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Multiple calculi

1.  What are these pathological specimens?
2.  What are their likely chemical composition?

This photograph show a collection of gallstones removed from a gall bladder during a cholecystectomy. Gallstones affect about 12% of men and 24% of women in the United Kingdom. There prevalence increases with age and diabetes mellitus, obesity, ileal disease and certain drugs (e.g. Clofibrate) appear to be important in the aetiology. Only 10% of gallstones are symptomatic. As a result about 40,000 cholecystectomies are performed annually. Over 10% of patients with gall bladder stones have stones in the common bile duct and as a result 4,000 patients require either ERCP or open or laparoscopic exploration of the duct each year. Only 10% of gallstones are radio-opaque and visible on a plain abdominal film.

Overall, 15% stones have cholesterol as their major component. Five percent of stones are pigment stones resulting from haemolysis or red blood cells. Most stones have a mixed composition (80%) but these are believed to be a variant of the pure cholesterol stone. Cholesterol stones are formed when a change in the bile constituents favours precipitation of cholesterol from solution. Under normal circumstances bile acids (e.g. chenodeoxycholic acid) acts as a detergent and in combination with lecithin maintains cholesterol in solution by the formation of micelles. Bile is, however, often supersaturated with cholesterol often favouring the formation of microcrystals. When this is associated with biliary infection, bile stasis or a change in gall bladder function, stones tend to form. Bile is infected in about 30% of patients with gallstones with gram-negative organisms being the most common isolated.

The possible clinical presentations of gall stones include:

  • Flatulent dyspepsia
  • Biliary colic
  • Acute cholecystitis
  • Empyema of the gallbladder
  • Mucocele of the gallbladder
  • Mirrizi's syndrome
  • Obstructive jaundice
  • Acute pancreatitis
  • Acute cholangitis

The first cholecystectomy was described by Langenbuch in 1882 in Berlin. Throughout this century it has been an operation associated with significant morbidity and mortality. Even today the reported mortality is often 0.5%. Complications specific to this operation include bile duct damage, biliary leaks and retained stones. The Kocher's incision often promotes pulmonary atelectasis and had a significant dehiscence rates. As a result recent interest has been shown in 'mini' cholecystectomy performed through a 5 cm transverse incision and laparoscopic cholecystectomy first described in 1988. Attempts at dissolution therapy and extra-corporeal shock wave lithotripsy have been disappointing.

Recent papers

Tait N, Little J M. The treatment of gall stones. Br Med J 1995; 311: 99-105.

Dennison A R, Azoulay D, Oakley N et al. What should I do about my patient's gall stones? Postgrad Med J 1995: 71: 725-729.



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