Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

Gallstone Disease 601

■mechanism promoting gallstones formation include bile supersat-

uration, nucleation factors (mucin, glycoproteins and calcium) and

bile stasis

■common bile duct (CBD) stones (choledocholithiasis) may form de

novo in bile ducts (primary) or migrate to the CBD from the gallblad-

der (secondary)

■risk factors for cholesterol gallstone formation:

➣Fat: obesity, type IV hyperlipidemia, rapid weight loss, diabetes

mellitus

➣Female gender

➣Family: maternal family history and Hispanic/Native American/

Scandinavian

➣Fetus: pregnancy

➣Forties/Fifties: increasing age

➣Fasting: TPN

➣Fat malabsorption after biliopancreatic bypass surgery, with

celiac disease due to impaired CCK release, and in Crohn’s dis-

ease

➣Fibric acid derivatives (lipid lowering agents) and other medica-

tions such as contraceptive steroids/postmenopausal estrogens,

octreotide, ceftriaxone

■diabetics are prone to obesity, hypertriglyceridemia and gallblad-

der hypomotility; no data to prove diabetes as an independent risk

factor

■Asians are predisposed to primary CBD stones due to higher preva-

lence of

■flukes/parasitic infections

Signs & Symptoms

■biliary colic main complaint in 70%–80% of symptomatic patients;

onset of pain sudden followed by rapid increase in intensity over next

10–15-min to steady plateau which can last up to 3 hours

■pain >3 hr indicates onset of acute cholecystitis

■older patients may present with minimal symptoms

■vomiting and sweating are not uncommon

■Murphy’s sign: direct palpation of the RUQ results in abrupt arrest

of breathing during inspiration due to pain (acute cholecystitis)

■acute suppurative cholangitis can present with pain, jaundice,

and chills/rigors (Charcot’s triad); refractory sepsis characterized

by altered mentation, hypotension and Charcot’s triad constitutes

Raynold’s pentad