Clinical Review ABC of diseases of liver, pancreas, and biliary system

Gallstone disease

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7278.91 (Published 13 January 2001) Cite this as: BMJ 2001;322:91
  1. I J Beckingham

    Gall stones are the most common abdominal reason for admission to hospital in developed countries and account for an important part of healthcare expenditure. Around 5.5 million people have gall stones in the United Kingdom, and over 50 000 cholecystectomies are performed each year.

    Prevalence of gall stones in United Kingdom according to age

    Types of gall stone and aetiology

    Normal bile consists of 70% bile salts (mainly cholic and chenodeoxycholic acids), 22% phospholipids (lecithin), 4% cholesterol, 3% proteins, and 0.3% bilirubin. Cholesterol or cholesterol predominant (mixed) stones account for 80% of all gall stones in the United Kingdom and form when there is supersaturation of bile with cholesterol. Formation of stones is further aided by decreased gallbladder motility. Black pigment stones consist of 70% calcium bilirubinate and are more common in patients with haemolytic diseases (sickle cell anaemia, hereditary spherocytosis, thalassaemia) and cirrhosis.

    Gall stones vary from pure cholesterol (white), through mixed, to bile salt predominant (black)

    Brown pigment stones are uncommon in Britain (accounting for <5% of stones) and are formed within the intraheptic and extrahepatic bile ducts as well as the gall bladder. They form as a result of stasis and infection within the biliary system, usually in the presence of Escherichia coli and Klebsiella spp, which produceβ glucuronidase that converts soluble conjugated bilirubin back to the insoluble unconjugated state leading to the formation of soft, earthy, brown stones. Ascaris lumbricoides and Opisthorchis senensis have both been implicated in the formation of these stones, which are common in South East Asia.

    Clinical presentations

    Biliary colic or chronic cholecystitis

    The commonest presentation of gallstone disease is biliary pain. The pain starts suddenly in the epigastrium or right upper quadrant and may radiate round to the back in the interscapular region. Contrary to its name, the pain often does not fluctuate but persists from 15 minutes up to 24 hours, subsiding spontaneously …

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