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home - Biliary - Gallstone Disease - Gallstone Lithotrypsy Written by Dr Sebastian Zeki
Knowledge


Knows the physiology and biochemistry of bile and the pathogenesis
of gallstones

Is familiar with the normal anatomy and the anatomical variations of
the biliary tree

Recognises the symptoms and signs of the potential complications of
galllstone disease including biliary colic acute cholecystitis jaundice
due to calculous bile duct obstruction cholangitis and carcinoma

Knows the various techniques of diagnostic imaging including
ultrasound CT MRI ERCP EUS radionuclide techniques

Knows the various treatment options the indications for operative and
non-operative management and the risks of each

Knows the current national guidelines for use of ERCP and the risks
of the technique

Knows the ways in which gallbladder polyps are diagnosed and
managed

Knows that gallbladder and sphincter of Oddi dysfunction (SOD) may
account for otherwise unexplained abdominal pain

Recognises different types of SOD how they may present and how
they are investigated

Skills
Can select the most appropriate diagnostic and therapeutic
techniques for each clinical situation

Recognises possibility of diagnostic uncertainty in biliary dysmotility
and shows thoughtful judgement in each individual situation

Behaviours
Makes appropriate assessment stratifies urgency and plans
management of patients who have complications of gallstones

Gallstone Lithotrypsy

URSO Indications:Small stone size (<1 cm).Mild symptoms.Good gallbladder function (ie, normal filling and emptying).Minimal calcification and low density on CT imaging. Problems:Incomplete dissolution as calcium on stone surface.Stone recurrence common esp. if multiple.Not good to reduce symptoms in long term StatinsDon’t reduce stone size or number as prob proportionate reduction in bile acid and phospholipid secretion.MonoterpenesRowachol (= po mix of cyclic monoterpenes)-dissolves radiolucent and some radio-opaque gallstones.Also enhances the efficacy of UDCA or lithotripsy when combined.Contact dissolutionPuncture gallbladder transhepatically, then inject Methyl tert-butyl ether (MTBE-a cholesterol solvent).The indications and patient selection similar to URSO but can treat patients with more severe symptoms65 % achieve complete stone dissolution- clearance is helped with URSOComplications of contact dissolution therapiesBleedingBile leaks.Oedematous gallbladderDuodenal absorption, leads to drowsiness, confusion, and anesthesia and duodenal wall edema.Recurrence- 70 % at four years. 3 Exclusion criteria:Coagulation/platelet abnormalities.Cystic or vascular liver abnormalities.Acute gallstone-related complications.Pregnancy. Complications35 % develop biliary colic w/in 3 days due to to passage of the stone fragments (co -prescribe URSO).True biliary obstruction and pancreatitis occur in <5 %.Abdominal wall petechiae are common esp if thin.Microscopic hematuria occurs in 2 % . OutcomesIt gives 95% clearance rates for single gallstones.It gives 67% clearance rate for 2/3 stones.It can treat some calcified stones.As with bile salt therapy, CT density and the pattern of calcification are predictive of the speed and likelihood of stone clearance. Gallstone Lithotrypsy 3 Stone recurrence9 % at one year.Especially in the obeseSymptom relief80 % get symptom relief following clearance. Inclusion criteria for lithotripsy:Mild symptoms.Normal gallbladder function with a patent cystic duct.Solitary radiolucent stones (less than 3).Stone diameter <20 mm.Preferably low BMI. <20 % of patients with gallstones are suitable for lithotripsy. Medication: Chenodeoxycholic acid or ursodeoxycholic acid (URSO)50 % patients on 10 mg/kg daily of URSO cleared gallstones after 18m. Other Means Of Gallstone Dissolution. Written by Dr Sebastian Zeki

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