Medically Fit For Exams
Medically Fit For Exams

Cholelithiasis (Gallstones)



  • Crystals form and block the bile duct


Risk factors

  • Four Fs – relate to high oestrogen levels
    • Female
    • Forty (represents pre-menopausal spike in oestrogen, common in middle age and older)
    • Fat
    • Fertile (pre-menopausal = high oestrogen, being pregnant = high oestrogen, more pregnancies = more progesterone)
    • Oestrogen affecting drugs such as COC and HRT
  • High cholesterol
  • High fat/low fibre diet
  • Diabetes
  • Rapid weight loss
  • Family history


Differential diagnosis

  • Peptic (gastric) ulcer
  • Cholecystitis (inflammation of gallbladder)
  • Appendicitis
  • Acute pancreatitis
  • Gallbladder cancer
  • Cholangiocarcinoma
  • Pancreatic cancer



  • In the US, 1-3% of population have gallstones in a year
  • 10-20% lifetime prevalence
  • More common in women
  • More common in over 60s
  • Higher prevalence in countries where parasitic infestation increases risk
  • Less common in Asia and African-americans



  • Oestrogen increases biliary cholesterol secretion
  • Progesterone reduces gallbladder contractility, increasing stasis
  • Cholesterol crystals form
    • Increased stasis
    • Increased cholesterol concentration
    • Insufficient solute, so crystals form
  • Crystals combine to form larger stones
  • Stones obstruct bile duct
  • Black and brown pigment stones are caused by high haem turnover
    • Unconjugated bilirubin and calcium form crystals
    • If oxidised turn a black colour
  • Can get mixed-cause gallstones – cholesterol core, that becomes infected, and gets a calcium bilirubin ‘shell’


Clinical features –

  • Frequently asymptomatic – in those with incidental diagnosis only 1-2% go on to be symptomatic
  • Biliary colic
    • Pain in epigastrium or right upper quadrant
    • Radiates to tip of right scapular (Collin’s sign)
  • Pain occurs postprandially (up to an hour after a meal)
  • Nausea and vomiting
  • Pain not relieved by antacids, vomting, flatus, defecation
  • Steatorrhoea
  • Belching
  • Bloating
  • ?Jaundice
  • Lack of fever or persistent tachycardia (cholangitis)



  • 80% are cholesterol (in US)
  • See aetiology



  • Plain radiograph – gallstones only visible in 10-30% of cases
  • Ultrasound – investigation of choice
  • FBC and LFT
    • Raised bilirubin
    • Possibly raised liver enzymes (if severe, caused by inflammation of liver)
    • May be normal
  • ERCP (endoscopic retrograde cholangiopancreatography)
    • Endoscope, contrast and radiograph imaging
    • Can extract gallstones at the same time
    • Often combined with endoscopic retrograde sphincterotomy (cutting the sphincter of Oddi, through which stones can be removed, which later heals to a certain degree)
  • MRCP (magnetic resonance cholangiopancreatography)
    • Non-invasive imaging technique
    • Expensive so only used when other methods can’t confirm suspected gallstones



  • Not necessary if asymptomatic
  • ERCP and sphincterotomy (see above)
  • Cholecystectomy – removal of gallbladder
  • Ursodiol – dissolves cholesterol in micelles, which breaks up stones



  • Generally very good prognosis – many patients asymptomatic
  • Complications of surgery may cause morbidity and mortality
  • Cholecystectomy is common and has minimal impact 
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