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| | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=cholelithiasis resident survival guide]]|| <br> || <br> |
| | | [[Cholelithiasis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| {{DiseaseDisorder infobox | | {{DiseaseDisorder infobox |
| | Name = Gallstone | | | Name = Gallstone |
| | ICD10 = {{ICD10|K|80||k|80}}
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| | ICD9 = {{ICD9|574}}
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| | ICDO =
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| | Image = Gallensteine 2006 03 28.JPG | | | Image = Gallensteine 2006 03 28.JPG |
| | Caption = gallstones | | | Caption = Gallstones <br> Source: commons.wikimedia.org by Stell98 https://commons.wikimedia.org/w/index.php?curid=666259 |
| | OMIM = 600803
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| | MedlinePlus = 000273
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| | eMedicineSubj = emerg
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| | eMedicineTopic = 97
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| | DiseasesDB = 2533
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| }} | | }} |
| {{SI}} | | |
| | {{Gallstone disease}} |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} | | {{CMG}}; {{AE}} {{HM}} |
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| '''''Synonyms and related keywords''''': Cholecystolithiasis, choleliths, cholelithiasis, Biliary colic.
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| ==Overview==
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| Gallstones is the presence of gallstones ([[cholelithiasis]]) within the gallbladder. Gallstones are [[crystalline]] bodies formed within the body by accretion or concretion of normal or abnormal [[bile]] components. is Gallstones can occur anywhere within the [[biliary tree]], including the [[gallbladder]] and the common [[bile duct]]. Obstruction of the [[common bile duct]] is ''[[choledocholithiasis]]''; obstruction of the biliary tree can cause [[jaundice]]; obstruction of the outlet of the pancreatic exocrine system can cause [[pancreatitis]]. ''Cholelithiasis'' is the presence of stones in the gallbladder—''chole-'' means "bile", ''lithia'' means "stone", and ''-sis'' means "process".
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| The characteristics of gallstones are various. Independent of appearance, however, gallstones from animals are valuable on the market.
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| Gallstones are, oddly, a valuable by-product of meat processing, fetching up to US$32 per gram in their use as a purported [[antipyretic]] and antidote in the herbal medicine of some cultures, particularly in China. The finest gallstones tend to be sourced from old dairy cows, which are called ''Niu-Huang'' (yellow thing of oxen) in Chinese. Those got from dogs, called ''Gou-Bao'' (treasure of dogs) in Chinese, are also used today. Much as in the manner of diamond mines, slaughterhouses carefully scrutinize offal department workers for gallstone theft.<ref>{{cite web |url=http://sunday.ninemsn.com.au/sunday/cover_stories/transcript_785.asp |title=Interview with Darren Wise. Transcript |accessdate=2007-08-25 |work=Sunday}}</ref>
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| ==Classification==
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| ===Size===
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| A gallstone's size varies and may be as small as a sand grain or as large as a golf ball. The gallbladder may develop a single, often large, stone or many smaller ones. May occur in any part of the biliary system
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| ===Content===
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| Gallstones have different appearance, depending of their contents. On the basis of their contents, gallstones can be subdivided into the two following types:
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| ====Cholesterol stones====
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| [[Cholesterol]] stones are usually green, but are sometimes white or yellow in color and account for about 80 percent of gallstones. They are made primarily of cholesterol.
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| ====Pigment stones====
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| Pigment stones are small, dark stones made of [[bilirubin]] and [[calcium]] [[salt]]s that are found in bile. They account for the other 20 percent of gallstones. Risk factors for pigment stones include [[cirrhosis]], [[biliary tract]] infections, and hereditary blood cell disorders, such as [[sickle cell]] anemia and [[spherocytosis]]. Stones of mixed origin also occur.
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| == Pathophysiology ==
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| '''Asymptomatic stones:'''
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| 16-26% of patients develop gallstone-related symptoms in 10 years. Prophylactic cholecystectomy ''not'' indicated UNLESS increased risk of gallbladder (gb) cancer:
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| :*Pima Indian
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| :*calcified gb
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| :*gb polyp >10 mm
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| :*gallstones >2.5 cm
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| :*Salmonella carrier
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| Diagrams shown below are courtesy of [http://www.wikisurgery.com Wikisurgery.com]
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| <div align="center">
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| <gallery heights="145" widths="125">
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| Image:STEP2330 acute cholecystitis.jpg
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| Image:STEP2334 perforation of gallbladder.jpg
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| Image:STEP2335 local inflammation around gall bladder.jpg
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| Image:STEP2336 perforation of gallbladder.jpg
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| Image:STEP2341.empyema and mucocele of gallbladder.jpg
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| Image:STEP2346 gallbladder fistula.jpg
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| Image:STEP2350chronic cholecystitis and carcinoma.jpg
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| </gallery>
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| </div>
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|
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| ===Symptomatic stones===
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| 38-50% of patients have pain recurrence/year after 1 episode biliary colic. 1-2% of patients have complication rate/year.
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| ==Causes==
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| [[Image:Gallstones.jpg|thumb|200px|left|[[Gall bladder]] opened to show numerous '''gallstones'''. Their brownish to greenish color suggest they are cholesterol [[Calculus (medicine)|calculi]].]]
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| Progress has been made in understanding the process of gallstone formation. Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, [[human weight|body weight,]] gallbladder motility (movement), and perhaps diet. Additionally, people with [[erythropoietic protoporphyria]] (EPP) are at increased risk to develop gallstones.<ref>{{cite web |url=http://www.merck.com/mmhe/sec12/ch160/ch160d.html |title=Erythropoietic Protoporphyria |accessdate=2007-08-25 |work=Merck Manual}}</ref>
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| Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors seem to be important in causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation. The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones.
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| In addition, increased levels of the hormone [[estrogen]] as a result of [[pregnancy]], [[hormone therapy]], or the use of combined (estrogen-containing) forms of [[hormonal contraception]], may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.
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| No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C.<ref>{{cite journal |author=R.M. Ortega |coauthors=M. Fernandez-Azuela, A. Encinas-Sotillos, P. Andres, and A. M. Lopez-Sobaler |year=1997 |month=February |title=Differences in diet and food habits between patients with gallstones and controls |journal=Journal of the American College of Nutrition |volume= 16 |pages=88-95 |accessdate= 2007-08-25}}</ref> On the other hand, wine and whole grain bread may decrease the risk of gallstones.<ref>{{cite journal |year=1995 |month=June |title=. |journal=European Journal Gastroenterology & Hepatology |volume=6 |pages=585-593 |accessdate= 2007-08-25}}</ref>
| | {{SK}} Cholecystolithiasis, choleliths, cholelithiasis, biliary colic, gall stones, gallbladder calculus. |
| == Risk Factors ==
| | == [[Gallstone disease overview|Overview]] == |
| *More common in females.
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| *Obesity
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| *Common amongst Pima Indians, North Americans and Chileans.
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| *Generally Japanese have the lowest incidence of stones.
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| *Sudden weight loss
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| *Prolonged fasting.
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| *Pregnancy
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| *Presence of Crohn's disease.
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| *Cystic fibrosis
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| *Diabetes,
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| *Liver cirrhosis
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| *Increasing age
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| *Extensive bowel resection
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| *Use of contraceptives and other medications like largactil, octreotide, and clofibrate
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| ==Diagnosis==
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| ===History and Symptoms===
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| Gallstones usually remain asymptomatic initially.<ref>{{cite web |url=http://www.emedicine.com/med/topic836.htm#section~clinical |title=Cholelithiasis |accessdate=2007-08-25 |work=emedicine from WebMD}}</ref> They start developing symptoms once the stones reach a certain size (>8mm).<ref>{{cite web |url=http://www.nlm.nih.gov/medlineplus/ency/article/000273.htm#Symptoms%20Medline%20Plus |title=Gallstones |accessdate=2007-08-25 |work=Medline Plus}}</ref> A main symptom of gallstones is commonly referred to as a gallstone "attack", also known as [[biliary colic]], in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but this is less common.
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| ====Biliary colic==== | |
| '''Biliary colic''' is [[pain]] associated with irritation of the viscera secondary to [[cholecystitis]] and gallstones. Unlike renal colic, the phrase 'biliary colic' refers to the actual [[cholelithiasis]].
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| Though unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis. Although it is frequently described as
| | == [[Gallstone disease historical perspective|Historical Perspective]] == |
| a [[colic]], the pain is steady, starts rapidly and lasts at least 30 minutes and up to several hours. Many patients complain of right upper quadrant pain, rt flank pain, or even mid chest pain with cholelithiasis. There may be
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| irradiation to the back and shoulders and other concomitant symptoms such as [[vomiting]] and [[diarrhea]]. Fatty foods
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| can provoke biliary pain, but this association is relatively non-specific.
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| Biliary pain can be associated with objective findings (dilation of the biliary tract, elevation of plasma liver enzyme
| | == [[Gallstone disease classification|Classification]] == |
| concentration, elevation of bilirubin, gamma-GT and alkaline phosphatase).
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| =====Causes===== | |
| Biliary pain is most frequently caused by obstruction of the [[common bile duct]] or the [[cystic duct]] by a [[gallstone]]. However,
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| the presence of [[gallstones]] is a frequent incidental finding and does not always necessitate treatment,
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| in the absence of identifiable disease. Furthermore, biliary pain may be associated with functional disorders of the
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| biliary tract, so called acalculous biliary pain, and can even be found in patients post-cholecystectomy (removal
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| of the gallbladder), possibly as a consequence of dysfunction of the [[biliary tree]] and the sphincter of oddi.
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| =====Differential Diagnosis=====
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| *Amoebic liver abscess
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| *Perforated peptic ulcer
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| *Upper small bowel obstruction.
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| =====Complications=====
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| The more serious complication is total blockage of the bile duct which leads to [[jaundice]], which if it is not corrected naturally or by a surgical procedure can be fatal as it causes [[liver]] damage.
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| The presence of gallstones can lead to infection of the gall bladder (cholecystitis) or the biliary tree
| | == [[Gallstone disease pathophysiology|Pathophysiology]] == |
| (cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, an impacted gallstone can obstruct
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| the bowel, causing [[gallstone ileus]] (mechanical [[ileus]]).
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| Biliary pain in the absence of gallstones may severely impact the patient's quality of life, even in the absence
| | == [[Gallstone disease causes|Causes]] == |
| of disease progression.
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| =====Presentation=====
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| This condition causes crescendos of severe pain in the [[right upper abdomen]] and sometimes through to the upper [[back]] and/or right shoulder. The pain relates to the obstruction of the passage of bile and can be associated with eating fatty foods. There is usually an inflammatory component to the pain as the characteristic colic is not completely relieved between crescendos.
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| Often, these attacks occur after a particularly fatty meal and almost always happen at night.
| | == [[Gallstone disease differential diagnosis|Differentiating Gallstone disease from other Diseases]] == |
| =====Treatment===== | |
| These attacks are intensely painful, similar to that of a [[kidney stone]] attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to regulate the bile in the [[gallbladder]], but this does not work in all cases. Another way is to take magnesium followed by a bitter liquid such as [[coffee]] or [[swedish bitters]] an hour later. Bitter flavors stimulate bile flow. A study has found lower rates of gallstones in coffee drinkers.<ref>{{cite web |url=http://jama.ama-assn.org/cgi/content/abstract/281/22/2106t |title=A Prospective Study of Coffee Consumption and the Risk of Symptomatic Gallstone Disease in Men |accessdate=2007-08-25 |work=The Journal of the American Medical Association}}</ref>
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| Pain management is an important part of treating biliary colic. Treatment is often with [[NSAIDs]] such as [[ketorolac]] (Toradol) and [[diclofenac]] (Voltaren). [[Hyoscine butylbromide]] (Buscopan) is occasionally used but is less effective than analgesics.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=882 |title=BestBets: Buscopan (hyoscine butylbromide) in biliary colic. |format= |work= |accessdate=}}</ref>
| | == [[Gallstone disease epidemiology and demographics|Epidemiology and Demographics]] == |
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| ====Other symptoms==== | | == [[Gallstone disease risk factors|Risk Factors]] == |
| Other symptoms include
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| *[[Jaundice]]
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| *[[Nausea]] and [[vomiting]]
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| *[[Diarrhea]]
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| *[[Bleeding]] caused by continuous vomiting
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| *[[Dehydration]] caused by the nausea and diarrhea.
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| *Abdominal bloating
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| *Intolerance of fatty foods
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| *Belching
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| *Indigestion.
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| If the above symptoms coincide with chills, [[low-grade fever|lowgrade fever]], yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately.<ref name="nih_gall">{{cite web |url=http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/index.htm#symptoms |title=Gallstones |accessdate=2007-08-25 |work=National Digestive Diseases Information Clearinghouse}}</ref>
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| Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called "silent stones" and do not affect the [[gallbladder]] or other internal organs. They do not need treatment.<ref name="nih_gall"/>
| | == [[Gallstone disease screening|Screening]] == |
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| ===Ultrasound === | | == [[Gallstone disease natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
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| Test of choice
| | == Diagnosis == |
| * 95% sensitivity and specificity for gallstones >2 mm diameter
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| * stones better visualized if patient is fasting
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| === Other Imaging Findings ===
| | [[Gallstone disease diagnostic study of choice|Diagnostic Study of Choice]] | [[Gallstone disease history and symptoms|History and Symptoms]] | [[Gallstone disease physical examination|Physical Examination]] | [[Gallstone disease laboratory findings|Laboratory Findings]] | [[Gallstone disease electrocardiogram|Electrocardiogram]] |[[Gallstone disease x ray|X Ray]] | [[Gallstone disease CT|CT]] | [[Gallstone disease MRI|MRI]] | [[Gallstone disease ultrasound|Ultrasound]] | [[Gallstone disease other imaging findings|Other Imaging Findings]] | [[Gallstone disease other diagnostic studies|Other Diagnostic Studies]] |
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| *Endoscopic Retrograde Cholangiopancreatography (ERCP): most sensitive/specific for common bile duct (CBD) stones
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| *Magnetic Resonance Cholangiopancreatography (MRCP): diagnostic accuracy equivalent to ERCP, but not therapeutic
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| *Hepatobiliary Iminodiacetic Acid (HIDA) scan: highly sensitive for acute cholecytitis
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| == Treatment == | | == Treatment == |
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| Nonoperative management is suboptimal (ursodiol, lithotripsy). Cholecystectomy is the therapy of choice.
| | [[Gallstone disease medical therapy|Medical Therapy]] | [[Gallstone disease lithotripsy|Lithotripsy]] | [[Gallstone disease surgery|Surgical Management]] | [[Gallstone disease primary prevention|Primary Prevention]] | [[Gallstone disease secondary prevention|Secondary Prevention]] | [[Gallstone disease cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Gallstone disease future or investigational therapies|Future or Investigational Therapies]] |
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| ===Medical therapy===
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| Cholesterol gallstones can sometimes be dissolved by oral [[ursodeoxycholic acid]]. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphinceterotomy (ERS) following [[endoscopic retrograde cholangiopancreatography]] (ERCP). A common misconception is that the use of [[ultrasound]] ([[Lithotriptor|Extracorporeal Shock Wave Lithotripsy]]) can be used to break up gallstones. Although this treatment is highly effective against [[kidney stone]]s, it can only rarely be used to break up the softer and less brittle gallstones.
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| ===Surgery===
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| [[Cholecystectomy]] (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients must be indicated to surgery. The lack of a gall bladder does not seem to have any negative consequences in many people. However, there is a significant proportion of the population, between 5-40%, who develop a condition called [[postcholecystectomy syndrome]].<ref>{{cite web |url=http://www.webmd.com/hw-popup/Postcholecystectomy-syndrome |title=Postcholecystectomy syndrome |accessdate=2007-08-25 |work=WebMD}}</ref> Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen. | |
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| There are two surgery options: open procedure and laparoscopic: see the [[cholecystectomy]] article for more details.
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| *Open cholecystectomy procedure: This involves a large incision into the abdomen ([[laparotomy]]) below the right lower ribs. A week of hospitalization, normal diet a week after release and normal activity a month after release.
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| *[[Laparoscopy|Laparoscopic]] cholecystectomy: 3-4 small puncture holes for camera and instruments (available since the 1980s). Typically same-day release or one night hospital stay, followed by a week of home rest and pain medication. Can resume normal diet and light activity a week after release. (Decreased energy level and minor residual pain for a month or two.) Studies have shown that this procedure is as effective as the more invasive open cholecystectomy, provided the stones are accurately located by cholangiogram prior to the procedure so that they can all be removed. The procedure also has the benefit of reducing operative complications such as bowel perforation and vascular injury.
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| ===Alternative medicine===
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| A regimen called a "gallbladder flush" or "liver flush" is a popular remedy in alternative medicine. In this treatment, often self-administered, the patient drinks four glasses of apple cider and eats five apples per day for five days, then fasts briefly, takes magnesium, and then drinks large quantities of lemon or grapefruit juice mixed with olive oil or other oil before bed; the next morning, they painlessly pass a number of green and brown pebbles purported to be stones flushed from the biliary system. A New Zealand hospital analyzed stones from a typical gallbladder flush and found them to be composed of fatty acids similar to those in olive oil, with no detectable cholesterol or bile salts,<ref>{{cite web|author=Alan R. Gaby|url=http://www.findarticles.com/p/articles/mi_m0ISW/is_268/ai_n15795429|title=The gallstone cure that wasn't|publisher=Townsend Letter for Doctors and Patients|accessdate = 2007-02-10}}</ref> demonstrating that they are little more than hardened olive oil. Despite the gallbladder flush, the patient still required surgical removal of multiple true gallstones. The note concluded: "The gallbladder flush may not be entirely worthless, however; there is one case report in which treatment with olive oil and lemon juice resulted in the passage of numerous gallstones, as demonstrated by ultrasound examination."<ref name="BrJS">{{cite journal |author= A. P. Savage |coauthors=T. O'Brien and P. M. Lamont |year=1992 |month=February |title=Case report. Adjuvant herbal treatment for gallstones |journal=British Journal of Surgery |volume=79 |issue=2 |pages=168 |accessdate= 2007-08-25}}</ref>
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| In the case mentioned, ultrasound confirmed multiple gallstones, but after waiting months for a surgical option, the patient underwent a treatment with olive oil and lemon juice resulting in the passage of four 2.5 cm by 1.25 cm stones and twenty pea-sized stones. Two years later symptoms returned, and ultrasound showed a single large gallstone; the patient chose to have this removed surgically.<ref name="BrJS"/>
| | == Case Studies == |
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| ==References==
| | [[Gallstone disease case study one|Case #1]] |
| {{Reflist|2}}
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| ==External links== | | ==External Links== |
| *[http://www.nlm.nih.gov/medlineplus/ency/presentations/100021_1.htm Gallbladder removal - series] from Nuggets Medical Encyclopedia | | *[http://www.nlm.nih.gov/medlineplus/ency/presentations/100021_1.htm Gallbladder removal - series] from Nuggets Medical Encyclopedia |
| * [http://www.chem-tox.com/gallstones/index.htm "Gall Stones and Gall Bladder Surgery"] Information for this article was located from the University of Florida, Medical Library in Gainesville, Florida, and researched by Richard Pressinger (M.Ed.) and Jerry Abraham (M.B.A)
| | *[http://medinfo.ufl.edu/year1/bcs/slides/abdomen/slide9.html Diagram of pain radiation] |
| * [http://medinfo.ufl.edu/year1/bcs/slides/abdomen/slide9.html Diagram of pain radiation] | | {{WH}} |
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Hepatology]] | | [[Category:Hepatology]] |
| [[Category:Surgery]] | | [[Category:Surgery]] |
| [[Category:Abdominal pain]]
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| [[Category:Disease]]
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