Ultrasonography of the gall bladder is the procedure of choice for the detection of stones due to several advantages over oral cholecystography (OCG). It can detect stones as small as 2mm in diameter, billiary sludge and access the emptying function of gallbladder. Plain abdominal film may detect gallstones containing sufficient calcium to be radio opaque (10 to 15% of cholesterol and approx 50% of pigment stones). Radio isotopes scan (HIDA, DIDA, DISIDA, etc. ) have their greatest application in the diagnosis of acute cholecystitis. (Guido Adler, 2004) Signs and Symptoms:
Most of the time gallstone is silent and asymptomatic however it produces symptoms by causing inflammation of obstructions following their migration into the cystic duct or common bile duct. The most specific and characteristic symptom of gallstone disease is billiary pain. Pain characterized by a severe steady ache or fullness in the epigastrium or right upper quadrant of the abdomen with frequent radiation to the interscapular area, right scapula or shoulder. This billiary pain begins quite suddenly may persist with severe intensity for 30mins to 5 hrs subsiding gradually or rapidly.
Nausea and vomiting frequently accompany episodes of billiary pain. Billiary pain may be precipitated by eating a fatty meal, large meal following a period of prolonged fasting or eating a normal meal. It is frequently nocturnal. On physical examination in symptomatic patients of acute cholecystitis there is marked tenderness in right upper quadrant with localized guarding, positive Murphy’s sign that is sudden inspiratory arrest with palpation of right subcostal region. (Lawrence M. Tierney, Jr. , Stephen J. McPhee, Maxine A. Papadakis, 1996) Lab test:
Laboratory investigations usually ordered in a clinical setup in a patient with gallstone are complete blood count (CBC), liver function test (LFT) and serum amylase level. Family History: A high prevalence of gallstones is found among first degree relatives of gallstones carriers and in certain ethnic populations such as American-Indians as well as Chilean-Indians and Chilean Hispanics. A common genetic trait has been identified for some of these populations by mitochondrial DNA analysis. Demographically it is most common in residents of Europe than the residents of North America and Asia.
(Alan C. Swedlund, George J. Armelagos, 1990) Treatment: Treatment options for gallstones have previously included only open abdomen surgery that is choeicystectomy and clinical observation. Nowadays laparoscopic cholecystectomy is also being practiced having a minimal access approach for the removal of gallbladder with its stone. Recently several non-surgical methods have been employed to dissolve or fragment gallstones. These include the use of UDCA which is cholelitholitic (stone dissolving) bile acids, transhepatic puncture of gallbladder with instillation of methyl ter-butyl ether.
Most recently fragmentation of gallstones is being practiced by extracorporeal shock waves (lithotripsy). Lithotripsy combined with medical litholitic therapy is safe and effective in carefully selective patients with gallstones (radiolucent, solitary stones less than 2 cm in well contracting gallbladder). (Edward L. Bradley III, 1994) Prognosis: Prognosis of gallstones varies from patient to patient depending upon the stage of presentation. It may lead to acute and chronic cholecystitis, obstructive jaundice, acute pancreatitis and carcinoma of gallbladder.
An uncommon complication is gallstone ilues, the development of mechanical bowel obstruction due to impaction of a gallstone > 2. 5cm in diameter in the intestinal lumen. The gallstone nearly always enters via a cholecystoduodenal fistula, and the stone typically becomes impacted in ileum. (Manila Bulletin, 2005)
References:
“Gallstones”; Newspaper article; Manila Bulletin, October 9, 2005 Alan C. Swedlund, George J. Armelagos. Disease in Populations in Transition: Anthropological and Epidemiological Perspectives; Bergin & Garvey, 1990 Edward L. Bradley III.
A Patient’s Guide to Surgery; University of Pennsylvania Press, 1994 Eve A. Kerr, Steven M. Asch, Eric G. Hamilton, Elizabeth A. Mcglynn. Quality of Care for General Medical Conditions: A Review of the Literature and Quality Indicators; Rand, 2000 Guido Adler. Gallstones: Pathogenesis and Treatment; Springer, 2004 Lawrence M. Tierney, Jr. , Stephen J. McPhee, Maxine A. Papadakis. Current medical diagnosis and treatment; 35th Edition; Appleton Lange medical book, 1996 Vinay Kumar, Ramzi S. Cotran, Stanley L. Robbins. Robbins Basic Pathology. 7th edition; Saunders, 2004