upper right abdomen. Complications from gallstones include cholecystitis (inflammation of the gallbladder), pancreatitis (inflammation of the pancreas), and cholangitis (infection of the bile ducts). Diagnosis is commonly achieved through ultrasound imaging, which can reveal the presence of stones, and other imaging techniques like CT scans or MRIs. Treatment options vary depending on the severity and symptoms; they range from conservative management with dietary changes and medications to surgical interventions, the most common being cholecystectomy, the surgical removal of the gallbladder. Non-surgical treatments like lithotripsy or bile acid pills to dissolve stones are less commonly used. Preventive measures include maintaining a healthy weight, a balanced diet, and regular physical activity. Gallstones are a prevalent condition, especially among women and older adults, often necessitating medical attention to manage symptoms and prevent complications.
Résumé
- Gallbladder stones are more common in females, particularly those over 40, but are increasingly seen in various age groups and both sexes. There are two main types: cholesterol stones, which are most prevalent overall, and pigment stones. Pigment stones, especially brown pigmented stones, are more common in Asian populations due to bacterial or parasitic infections and stasis from partial biliary obstruction.
- The formation of cholesterol stones is primarily due to four factors: supersaturation of secreted bile, concentration of bile in the gallbladder, crystal nucleation, and gallbladder dysmotility. Pigment stones, on the other hand, result from bacterial infections that lead to the deconjugation of bilirubin and the formation of calcium bilirubinate complexes.
- Genetic factors can contribute to gallbladder stone development in about 30% of cases. Excess cholesterol in the blood, altered gallbladder motility (as seen in pregnancy), rapid weight changes, and intestinal factors affecting cholesterol absorption also play a role. Risk factors include age, female sex (due to estrogen and progestin effects), and certain medical conditions like cirrhosis.
- Most patients with gallstones (around 80%) are asymptomatic, and only 2-3% develop symptoms annually. Common symptoms include biliary colic (episodic right abdominal pain), dyspepsia, and, in advanced stages, vomiting. Complications of untreated gallstones can include acute cholecystitis, pancreatitis, and obstructive jaundice.
- Diagnosis is primarily through abdominal ultrasound, which is about 95% accurate. In cases where ultrasound is inconclusive, MRCP or endoscopic ultrasound may be used. Acute cholecystitis, often diagnosed using the Tokyo guidelines, can be graded based on organ dysfunction, with management varying from antibiotics and observation to early or delayed cholecystectomy.
- The management of acute cholecystitis involves antibiotics and cholecystectomy, with early cholecystectomy (within 7 days) being increasingly favored. Acalculous cholecystitis, more common in critically ill patients, is managed differently, often with percutaneous drainage followed by selective cholecystectomy based on follow-up imaging.
- Symptomatic gallstones are generally treated with cholecystectomy. Exceptions include cases of sickle cell disease, total parenteral nutrition, chronic immunosuppression, and those with no immediate access to healthcare. Absolute contraindications to laparoscopic cholecystectomy include the inability to tolerate general anesthesia and refractory coagulopathy. Relative contraindications include prior upper abdominal surgery, cholangitis, cirrhosis, pregnancy, and morbid obesity.
- The surgical procedure involves defining Calot's triangle and achieving a critical view of safety, ensuring only the cystic duct and artery enter the gallbladder. If the critical view of safety cannot be achieved, a subtotal cholecystectomy may be performed. Complications of laparoscopic cholecystectomy can include bleeding, bile leaks, bile duct injuries, and visceral injuries.
Exemple de certificat
À propos des intervenants
Dr Prasad Neelam
Directeur général, Gastroentérologie chirurgicale, Sravani Hospitals, Hyderabad
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