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Cholelithiasis refers to the presence of gallstones in the gallbladder. It is one of the most common biliary disorders, often asymptomatic, but can lead to complications such as cholecystitis, choledocholithiasis, or pancreatitis when obstructive.

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https://www.youtube.com/watch?v=UPw3ot1M_o0

https://youtu.be/uo2jhQB2cww

Pathophysiology

Gallstones

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Gallstones are crystalline concretions formed in the gallbladder or biliary ducts, composed primarily of cholesterol, bilirubin, and calcium salts.

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![The burden of gallstone disease. (A) Ultrasonographic appearance of a single small gallstone (0.4 mm) within the GB neck (arrow), seen on a longitudinal transabdominal scan. The hyperechogenic spot is mobile, with decubitus, and is not associated with a posterior acoustic shadow. The GB wall is not thickened (i.e., ≤3 mm in the fasting state) and the remaining lumen is anechoic. A 1-cm scale is shown on the left. (B) Macroscopic appearance of a solitary pure cholesterol gallstone (approximately 12 mm) showing yellowish morular surfaces. (C) Multiple cholesterol gallstones (2–5 mm) with smooth surfaces. (D) Multiple mixed cholesterol gallstones (approximately 5 mm) with pigment centers on the cut surfaces. (E) Multiple black pigment gallstones, forming a largely friable sandy powder (approximately 1 mm). GB, gallbladder.

Piero Portincasa, Agostino Di Ciaula, Ignazio Grattagliano. Preventing a Mass Disease: The Case of Gallstones Disease: Role and Competence for Family Physicians. Korean Journal of Family Medicine. 2016;37(4):205-205. doi:https://doi.org/10.4082/kjfm.2016.37.4.205](attachment:46d349d7-b178-4666-b708-b0cae7852700:kjfm-37-205-g001.jpg)

The burden of gallstone disease. (A) Ultrasonographic appearance of a single small gallstone (0.4 mm) within the GB neck (arrow), seen on a longitudinal transabdominal scan. The hyperechogenic spot is mobile, with decubitus, and is not associated with a posterior acoustic shadow. The GB wall is not thickened (i.e., ≤3 mm in the fasting state) and the remaining lumen is anechoic. A 1-cm scale is shown on the left. (B) Macroscopic appearance of a solitary pure cholesterol gallstone (approximately 12 mm) showing yellowish morular surfaces. (C) Multiple cholesterol gallstones (2–5 mm) with smooth surfaces. (D) Multiple mixed cholesterol gallstones (approximately 5 mm) with pigment centers on the cut surfaces. (E) Multiple black pigment gallstones, forming a largely friable sandy powder (approximately 1 mm). GB, gallbladder.

Piero Portincasa, Agostino Di Ciaula, Ignazio Grattagliano. Preventing a Mass Disease: The Case of Gallstones Disease: Role and Competence for Family Physicians. Korean Journal of Family Medicine. 2016;37(4):205-205. doi:https://doi.org/10.4082/kjfm.2016.37.4.205

Risk Factors

5 Fs for Cholesterol Stones:

• Female
• Fat (obesity)
• Fertile (pregnancy, high estrogen)
• Forty (age 40–60)
• Fair (Caucasian, though ethnic variability exists)

Additional risk factors:

• Rapid weight loss
• Diabetes
• Ileal disease/resection (↓ bile salt resorption)
• Total parenteral nutrition

![Aetiological factors involved in the formation of cholesterol gallstones and brown pigment gallstones: a | Hepatic hypersecretion of cholesterol is the primary cause of cholesterol gallstone formation and depends largely on genetic predisposition. Gallbladder hypomotility and rapid phase transitions are downstream consequences. The intestinal factors that contribute to cholesterol gallstone formation include increased absorption of cholesterol and reduced absorption of bile salts. b | Brown pigment gallstones are the consequence of excess bacterial β-glucuronidase, which results in the hydrolysis of bilirubin glucuronide into free bilirubin and glucuronic acid. Free bilirubinate combines with calcium to form water-insoluble calcium bilirubinate as a consequence. Dead bacteria and parasites could act as nuclei that accelerate the precipitation of calcium bilirubinate. The mucin gel in the gallbladder traps these complex precipitates and promotes their growth into macroscopic stones.

Lammert, F., Gurusamy, K., Ko, C. et al. Gallstones. Nat Rev Dis Primers 2, 16024 (2016). https://doi.org/10.1038/nrdp.2016.24](attachment:3e597154-b816-4073-8b62-72df038cbc88:41572_2016_Article_BFnrdp201624_Fig4_HTML.webp)

Aetiological factors involved in the formation of cholesterol gallstones and brown pigment gallstones: a | Hepatic hypersecretion of cholesterol is the primary cause of cholesterol gallstone formation and depends largely on genetic predisposition. Gallbladder hypomotility and rapid phase transitions are downstream consequences. The intestinal factors that contribute to cholesterol gallstone formation include increased absorption of cholesterol and reduced absorption of bile salts. b | Brown pigment gallstones are the consequence of excess bacterial β-glucuronidase, which results in the hydrolysis of bilirubin glucuronide into free bilirubin and glucuronic acid. Free bilirubinate combines with calcium to form water-insoluble calcium bilirubinate as a consequence. Dead bacteria and parasites could act as nuclei that accelerate the precipitation of calcium bilirubinate. The mucin gel in the gallbladder traps these complex precipitates and promotes their growth into macroscopic stones.

Lammert, F., Gurusamy, K., Ko, C. et al. Gallstones. Nat Rev Dis Primers 2, 16024 (2016). https://doi.org/10.1038/nrdp.2016.24

![Classification of gallstones: a | Potential localization of gallstones in the biliary tree are illustrated. Different colours of the stones represent composition, including cholesterol stones (yellow) and pigment stones (brown and black). b | Endoscopic view of secondary cholesterol stones (with a typical yellow colour) in the bile duct during stone retrieval with a Dormia basket.

Lammert, F., Gurusamy, K., Ko, C. et al. Gallstones. Nat Rev Dis Primers 2, 16024 (2016). https://doi.org/10.1038/nrdp.2016.24](attachment:c8154e80-880b-498a-8435-160e26ed0198:41572_2016_Article_BFnrdp201624_Fig1_HTML.webp)

Classification of gallstones: a | Potential localization of gallstones in the biliary tree are illustrated. Different colours of the stones represent composition, including cholesterol stones (yellow) and pigment stones (brown and black). b | Endoscopic view of secondary cholesterol stones (with a typical yellow colour) in the bile duct during stone retrieval with a Dormia basket.

Lammert, F., Gurusamy, K., Ko, C. et al. Gallstones. Nat Rev Dis Primers 2, 16024 (2016). https://doi.org/10.1038/nrdp.2016.24

Clinical Presentation

Complications

Radiology

Management