Gallstone disease: causes, symptoms, signs, classification, diagnosis and treatment

Gallstone disease (Cholelithiasis) is a multifactorial condition. It is characterized by bilirubin and cholesterol metabolism disorders with gallstones formation in the hepatobiliary system.

Gallstones risk factors

Cholelithiasis is associated with a range of risk factors. They include as follows:

1. Imbalanced diet. A diet high in trans fats, low-density lipoproteins (LDL), and very low-density lipoproteins (VLDL);
2. Low or a lack of physical activity;
3. Endocrine disorders accompanied by dyslipidemia;
4. Use of antiepileptic drugs;
5. Age;
6. Female sex;
7. Genetic predisposition;
8. Smoking and alcohol abuse;
9. Impaired bile outflow from the gallbladder.

Pathogenesis

Сalculi (stones) in the hepatobiliary system primarily associated with the presence of risk factors, which lead to the development of bile sludge.

Bile consists of fractions of bile acids, such as cholic, chenodeoxycholic and deoxycholic acids, as well as phospholipids, proteins, bilirubin, bioactive compounds, metals (zinc, copper, magnesium, etc.), and ions of sodium, chlorine and potassium. The process of bile formation occurs in hepatocytes.

Through the excretory ducts of the hepatobiliary system, bile enters the duodenum, where it emulsifies dietary fats and activates the enzymatic systems of the gastrointestinal tract. In this process, the gallbladder serves as a bile reservoir.

Calculi are formed secondary to biliary sludge when bile becomes too dense due to an unbalanced bile composition or impaired bile outflow from the hepatobiliary system in high-risk patients. Biliary sludge syndrome is associated with an imbalance among the components of bile.

Classification of gallstone disease

The classification of gallstone disease includes the morphological characteristics, the number of calculi, and the clinical presentation of the disease.

Based on the composition of gallstones:

1. Cholesterol gallstones;
2. Pigmented;
3. Mixed gallstones.

3D Models of gallstones Based on the gallstone composition:

Single cholesterol calculus in the gallbladder

Single pigment calculus in the gallbladder

Single mixed calculus in the gallbladder

Based on the number of calculi:

1. Single;
2. Multiple.
   

By clinical manifestations:

1. Asymptomatic gallstones;
2. With clinical signs and symptoms.

Clinical presentation

If a patient has no relevant complaints, cholelithiasis is considered asymptomatic. Since there are no specific signs, gallstones in the hepatobiliary system are often an accidental finding during a routine abdominal examination.

The clinical manifestations of the disease include the following symptoms:

• Pain syndrome;
• Dyspeptic disorders;
• (Frequently) jaundice;
• Fever.

The pain syndrome is characterised by colicky pains that vary in intensity and duration. As a rule, the pain is associated with food intake, particularly the consumption of fatty meals. Colicky pain is usually localised in the right hypochondrium; sometimes the pain may radiate to the right lumbar and right groin areas.

An episode of biliary colic may resolve spontaneously without the need for antispasmodic therapy. During an attack, the patient may develop a low-grade or, in some cases, a high-grade fever.

Jaundice as a symptom develops when the biliary tract is obstructed by gallstones. The mechanism of obstruction is purely mechanical. Such patients typically present with yellowish discoloration of the skin, scleral icterus, dark urine and acholic (pale) stools.

Dyspeptic manifestations are characterised by symptoms such as nausea, vomiting that does not bring relief, abdominal bloating, heartburn and decreased appetite.

Diagnosis of gallstone disease

Diagnosis of gallstone disease is based on physical examination, imaging and laboratory diagnostic methods.

Imaging and laboratory diagnostic methods:

1. Abdominal ultrasound;
2. Esophagogastroduodenoscopy (EGD);
3. Endoscopic retrograde cholangiopancreatography (ERCP);
4. Computed tomography (CT);
5. Magnetic resonance imaging (MRI);
6. Blood biochemistry (liver function tests);
7. Complete blood count (CBC).

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Treatment of gallstone disease

Gallstone disease may be treated both with non-surgical therapy and surgical interventions.

Non-surgical therapy

Lifestyle modification is a key component in the treatment of gallstone disease:

• Patients are advised to: avoid fatty, smoked and high-salt foods.
• Elimination of unhealthy habits: including alcohol withdrawal and smoking cessation

Pharmacological therapy involves several groups of medications, depending on the therapeutic goal:

• For pain relief: antispasmodic agents and nonsteroidal anti-inflammatory drugs (NSAIDs) are used;
• Pathogenetic therapy: includes the use of ursodeoxycholic acid agents.
• For the management of dyspeptic symptoms, prokinetic agents and proton pump inhibitors (PPIs) are prescribed;
• During exacerbations: infusion therapy is administered for detoxification purposes.
• As well, antibiotics are used to control infectious processes.

If conservative therapy appears ineffective, surgical intervention is indicated.

Surgical treatment

The main surgical procedures are aimed at removing the gallbladder or extracting stones from the bile ducts:

• Cholecystectomy : removal of the gallbladder. It may be performed either as an elective or emergency procedure. Two primary surgical access types are used:
  • Laparoscopic cholecystectomy is performed through small incisions and considered the “gold standard” technique.
  • Open (laparotomic) cholecystectomy is performed through a conventional abdominal incision.
• Choledocholithotomy: removal of stones from the common bile duct in cases where they have migrated from the gallbladder.

Sometimes, as part of an elective procedure, a patient may undergo a non-invasive treatment called lithotripsy that is the breaking up of stones using focused shock waves without any incisions. This method is used infrequently and is suitable only for certain types of gallstones.