Gallstones

Gallstones, also called cholelithiasis, are concretions that occur anywhere within the biliary system, most commonly within the gallbladder

Gallstones (cholelithiasis) describes stone formation at any point along the biliary tree. Specific names can be given to gallstones depending on their location:

Biliary microlithiasis refers to gallstones less than 3 mm in diameter. 

Gallstones occur in ~10% of the population with a predominance in women (F:M = 2:1). The prevalence increases with age in both sexes 3

Genetics may have an important role in gallstone formation. Several studies have shown an association between age-adjusted prevalence of gallstone, ethnicity 4 and family history of gallstones:

  • highest age-adjusted prevalence (~50%): Pima Indians, some North and South American Indians
  • intermediate age-adjusted prevalence (up to 20%): Caucasians (20%), and Asian population (5-20%)
  • lowest age-adjusted prevalence (≤5%): Africans
Risk factors

Common risk factors for cholesterol gallstones include female sex, middle age, obesity, and positive family history (see 5-F rule).

Gallstones may be symptomatic in only 25% of cases. The most common presentation is right upper quadrant or epigastric abdominal pain or discomfort, especially after a fat-rich meal. Other symptoms include belching, bloating, flatulence, heartburn, and nausea.

Abdominal pain is often referred to shoulder. Patients may demonstrate this radiation to the tip of scapula by placing their hand behind the back and thumb pointing upwards: the "Collins' sign". This may be useful in distinguishing gallstone pain from oesophagitis, gastritis, or duodenal ulcer in ~50% of patients 5

There are three types of gallstones 3,4,7-10:

  • cholesterol (10%)
    • >50% cholesterol contents; form with supersaturation of bile, nucleation and stone growth
    • predisposing factors
      • diet, sedentary lifestyle, rapid loss of weight, obesity, oral contraceptive pill, total parenteral nutrition (TPN)
      • ethnicity, genetic predisposition, older age, female sex
  • mixed (80%)
    • 20-50% cholesterol content
    • predisposing factor: similar to cholesterol stones
  • pigment stones (10%)
    • <20% cholesterol content; high bilirubin content and occur when there is supersaturation of unconjugated bilirubin
    • two further subtypes each with their own predisposing factors:
      • black pigment stones: chronic haemolysis, liver cirrhosis, intestinal malabsorption (e.g. in Crohn disease)
      • brown pigment stones: bacterial infection, parasitic infection (e.g. Clonorchis sinensis) and biliary stasis
Complications

Small gallstones carry a higher risk of causing pancreatitis than larger ones.

Plain radiograph

Some radiopaque gallstones may be seen on plain film:

  • gallstones are radiopaque only in 15-20% of cases 3
  • may have a laminated appearance 
  • may have a faceted outline 
  • may show a Mercedes-Benz sign: radio-opaque outline with lucent center
Ultrasound

Ultrasound is considered the gold standard for detecting gallstones 6:

  • grey scale ultrasound
    • highly reflective echogenic focus within gallbladder lumen, normally with prominent posterior acoustic shadowing
    • gravity dependent movement is often seen with change of patient position (the rolling stone sign)
  • color Doppler
    • may demonstrate a twinkle artefact and is particularly useful for identification of small stones
CT

Pure cholesterol stones are hypoattenuating to bile and calcified gallstones are hyperattenuating to bile. Some gallstones are isodense to bile and these may not be clearly identified on CT.

MRI
  • T2: signal void or low signal outlined by markedly hyperintense bile within gallbladder 
  • MRCP: focus of signal void inside gallbladder

Possible imaging differential considerations in selected situations include

  • gallstone acoustic shadowing is prominent with
    • larger size stones (usually >3 mm for shadowing)
    • higher transducer frequency
    • focal zone at the level of gallstone
  • a gallbladder full of stones may paradoxically be hard to visualise (wall-echo-shadow sign)
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Article information

rID: 20125
Section: Pathology
Synonyms or Alternate Spellings:
  • Cholelithiasis

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Cases and figures

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    coronal
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    Case 19: with hepatolithiasis
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