Incidence	- present in 10-20% of the population in the West
Age
Sex	- in young people, F > M - difference decreases with increasing age
Geography	- rare in Far East and Africa - common in native North Americans, in Chile and Sweden
Aetiology	Cholesterol gallstones - > 70% cholesterol, often with some bile pigment and calcium - cholesterol is synthesized in liver, small intestine, skin and adrenals - cholesterol is secreted into bile ducts with phospholipids in unilamellar vesicles - stones develop only in bile that has an excess of cholesterol relative to bile salts and phospholipids (supersaturated bile) - this is due either to excess cholesterol or reduced bile salts - in supersaturated bile, bile salts solubilize phospholipids more than cholesterol - unilamellar vesicles become unstable and fuse -> seeds for cholesterol crystals - risk factors include age, F > M, multiparity, obesity, rapid weight loss, diet, OCP, ileal disease or resection, diabetes, acromegaly treated with octreotide, liver cirrhosis Bile bigment stones - black pigment stones contain calcium salts of bilirubin, phosphate, carbonate, bilirubin polymers and mucin glycoproteins; they form in the gallbladder and are seen in patients with chronic haemolysis - brown pigment stones contain cholesterol, calcium salts of fatty acids and calcium bilirubinate; they form in the common bile duct when there is bile stasis and infected bile; also found with strictures, sclerosing cholangitis, Caroli's syndrome
Presentation	- in 80%, gallstones remain within the gallbladder and are asymptomatic - impaction in the neck of the gallbladder or cystic duct gives biliary pain or acute cholecystitis - impaction in the common bile duct can give rise to biliary obstruction ± cholestatic jaundice - bacterial infection -> cholangitis - biliary "colic" occurs in epigastrium and R hypochondrium and is not colicky - rarely, stones may perforate from an inflamed gallbladder into the intestine -> fistula
Investigations
Macro
Micro
Staging
Serum markers
Management	Stones in gallbladder Cholecystectomy - laparoscopic - mini laparotomoy Gallstone dissolution or disruption - cholesterol gallstones can be dissolved with chenodeoxycholic acid and ursodeoxycholic acid (not calcified stones); takes 6 months - 2 years, 50% of gallstones recur on stopping treatment - shock-wave treatment using ultrasound-guided lithotriptors Stones in the common bile duct - found in approx 15% of patients undergoing cholecystectomy - patients likely to have CBD stones should have their common bile ducts visualised directly by ERCP, with sphincterotomy, removal of stones using a Dormia basket, and sweeping of the duct with a balloon - in patients who require cholecystectomy, laparoscopic CBD exploration should be performed at the same time - in the persistently jaundice patient, CDB stones are removed endoscopically before cholecystectomy
Prognosis	- asymptomatic gallstones tend to remain asymptomatic and require no treatment - laparoscopic cholecystectomy - mortality < 0.1%
Complications	Laparoscopic cholecystectomy - wound sepsis, bile duct injury, retained gallstones in CBD

Hepatobiliary medicine

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