Cholelithiasis

Cholelithiasis means stones in the gallbladder. Most are cholesterol or mixed stones; pigment stones occur with haemolysis and cirrhosis. Many people never develop symptoms.

Clinical presentation

Biliary colic: episodic right upper quadrant or epigastric pain after meals, lasting hours. Complications include acute cholecystitis, choledocholithiasis with obstructive jaundice or cholangitis, gallstone pancreatitis and, rarely, gallstone ileus.

Radiographic features

Ultrasound

• Echogenic foci within the gallbladder lumen
• Posterior acoustic shadowing
• Mobility with change of patient position
• A contracted gallbladder full of stones gives the wall–echo–shadow sign

Signs of acute cholecystitis include wall thickening over 3 mm, pericholecystic fluid and a positive sonographic Murphy sign.

CT and MRI

Many stones are invisible on CT because they match bile density. MRCP is the best non-invasive test for stones in the common bile duct.

Treatment and prognosis

Asymptomatic stones are usually left alone. Symptomatic gallstones are treated with laparoscopic cholecystectomy; bile duct stones are removed by ERCP or at surgery.

Differential diagnosis

• Gallbladder polyp (non-shadowing, non-mobile)
• Biliary sludge
• Gas in the adjacent duodenum