Gallbladder & extrahepatic bile ducts
Gallbladder nonneoplastic

Topic Completed: 1 September 2012

Minor changes: 5 September 2019

Copyright: 2003-2019,, Inc.

PubMed Search: Cholelithiasis[TI] gallbladder[TI] full text[sb]

Hanni Gulwani, M.B.B.S.
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Cite this page: Gulwani H. Cholelithiasis. website. Accessed October 26th, 2020.
Definition / general
  • Also called gallstones
  • Accounts for 1% of national heath care budget
  • Affects 10% of adults in developed countries (80% are silent) vs. < 1% of children
  • 80% of gallstones in West are cholesterol stones with 50% or more crystalline cholesterol monohydrate
  • 20% of gallstones in West are pigment stones composed of bilirubin calcium salts
  • Gallstones impact at neck just proximal to cystic duct
  • Typically within lumen but may be intramural

Risk factors:
  • Pima, Hopi or Navajo (75% of stones are pure cholesterol vs. 25% in industrialized vs. minimal in developing countries), also Scandinavians, Chileans, Mexican Americans, increasing age (> 50% risk by age 80)
  • Fat, fertile [multiple pregnancies], forty, female, obesity (Korean J Gastroenterol 2012;59:27), rapid weight loss, gallbladder stasis, genetic disorders that impair bile salt synthesis / secretion or increase cholesterol levels (serum or biliary), low HDL levels
  • May be influenced by Apolipoprotein E genotype (Ann Epidemiol 2006;16:763)
  • Biliary sludge typically occurs before gallstones
  • Estrogens from birth control pills or pregnancy increase expression of hepatic LDL receptors, which increase cholesterol uptake, which stimulate HMG CoA reductase, which synthesizes cholesterol
  • Pigment stone risk factors are increased unconjugated bilirubin (from hemolytic syndromes, ileal dysfunction / bypass, bacterial contamination of biliary tree)

  • Anticholesterol drug that increases HMG CoA reductase activity and decreases conversion of cholesterol to bile acids by reducing cholesterol 7 alpha hydroxylase activity, causes excess biliary secretion of cholesterol

  • Usually none but may have biliary colic (severe, right upper quadrant pain)

  • 1 - 2% have acute or chronic cholecystitis, choledocholithiasis, cholangitis, empyema, gallstone ileus, acute pancreatitis

Mirizzi syndrome:
  • Rare
  • Stone impacting in cystic duct or gallbladder neck causes extrinsic compression or obstruction of common bile duct, causing jaundice

  • Presence of biliary sludge, number, size and type of gallstones
  • Ultrasound (95% sensitive and specific for gallstones 2 mm or larger or gallbladder sludge), Xrays detect 10 - 25% of gallstones that are radiopaque due to calcium
  • Laparoscopic cholecystectomy if symptomatic or in children, Native Americans, patients with sickle cell disease or porcelain gallbladder, stones 3 cm or larger
Gross description
  • 85% are 2 cm or less
Microscopic (histologic) description
  • Minimal / mild lymphocytic mucosal inflammation, Rokitansky-Aschoff sinuses, fibrosis, thickening of muscularis propria (Am J Surg Pathol 2003;27:1313), cholesterolosis, focal epithelial metaplasia (pyloric / gastric mucin cell metaplasia or intestinal metaplasia)
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