Cholelithiasis (Gallstones)
• Mahfooz Medical Health • Audience: Clinicians, MBBS/MD students, and informed patients
Introduction / परिचय
Cholelithiasis (Gallstones) पित्ताशय में बनने वाली ठोस पथरियों (stones) को कहते हैं। ये cholesterol stones, pigment stones (bilirubin-derived) या mixed composition के हो सकते हैं। अधिकांश gallstones asymptomatic रहते हैं पर कुछ में biliary colic, acute cholecystitis, choledocholithiasis या gallstone pancreatitis जैसी गंभीर complications हो सकती हैं।
Note (हिंदी): Asymptomatic gallstones में routine surgery जरूरी नहीं; symptomatic cases में definitive treatment laparoscopic cholecystectomy है।
Epidemiology / प्रसार
Global prevalence western populations में ~10–20% है; developing countries में कम लेकिन risk factors (obesity, metabolic syndrome, older age) के बढ़ने से incidence बढ़ रही है। महिलाओं, multiparous women, और obese individuals में prevalence ज्यादा होता है। Rapid weight loss (bariatric surgery, crash diets), TPN, hemolytic anemias जैसे factors risk बढ़ाते हैं।
Etiology / कारण
- Cholesterol supersaturation of bile — most common mechanism.
- Increased cholesterol secretion (obesity, OCP, estrogen therapy, pregnancy).
- Gallbladder hypomotility / stasis (prolonged fasting, TPN, critical illness).
- Pigment stones: hemolysis (sickle cell), cirrhosis, infections.
- Genetic predisposition and ileal disease / resection increasing enterohepatic bile salt loss.
Mnemonic (Hindi/English): 4Fs — Female, Fat (obesity), Fertile (pregnancy/OCP), Forty — traditional risk factors.
Pathophysiology / रोगजनन (MBBS/MD level)
Stone formation के तीन मुख्य चरण हैं:
- Bile supersaturation: cholesterol > solubilizing bile salts and phospholipids → cholesterol crystallization.
- Nucleation: cholesterol microcrystals aggregate—mucin and calcium salts act as nidus.
- Gallbladder hypomotility: stasis favors growth and retention of crystals → stone formation.
Histopathology (complications): chronic cholecystitis में Rokitansky-Aschoff sinuses, fibrosis और wall thickening दिखते हैं; empyema और gangrene severe inflammation के रूप हैं।
Clinical features / लक्षण
Most gallstones asymptomatic रहते हैं। Symptomatic spectrum:
- Biliary colic: severe episodic RUQ or epigastric pain, often after fatty meal; may radiate to right scapula; lasts 30 min – several hours; patient restless.
- Acute cholecystitis: persistent RUQ pain, fever, leukocytosis, Murphy's sign positive.
- Choledocholithiasis: stone in common bile duct → obstructive jaundice, dark urine, pale stools.
- Ascending cholangitis: Charcot triad (fever, jaundice, RUQ pain); Reynolds pentad adds hypotension and altered mental status — medical emergency.
- Gallstone pancreatitis: epigastric pain radiating to back, raised amylase/lipase.
Clinical tip: Biliary colic patient is restless; peritonitis patient prefers to lie still — important bedside distinction.
Investigations / जाँच
First-line
- RUQ Ultrasound (USG): best initial test—high sensitivity for gallstones, demonstrates acoustic shadowing, gallbladder wall thickening, pericholecystic fluid.
- Liver function tests (LFTs): bilirubin, ALP, GGT, AST/ALT to assess obstruction or cholestasis.
When further imaging is needed
- MRCP: non-invasive for CBD stones when US equivocal or dilated ducts seen.
- EUS: high sensitivity for microlithiasis / small CBD stones.
- ERCP: diagnostic + therapeutic for choledocholithiasis and cholangitis (stone extraction, sphincterotomy, stenting).
- HIDA (hepatic iminodiacetic acid) scan: useful to confirm cystic duct obstruction/acalculous cholecystitis.
Bloods
- CBC (leukocytosis in infection), serum amylase/lipase (pancreatitis), coagulation profile if planning intervention.
Differential diagnosis / अलग diagnosis
- Peptic ulcer disease / GERD
- Right lower lobe pneumonia (referred pain)
- Hepatitis / hepatic abscess
- Cardiac ischemia (atypical epigastric pain)
- Pancreatitis (if epigastric severe radiating to back)
Management overview / उपचार का सार
Management tailored to presentation:
- Asymptomatic gallstones: conservative — counsel and observe; surgery not routinely indicated.
- Symptomatic biliary colic: consider elective laparoscopic cholecystectomy if recurrent / severe.
- Acute cholecystitis: hospitalize, IV fluids, analgesia, antibiotics if infected; early laparoscopic cholecystectomy within 72 h if fit, else delayed.
- Choledocholithiasis / cholangitis: ERCP with biliary decompression — urgent if cholangitis.
- Gallstone pancreatitis: supportive care (IV fluids, analgesia); cholecystectomy during same admission for mild cases after stabilization.
Medical treatment — details, doses, timing & duration
Medical options are limited; surgical removal remains definitive for symptomatic disease. Medical therapy acceptable in selected high-risk surgical patients or those refusing surgery.
1) Ursodeoxycholic acid (UDCA)
- Indication: small cholesterol stones, functioning gallbladder, patients unfit for surgery.
- Dose: 8–10 mg/kg/day oral in divided doses (e.g., 300 mg BD for 70 kg patient ≈ 600 mg/day).
- Timing & duration: daily, long-term (6–24 months) required for dissolution; monitor by serial USG.
- Limitations: slow, recurrence common after stopping; ineffective for pigment and large stones (>2–3 cm).
2) Analgesia for biliary colic
- Paracetamol: 1 g oral/IV as initial analgesic (q6–8h as needed, max 3 g/day depending on local guidelines).
- NSAIDs (e.g., Diclofenac): Diclofenac 75 mg IM stat or 50 mg oral TDS for short course (unless contraindicated — renal impairment, peptic ulcer, bleeding risk).
- Opioids: Tramadol 50–100 mg IM/PO or if severe morphine under monitoring; avoid meperidine due to neurotoxic metabolites.
3) Antibiotics (for cholecystitis/cholangitis)
- Acute uncomplicated cholecystitis (mild): ceftriaxone 1–2 g IV OD OR cefuroxime 1.5 g IV OD plus metronidazole 500 mg TDS — local antibiogram dependent.
- Severe / cholangitis: broad-spectrum cover (piperacillin-tazobactam 4.5 g IV q6–8h or carbapenem if ESBL risk) and urgent ERCP for source control.
- Duration: 5–7 days for uncomplicated; longer if complicated or based on culture results.
4) ERCP-related prophylaxis
- To reduce post-ERCP pancreatitis risk: rectal indomethacin 100 mg PR immediately (unless contraindicated) and periprocedural aggressive IV hydration as per center protocol.
Surgical management — Laparoscopic cholecystectomy & perioperative care
Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gallstones and many cases of acute cholecystitis. Key surgical points:
- Indications: symptomatic gallstones, acute cholecystitis, choledocholithiasis after ERCP or synchronous management, gallstone pancreatitis (after stabilization).
- Timing: Early LC within 72 h of presentation for acute cholecystitis when feasible; otherwise delayed elective LC 6–12 weeks after initial conservative therapy.
- Technique: 4-port LC, emphasize critical view of safety (CVS) to avoid bile duct injury.
- IOC (intraoperative cholangiography): optional for suspected CBD stones or unclear anatomy; reduces retained stone risk.
Perioperative optimization
- Pre-op: optimize diabetes, BP, correct coagulopathy, NPO instructions, prophylactic antibiotics if indicated (single dose cefazolin 1–2 g IV within 60 min before incision in elective cases per local policy).
- Post-op: early ambulation, multimodal analgesia (paracetamol ± low-dose opioid), discharge typically 24–48 h if uncomplicated.
- Complications: wound infection, bleeding, postoperative bile leak, retained stones, post-cholecystectomy diarrhea (usually self-limited), rare bile duct injury — requires specialist management.
ERCP — Endoscopic management of choledocholithiasis
ERCP indicated for symptomatic CBD stones, obstructive jaundice, and cholangitis. Steps include sphincterotomy, stone extraction (balloon/basket), and stent placement if needed. Post-ERCP pancreatitis prevention and recognition are critical.
Note: In many centres ERCP is used pre- or post-cholecystectomy depending on local practice and stone burden.
Diet & lifestyle — क्या खाएँ और क्या बचाएँ (Practical advice)
During symptomatic period
- Avoid fatty, fried and very spicy meals — typical trigger for biliary colic.
- Prefer small frequent meals rather than large fatty meals.
- Hydration and rest; avoid alcohol in symptomatic phase.
After cholecystectomy (post-op)
- Start with clear fluids → soft diet → normal diet as tolerated over 24–72 h; reintroduce fats gradually.
- Most patients tolerate normal diet long-term; a minority may experience bile acid diarrhea — treat with loperamide or bile acid sequestrants (cholestyramine) if persistent.
Prevention
- Avoid crash diets — prefer gradual weight loss; bariatric patients should be monitored.
- Maintain healthy body weight, balanced diet rich in fiber, and regular physical activity.
Hindi note: \"Zyada tel, fried cheezein se bachiye; healthy fats (nuts, olive oil in moderation) aur fiber rich diet faydemand hain.\"
Complications & emergency signs — कब doctor ko dikhana चाहिए
- Ascending cholangitis: fever, jaundice, RUQ pain — emergency ERCP + IV antibiotics.
- Gallstone pancreatitis: severe epigastric pain, vomiting — resuscitate and refer to HDU/ICU as needed.
- Empyema or gangrenous cholecystitis: systemic toxicity — urgent surgical intervention.
- Bile duct injury: post-op abdominal pain, biliary leak signs — urgent imaging and surgery referral.
Special situations / विशेष परिस्थितियाँ
Pregnancy
Conservative approach preferred initially. If surgery required, second trimester safest window for laparoscopic cholecystectomy. ERCP with fetal shielding is acceptable for cholangitis/obstruction with multidisciplinary care.
Elderly & high-risk patients
Balance surgical risk vs symptom burden. Percutaneous cholecystostomy (radiologically guided) can be life-saving temporary measure in critically ill or unfit patients with acute cholecystitis.
Clinical pearls / परीक्षा और क्लिनिकल नुक्ते
- Biliary colic typically occurs after fatty meals and is colicky; patient restless during attack.
- Murphy's sign supportive for acute cholecystitis — not fully sensitive/specific.
- Charcot triad (fever, jaundice, RUQ pain) — think cholangitis; Reynolds pentad adds hypotension/altered mental status (urgent!).
- Asymptomatic stones rarely need prophylactic cholecystectomy except in high-risk groups (porcelain gallbladder, primary sclerosis cholangitis, large stones >3 cm).
Investigations cheat-sheet / Quick reference
| Test | Indication / Use |
|---|---|
| RUQ Ultrasound | First-line — detect gallstones, GB wall changes, pericholecystic fluid |
| LFTs | Assess obstructive pattern — ALP, GGT, bilirubin |
| MRCP / EUS | Detect CBD stones if US unclear |
| ERCP | Therapeutic for CBD stones / cholangitis |
| HIDA scan | Confirm cystic duct obstruction or acalculous cholecystitis |
Related Articles / संबंधित लेख (Internal Linking)
नीचे संबंधित posts हैं — इन्हें पेज के बीचों-बीच भी उपयुक्त जगहों पर लिंक किया गया है जहाँ keywords आए हैं (site-wide internal linking के लिए)।
FAQs / अक्सर पूछे जाने वाले प्रश्न
Q1: क्या gallstones बिना surgery के dissolve हो सकते हैं?
A: कुछ छोटे cholesterol stones Ursodeoxycholic acid (UDCA) से dissolve हो सकते हैं पर treatment लंबा होता है (6–24 months) और recurrence आम है। Definitive option symptomatic patients के लिए cholecystectomy है।
Q2: Pregnancy में gallstone दर्द आए तो क्या करें?
A: Conservative management first-line — pain relief (paracetamol), IV fluids if required; surgery अगर necessary हो तो second trimester consider करें; multidisciplinary management जरूरी है।
Q3: Choledocholithiasis में first step क्या है?
A: If obstructive jaundice or cholangitis suspected — urgent ERCP for biliary decompression and stone extraction; start IV antibiotics.
Conclusion / निष्कर्ष
Cholelithiasis common surgical/gastrointestinal problem है। Accurate diagnosis (primarily RUQ USG), prompt management of complications (ERCP for obstructive disease, early cholecystectomy for symptomatic cases) और proper perioperative optimization essential हैं। Prevention में lifestyle modification, controlled weight loss और avoiding rapid weight loss महत्वपूर्ण भूमिका निभाते हैं।