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CHOLELITHIALIS
(Gall stones)

Gall stones are the most common biliary pathology. They are classified according to their chemical composition into:
  • Cholesterol stones:
    Consist almost entirely of cholesterol and are often solitary, large and smooth
  • Mixed stones:
    Mixed stones account for 90% of the gall stones, and cholesterol is their major component. Other components include Calcium bilirubinate, calcium phosphate, calcium carbonate, calcium palmitate and proteins. Usually they are multiple and faceted
  • Pigmented stones:
    Pigmented stones are composed almost entirely of calcium bilirubinate,, they are mostly small, black and multiple, some are hard and choral like (red, pink or white) while others are soft and really concretion of sludge (thick soft mud) rather than stones
Etiology:
  • Metabolic: (for cholesterol and mixed stones) Bile containing cholesterol stones have an excess of cholesterol relative to bile salts and phospholipids thus allowing cholesterol crystals to form, such bile is termed as supersaturated or lithogenic bile.
    • Conditions increasing bile cholesterol
      * Aging
      * Women especially those taking contraceptive pills
      * Obesity
      * Clofibrate (drug of treatment of hyperlilpoproteinemia)
    • Conditions decreasing bile salts in bile
      * Estrogen
      * Ileal disease
      * Resection or bypass of ileum
      * Cholestyramine therapy
  • Infection: The role of infection in causing stones is unclear.
  • Bile stasis: Gall bladders contractility is reduced by:
    * Estrogen
    * Pregnancy
    * Truncal vagotomy
    * Long term parenteral nutrition
  • For the pigmented stones: Hemolytic disorders in which bilirubin production is increased e.g.
    * Hereditary spherocytosis
    * Sickle cell anemia
    * Thalassemia
    * Malaria
    * Mechanical destruction of RBC by prosthetic heart valve
    * Benign and malignant strictures of biliary duct
    * Cirrhosis
    * Infestation of biliary tree by Ascaris Lumbricoides
    * E.Coli infection which produces β-glucoronidase which converts bilirubin in to unconjugated form
Complications:
  • In the gall bladder:
    •
    • Silent stones
    • Chronic cholecystitis
    • Acute cholecystitis (gangrene, perforation, empyema)
    • Mucocoeles
    • Hydrops of gall bladder
    • Carcinoma of gall bladder
  • In the bile duct:
    •
    • Obstructive jaundice
    • Cholangitis and multiple abscesses in the liver
    • Chronic pancreatitis
  • In the intestine:
    •
    • Acute intestinal obstruction (gall stone ileus)
    • Biliodigestive fistulas
    • Acute peritonitis
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This article has been written by Dr. M. Javed Abbas.
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18:55 09/02/2003