Table of contents · 10 sections
In a nutshell. Cholelithiasis is the formation of stones in the gallbladder and/or bile ducts. 80% of stones are cholesterol stones. Clinical presentation: from asymptomatic carrier state to biliary colic, acute cholecystitis, and choledocholithiasis with obstructive jaundice. Diagnostics: ultrasound. Treatment: laparoscopic cholecystectomy. In acute cholecystitis according to TG18: within the first 72 hours.
1. Epidemiology and Risk Factors
Gallbladder disease (cholelithiasis) occurs in 10–15% of the adult population in developed countries. F:M ratio = 2–3:1. Peak incidence is at 40–60 years.
Classic risk factors (the "6F" rule): Female, Forty, Fertile (multipara), Fat, Fair, Family history. Additional: rapid weight loss, parenteral nutrition, estrogen intake, diabetes mellitus, cirrhosis, Crohn's disease with ileal resection.
2. Pathogenesis of Gallstone Formation
Cholesterol stones (80%)
Conditions for formation: supersaturation of bile with cholesterol (with decreased synthesis of bile acids or phospholipids), bile stasis in the gallbladder, impaired gallbladder motility, nucleation around mucin or calcium salts.
Pigment stones (20%)
- Black stones: in hemolytic anemias, cirrhosis (↑ unconjugated bilirubin).
- Brown stones: in biliary tract infections (parasitic, bacterial), more frequently in the ducts.
3. Disease Forms
- Gallstone carriers (asymptomatic cholelithiasis) — 60–80% of patients.
- Chronic calculous cholecystitis — "latent" colic, dyspepsia after fatty food.
- Biliary colic — pain attack without inflammation.
- Acute cholecystitis — inflammation of the gallbladder wall: catarrhal, phlegmonous, gangrenous.
- Choledocholithiasis — stone in the common bile duct → obstructive jaundice, cholangitis.
- Biliary pancreatitis — stone in the ampulla of Vater with impaired outflow of pancreatic secretion.
- Mirizzi syndrome — compression of the common bile duct by a stone in the neck of the gallbladder.
4. Clinical presentation
Biliary Colic
- Intense pain in the right upper quadrant / epigastrium, radiating to the right scapula and shoulder.
- Triggered by fatty or fried food.
- Duration: 30 minutes – 6 hours.
- Nausea, vomiting that does not bring relief.
- Normal temperature (unlike acute cholecystitis).
Acute cholecystitis
- Prolonged (> 6 h) pain in the right upper quadrant.
- Fever, leukocytosis, ↑ CRP.
- Murphy's sign: inspiratory arrest upon deep palpation in the projection area of the gallbladder.
- Ortner's sign (pain on percussion over the right costal margin), Kerley's sign.
- Jaundice possible (with concomitant choledocholithiasis), peritoneal signs in case of perforation.
5. Diagnostics
| Method | Role |
|---|---|
| Abdominal Ultrasound | Method of choice: sensitivity > 95% for gallbladder stones; signs of acute cholecystitis include wall thickening > 4 mm, pericholecystic fluid, ultrasound Murphy's sign. |
| Complete Blood Count | Leukocytosis, left shift. |
| Biochemistry | ↑ bilirubin, ALP, GGT — suspicion of choledocholithiasis; ↑ amylase — biliary pancreatitis. |
| MRCP | Non-invasive imaging of the bile ducts — indicated when choledocholithiasis is suspected. |
| ERCP | Diagnostic + therapeutic (papillosphincterotomy, stone extraction). |
| CT | In case of complications (empyema, perforation), diagnosis of gangrene. |
6. Severity Classification of Acute Cholecystitis (TG18)
| Grade | Criteria |
|---|---|
| Grade I (Mild) | No organ dysfunction, no prominent local inflammation |
| Grade II (Moderate) | Leukocytosis > 18 × 10⁹/L, palpable mass, duration of symptoms > 72 h, local complications (pericholecystic abscess, gangrene) |
| Grade III (Severe) | Organ dysfunction: cardiovascular, neurological, respiratory, renal, hepatic, hematological |
7. Treatment
Elective Cholecystectomy
Indications: symptomatic cholelithiasis (colic, dyspepsia), history of complications, "porcelain" gallbladder (risk of carcinoma), polyps > 10 mm, combination with diabetes mellitus, organ transplantation.
Method of choice is laparoscopic cholecystectomy: 4 ports, conversion to open surgery < 5%. Advantages: minimal trauma, short hospital stay (1–2 days), rapid rehabilitation.
Management of acute cholecystitis
- Hospitalization, bowel rest, infusion therapy.
- Broad-spectrum antibiotic therapy: ceftriaxone + metronidazole, piperacillin/tazobactam.
- Analgesia (NSAIDs, tramadol for severe pain).
- Early laparoscopic cholecystectomy within the first 72 hours is the standard for Grade I–II.
- For Grade III or surgical contraindications — ultrasound-guided percutaneous cholecystostomy as a "bridge" to elective surgery.
Choledocholithiasis
- ERCP with papillosphincterotomy and stone extraction.
- Followed by elective cholecystectomy (during the same or subsequent hospitalizations).
- Alternative: "rendez-vous" technique — intraoperative cholangiography with single-session stone removal.
8. Complications
- Gallbladder empyema — accumulation of pus.
- Gangrenous cholecystitis with perforation → biliary peritonitis.
- Cholecystenteric fistula (with the duodenum) → gallstone ileus (Bouveret syndrome / gallstone obstruction).
- Cholangitis (Charcot's triad: right upper quadrant pain, jaundice, fever; Reynolds' pentad adds hypotension and altered mental status).
- Acute biliary pancreatitis.
- Mirizzi syndrome (types I–V according to McSherry).
- Gallbladder carcinoma (5–10x risk with "porcelain" gallbladder, long-standing gallstones).
9. Postoperative period and complications
- Early: hemorrhage, bile leak, common bile duct injury (0.1–0.5%).
- Late: postcholecystectomy syndrome — dyspepsia, diarrhea, right upper quadrant pain; causes include residual choledocholithiasis, papillary stenosis, functional disorders.
10. FAQ
Should an asymptomatic gallstone carrier undergo surgery?
No, in most cases. Indications for elective surgery: stones > 3 cm, polyps > 10 mm, "porcelain" gallbladder, diabetes mellitus, immunosuppression, planned transplantation.
Can gallstones be dissolved?
Only cholesterol stones (< 1.5 cm) in patients with preserved gallbladder function using ursodeoxycholic acid preparations. Success rate is 30–60%, course of treatment is 6–12 months. High recurrence rate after discontinuation.
Which is better — laparoscopy or open surgery?
Laparoscopic in 95% of cases. Open — for severe anatomical challenges, previous extensive abdominal surgeries, or conversion.
How to differentiate biliary colic from acute cholecystitis?
Colic resolves within 6 hours without fever. In acute cholecystitis, pain lasts > 6 hours + fever + leukocytosis + ultrasound findings.
When is ERCP indicated?
In confirmed or high-probability choledocholithiasis (common bile duct dilation > 7 mm, bilirubin > 40 µmol/L, stone on MRCP), and in cholangitis.
See also: Acute abdomen · Peritonitis · Abdominal hernias · Acute pancreatitis · Surgery catalog · Clinical scales