Page 3 - 05- Cholelithiasis

rapid weight loss
Hereditary (p.D19H variant for the hepatic canalicular cholesterol transporter ABCG5/ABG8)
Short gut syndrome, terminal ileal resection, IBD
Hemolytic disorders (hereditary spherocytosis, sickle cell anemia, etc.), cirrhosis
(black/pigment stones)
Medications (birth control pills, estrogen replacement therapy at high doses, and long-term
corticosteroid or cytostatic therapy)
Viral hepatitis, biliary tract infection, and stricture (promotes intraductal formation of pigment
stones)

GENERAL PREVENTION
Ursodiol (Actigall) taken during rapid weight loss prevents gallstone formation.
Regular exercise and dietary modification may reduce the incidence of gallstone formation.
Lipid-lowering drugs (statins) may prevent cholesterol stone formation by reducing bile
cholesterol saturation.

COMMONLY ASSOCIATED CONDITIONS
90% of people with gallbladder carcinoma have gallstones and chronic cholecystitis.

DIAGNOSIS

HISTORY
Mostly asymptomatic (80%): 2% become symptomatic each year. Over their lifetime, <50% of
patients with gallstones develop symptoms.
Episodic right upper quadrant or epigastric pain lasting >15 minutes and sometimes radiating
to the back (biliary colic—due to transient cystic duct obstruction)
Pain is usually postprandial.
Pain sometimes awakens patients from sleep.
Most patients develop recurrent symptoms after a first episode of biliary colic.
Other symptoms include nausea, vomiting, indigestion or bloating sensation, and fatty food
intolerance.

PHYSICAL EXAM
Physical exam is usually normal in patients with cholelithiasis in the absence of an acute
attack.
Epigastric and/or right upper quadrant tenderness (Murphy sign) is a traditional physical
finding associated with acute cholecystitis. Murphy sign has limited sensitivity and specificity.
Charcot triad: fever, jaundice, right upper quadrant pain historically associated with cholangitis
Reynolds pentad: fever, jaundice, right upper quadrant pain, hemodynamic instability, mental
status changes; also classically associated with ascending cholangitis
Flank and periumbilical ecchymoses (Cullen sign and Grey Turner sign) in patients with acute
hemorrhagic pancreatitis
Courvoisier sign: palpable mass in the right upper quadrant in patient with obstructive jaundice
most commonly due to malignant tumors within the biliary tree or pancreas

DIFFERENTIAL DIAGNOSIS
Peptic ulcer diseases and gastritis