The Gallstone Elimination Report

The Gallstone Elimination Manual

The Gallstone Elimination Report is a new program developed by David Smith, who has many years of experience in the health industry. The program provides people with step-by-step strategies on how to remove their gallstones quickly and effectively. The Gallstone Elimination Report will give you the info and tools that you need to live a gallstone-free and healthy life. Inside the e-book, you will learn the simple steps that you must take to pass your gallstones, the 3 ordinary items that can dissolve your gallstones within 24 hours, natural remedies for healing your gallbladder and improving your digestion. The program is detailed out in simple, easy to follow script. It also reveals those few steps that will have to be followed immediately to get a better control over this abnormal body condition. Read more...

The Gallstone Elimination Report Summary


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Contents: 99 Page EBook
Author: David Smith
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Highly Recommended

I usually find books written on this category hard to understand and full of jargon. But the writer was capable of presenting advanced techniques in an extremely easy to understand language.

All the modules inside this book are very detailed and explanatory, there is nothing as comprehensive as this guide.

Role of ERCP in Acute Gallstone Pancreatitis

The exact mechanism through which gallstones induce pancreatitis is still debated, but the most likely explanation is acute obstruction of the pancreatic duct. Most gallstones will pass spontaneously into the duodenum following an attack of acute pancreatitis. Studies of urgent (within 72 hours of admission) ERCP with biliary sphincterotomy have demonstrated an improved outcome in patients with severe acute gallstone pancreatitis (Neoptolemous et al, 1988) and evidence of persistent biliary obstruction. These are patients with hyperbilirubinemia, common bile duct dilatation, or sepsis. The improvement appears to result from treatment of cholangitis. The role of urgent ERCP in severe acute gallstone pancreatitis without clinical biliary obstruction is controversial with at least one study by Flosch and colleagues (1997) demonstrating an increased mortality. In these patients we would perform an endo-scopic ultrasound (EUS) to detect common duct stones, prior to ERCP. It should be noted...

Asymptomatic Gallstones The Case for a Conservative Approach

The most common situation, due to the high incidence of gallstones in the age group with aortic disease is the combination of asymptomatic gallstones in a patient scheduled to undergo elective aorta surgery. Evans et al6 performed screening of 394 aortic-reconstruction patients using preoperative oral cholecystography and found gallbladder disease in 73 patients (18 ). The risk of postoperative cholecystitis was low and the long-term sequelae of those with retained diseased gallbladders were not judged to be significant. Concomitant cholecystectomy in the asymptomatic patient is not justified by these data. Asymptomatic cholelithiasis is generally a benign disease, with development of symptoms at the rate of approximately 1 year.6,7 Postoperative cholecystitis after AAA resection is mainly seen after a ruptured AAA and may be acalculous.7

Asymptomatic Gallstones The Case for a Combined Approach

This is one of the more common scenarios of combined disease, due to the relative frequency of gallstones in the aneurysm population. The near universal use of ultrasound and or CT scanning in the diagnosis of aneurysm disease often provides this information to the surgeon preoperatively. When gallstones are diagnosed before aortic operation, the surgeon should attempt to elicit any symptoms of biliary tract disease from the patient. This may not always be initially apparent, since the symptoms of biliary disease are often nonspecific, however the questions must always be asked. Laboratory investigation to evaluate the possibility of choledocholithiasis (alkaline phosphates, bilirubin and liver enzymes) should be performed prior to surgery. If there is suggestion of choledocholithiasis, this should be evaluated and if possible, treated endoscopically prior to laparotomy. If the biliary tract lesion can be treated by simple cholecystectomy this is performed at the time of aneurysm...

Supplemental Reading

The natural history of silent gallstones. N Engl J Med 1982 307 798. MacFadyen BV, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc 1998 12 315-21. May GR, Sutherland LR, Shaffer EA. Efficacy of bile acid therapy for gallstone dissolution a meta-analysis of randomized trials. Aliment Pharmacol Ther 1993 7 139-48. Orlando R III, Russell JC, Lynch J, Mattie A. Laparoscopic cholecystectomy. A statewide experience. The Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg 1993 128 494-9. Sackmann M, Miller H, Klueppelberg U, et al. Gallstone recurrence after shock-wave therapy. Gastroenterology 1994 106 225-30. Sackmann M, Pauletzki J, Sauerbruch T, et al. The Munich gallbladder lithotripsy study. Ann Intern Med 1991 114 290-6. The Southern Surgeons Club. A prospective analysis of 1,518 laparoscopic cholecystectomies. N Engl J Med 1991 324 1073. Villanova N, Bazzoli F, Taroni F,...

Prevention of Recurrence

In patients with predicted biliary pancreatitis, if gallstones are not observed on an initial ultrasound, the procedure should be repeated after the pancreatitis has resolved. Patients with biliary pancreatitis have a significant risk of recurrence unless a cholecystectomy is performed. In patients with mild to moderate pancreatitis, this can be accomplished prior to discharge. Patients who refuse surgery or are very high operative risks benefit from endo-scopic biliary sphincterotomy to prevent recurrence. Patients with alcohol use should be counseled about cessation. The treatment of patients with pancreas divisum is controversial, but those with recurrent pancreatitis in whom no other etiology is identified may benefit from pancreatic sphincterotomy of the minor ampulla. Hyperlipidemic patients should receive appropriate lipid lowering medications and patients with acute recurrent pancreatitis may benefit from further endoscopic workup including ERCP, EUS, and SO manometry....

Laparoscopic Cholecystectomy for Expanded Indications

With growing experience, surgeons are now successful in performing laparoscopic cholecystectomy on the majority of patients regardless of presentation. However, several clinical scenarios continue to provide challenging settings for the laparoscopic technique and controversies with regard to methods of treatment. Acute cholecystitis, gallstone pancreatitis, choledocholithiasis, hepatitis or cirrhosis with portal hypertension, previous abdominal surgery, severe obesity, sepsis, and pregnancy are areas where dramatic improvements have occurred. Gallstone pancreatitis, once considered a contraindication for the minimally invasive approach, is now successfully treated with laparoscopic cholecystectomy on a regular basis. Timing of cholecystectomy remains controversial and is determined by severity of the pancreatitis. Recovery from an attack of mild acute pancreatitis is signaled by normalization of white blood cell count, serum amylase and lipase, and resolution of pain. Long delay in...

Complications and Outcomes

Elective laparoscopic cholecystectomy for calculous disease is a safe and successful procedure with a morbidity of 5 and a mortality of 0.25 . Greater than 90 of patients with a classic presentation of right upper quadrant pain and ultrasonographic diagnosis of gallstones experience relief of symptoms following laparoscopic cholecys-tectomy. Although elective laparoscopic cholecystectomy for uncomplicated symptomatic cholelithiasis may have a conversion rate of 2 or 3 in skilled hands, the majority of reported series have demonstrated a consistent conversion Common complications following laparoscopic chole-cystectomy include those seen with operations of any type including bleeding, infection, and risks of general anesthesia, and those complications specific for the laparoscopic cholecystectomy, including conversion to an open procedure, bile duct injury, injury to surrounding organs, and bile or gallstone spillage into the peritoneal cavity. Although considered a complication by...

Cynthia W Ko MD MS and Sum P LeeMD PhD

Gallstones are commonly found but are often asymptomatic. In general, the risk of developing biliary colic in asymptomatic patients is low, but once a person develops symptoms, the risk of ongoing biliary colic or more serious complications of cholelithiasis is substantial (Gracie and Ransohoff, 1982). However, serious complications of cholelithiasis, such as cholecystitis, cholangitis, or acute pancreatitis, are frequently preceded by attacks of biliary colic. Therefore, in patients with gallstones who are otherwise asymptomatic, treatment is not recommended. However, once symptoms or complications develop, treatment of cholelithiasis, either surgical or medical, should be strongly considered (Table 132-1). In general, chole-cystectomy is the treatment of choice for symptomatic or complicated gallstones. However, in selected patients, dissolution with ursodeoxycholic acid (UDCA) or fragmentation of stones with extracorporeal shock wave lithotripsy can be useful.

Alexandra L B WebbMD and Aaron S Fink Md Facs

Acute cholecystitis is usually caused by obstruction of the cystic duct or Hartmann's pouch with gallstones, leading to painful gallbladder distention. Edema of the gallbladder and lymphatic and venous congestion then occur. Superinfection of the bile may then supervene.

Preoperative abnormalities

Those with the X-linked form that survive often develop other medical problems, which suggests that the protein abnormality may not affect muscle alone. In a study of 55 males who survived beyond 1 year, 80 were partially or completely ventilator dependent, four had pyloric stenosis, six had evidence of liver dysfunction, four gallstones, two spherocytosis, and two renal calculi (Herman et al 1999).

Liver Disease During Pregnancy

Cholelithiasis and gallstone disease are seen in 3 to 12 of pregnant women, with higher incidence in the second and third trimesters. Most women are asymptomatic, however, up to 50 will have recurrent pain and worsening symptoms as pregnancy advances. Asymptomatic cholelithiasis requires no treatment. Symptomatic disease should initially be managed conservatively, but up to 35 will fail medication management and require surgical intervention. If possible surgery should be delayed until the second trimester. Likewise, medical management during the third trimester is preferable with surgical intervention following delivery.

Opened ampulla and common wall

Once a decision has been made to proceed with surgical relief of the obstructed bile duct, the choice of the appropriate operative procedure revolves around whether a resection is being done and the natural history of the problem causing the stricture. In this regard, the ultimate fate of the duodenum and lower bile duct figures prominently. By and large, resections of the bile duct are reconstructed with a Roux-en-Y cholehepatico-jejunostomy, or a hepaticojejunostomy if the anastomosis is up in the liver. Although it seems logical to bypass all benign strictures, a stricture situated high in the bile duct may be best handled by resection. The anastomosis is then performed in normal tissue above the scar. The reason is that a resection sometimes provides better exposure of the structures the surgeon wishes to preserve (portal vein and hepatic artery) while seeking more normal bile duct tissue. Conversely, benign strictures in the distal bile duct are often most expeditiously dealt...

Risk Factors Epidemiology

In general, simultaneous gastrointestinal procedures should be avoided during aortic surgery, though cholecystectomy may be an exception. Ouriel reported an incidence of postoperative cholecystitis of18 in patients with gallstones undergoing aortic repair without cholecystectomy.1 Several series have documented the safety of performing simultaneous cholecystectomy after closure of the posterior peritoneum over the aortic graft.

Indications for the Procedure

Intestinal transplantation is indicated in cases of intestinal failure, defined as the irreversible inability of the intestine to adequately sustain the body's nutritional, fluid, and electrolytic balance in the absence of parenteral support. Irreversible intestinal failure can be the result of loss of surface area, functional disturbances, or the presence of unresectable tumors involving the intestine. The etiology of these in turn can be either congenital or acquired. Clinical manifestations include but are not limited to dehydration, deficiencies of nutrients and vitamins, gallstones, stomach hyperacidity, renal stones, hyperoxaluria, skin irritation, and malabsorptive diarrhea. It has been observed that 20 of adults with 100 cm of intestine or end jejunostomy will be able to maintain nutritional requirements in the absence of total parenteral nutrition (TPN) (Messing et al, 1999). In the pediatric population, failure to wean from TPN has been found to be associated with absence of...

Vasoactive Intestinal Polypeptideproducing Tumors

The original report of a VIPoma was by Priest and Alexander in 1957, but it remained for Verner and Morrison, a year later, to fully characterize the entity as a distinct syndrome.4041 Synonyms for this disease include pancreatic cholera, Verner-Morrison syndrome, and WDHH. The latter term is a reference to the watery diarrhea, hypokalemia, and hypochlorhydria caused by these tumors. Initially, diarrhea is intermittent, and during periods of quiescence, stools are semisolid and relatively few in number. Progressively, however, the diarrhea becomes more severe and unrelenting. Because the diarrhea is secretory and hypermotility is not a feature, crampy abdominal pain is unusual. Characteristically, patients may have 10 to 15 bowel movements and produce up to 10 L of tea-colored liquid stool per day. Approximately 50 of these patients have hyperglycemia caused by the glucagon-like activity of VIP. Hypercalcemia and hypomagne-semia are also common. Twenty percent of patients...

Analytic Issues 2131 Compliance

A second analytic issue relates to missing data for either efficacy or safety evaluations. The set of subjects included in a safety evaluation may differ from those included in the efficacy evaluation. The measurements needed for safety may not be recorded because they never were taken (e.g., no tests of an organ system because there was no suspicion of an effect on that system), because they were considered optional, or for other reasons. Thus, it may not be possible to distinguish those truly missing responses from responses implying no safety concern. Efforts in controlled trials to minimize the amount of missing primary efficacy outcome data frequently cannot be applied to emerging safety concerns. The mechanisms of missingness may be very different for safety outcomes than for efficacy outcomes Touloumi et al. (2002) and Mertens (1993) . Missing essential information often cannot be anticipated, for example, a spontaneous report of a case of suspected drug-induced pancreatitis...

Chronic Acalculous Cholecystitis Presentation

This diagnosis is synonymous with gallbladder dyskinesia. Patients present with similar complaints as those with chronic cholecystitis however, gallstones are absent on US. Typical presenting symptoms include nausea, bloating, fatty food intolerance, vomiting, weight loss, irregular bowel habits, and fever. There is a strong female predominance approximately 80 of patients with this disease entity are female. Gallbladder dyskinesia is frequently associated with other gastrointestinal (GI) motility disorders, such as irritable bowel syndrome.

Gallbladder And Biliary Imaging

Gallbladder Wall Anatomy

Ultrasound and cholescintigraphy are the preferred imaging methods for the routine evaluation and diagnosis of gallbladder pathology and each offers unique advantages and limitations. Ultrasound is used most frequently for several reasons. First, the typical right upper quadrant ultrasound exam can be performed quickly and takes about 15 min for the experienced technician to complete. Second, other abdominal organs such as the liver, pancreas, kidneys, and spleen can be visualized and other sources of pain and symptoms can be diagnosed when the gallbladder is normal. Third, the possibility of other gallbladder pathology, cancer for example, may be evaluated. Finally, ultrasound can identify gallstones, thickening of the gallbladder wall, pericholecystic fluid and tenderness when the ultrasound probe presses down directly over the gallbladder (sonographic Murphy sign). This constellation of ultrasound findings is highly sensitive and specific for the diagnosis of acute cholecystitis (...

Coagulation Disorders

In a process as complex as coagulation, it is not surprising that things can go wrong. Clotting deficiencies can result from causes as diverse as malnutrition, leukemia, and gallstones (see insight 18.4). Proper blood clotting depends on normal liver function for two reasons. First, the liver synthesizes most of the clotting factors. Therefore, diseases such as hepatitis, cirrhosis, and cancer that degrade liver function result in a deficiency of clotting factors. Second, the synthesis of clotting factors II, VII, IX, and X require vitamin K. The absorption of vitamin K from the diet requires bile, a liver secretion. Gallstones can lead to a clotting deficiency by obstructing the bile duct and thus interfering with bile secretion and vitamin K absorption. Efficient blood clotting is especially important in childbirth, since both the mother and infant bleed from the trauma of birth. Therefore, pregnant women should take vitamin K supplements to ensure fast clotting, and newborn infants...

Indirect Inguinal Hernia

Indirect inguinal hernia (Fig. 1.19) occurs when the processus vaginalis persists, connecting the peritoneal cavity of the abdomen and that of the scrotum or major labium. Indirect inguinal hernia is common in all ages and in both sexes. Kahn and Hamlin 45 concluded that patent processus vaginalis is not always a prerequisite for the occurrence of indirect inguinal hernia. It is often associated with cryptorchid testis and hydrocele. Incarcerated indirect inguinal hernia may occur as a complication of spilled gallstones 54-56 . Persistent processus vaginalis may be unmasked by the presence of fluid that fills this peritoneal extension and presents as a scrotal or occasionally as labial edema. In a large indirect inguinal hernia, the inguinal canal is no longer oblique due to the close proximity of the dilated superficial and deep inguinal rings. Since the deep inguinal ring lies lateral to the inferior epigastric vessels, the neck of the hernial sac protrudes through the lateral...

Endoscopic Retrograde Cholangiopancreatography with Stone Removal

Use of endoscopic sphincterotomy alone can be considered in patients who are either unable or unwilling to undergo cholecystectomy. However, endoscopic sphinc-terotomy alone may be associated with an unacceptably high risk of recurrent symptoms or complications (Boerma et al, 2002). Thus, in most patients, endoscopic sphinc-terotomy should be accompanied by cholecystectomy for definitive management of gallstones.

Extracorporeal Shock Wave Lithotripsy

Large gallbladder stones in patients who are not surgical candidates or common bile duct stones that cannot be removed using standard endoscopic techniques may need to be fragmented using extracorporeal shock-wave lithotripsy. This is only available in selected centers within the United States. Several different types of lithotripters are available, which differ in their method of generating the shock waves and in specific operating characteristics. To be a candidate for lithotripsy, patients should have few stones (usually 3) and a functioning gallbladder with a patent cystic duct. The stones should be radiolucent, and generally 20 mm in diameter. Very small stones may be difficult to target, and some centers will exclude patients with stones less 5 to 10 mm in diameter. Patients who have coagulation or platelet abnormalities, vascular anomalies of the liver, acute gallstone-related complications, or who are pregnant are not good candidates for lithotripsy.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy has, over the past 10 years, evolved to become the standard procedure for symptomatic gallstones. The majority of cholecystectomies are now performed via this route but certain preconditions must apply before this should be undertaken. These are as follows There must be no evidence of biliary obstruction as determined by the liver function tests. Transabdominal ultrasound should always be performed to confirm the diagnosis of gallstones and exclude the presence of intra- and extrahepatic biliary dilation. The patient must have proven gallstones as the cause of their symptoms. Gallstones causing (b) Gallstone pancreatitis

Intrahepatic Cholestasis of Pregnancy

Diagnosis is made clinically, based upon history, symptoms, and laboratory studies. Other causes of liver disease, such as viral hepatitis or gallstone disease, must be ruled out. Liver biopsy is rarely needed and histopathology reveals normal portal tracts, and bland cholestasis, with bile plugs predominating in zone 3.

Pathophysiology Of Cholithiaisis

Gallstone Pancreatitis The role of ERCP in acute pancreatitis involves the treatment of an impacted or ball-valving CBD stone. Gallstones are implicated in 50 to 80 of cases of acute pancreatitis. Supportive care is the mainstay of treatment for acute gallstone pancreatitis, but early recognition of gallstone pancreatitis is imperative. Abdominal imaging with US demonstrating the presence of cholelithiasis and elevated transaminases have a high predictive value for diagnosing acute gallstone pancreatitis. The timing of endoscopic sphincterotomy with stone extraction should be performed in specific clinical scenarios either before or after chole-cystectomy. ERCP should be performed before cholecys-tectomy if the patient has concomitant cholangitis, obstructive jaundice, or severe pancreatitis not responding to conservative measures. However, preoperative ERCP is of low yield and is not indicated in the majority of patients with resolving or normal liver enzymes. Patients should undergo...

Medical Therapy Oral Bile Acid Dissolution Therapy

Dissolution of cholesterol gallstones with oral bile acid supplementation is appropriate in selected candidates. The two bile acids which have been studied are chenodeoxycholic acid and UDCA.However, UDCA (ACTIGAL) has very few side effects, and has become the preferred bile acid for this indication. UDCA works by decreasing biliary cholesterol secretion and thus inducing the secretion of undersatu-rated bile. This favors the dissolution of cholesterol stones. To be considered for this therapy, patients should have small cholesterol gallstones (preferably 10 mm) with a patent cystic duct. Stones with a diameter greater than 15 mm cannot usually be treated successfully. The number of stones is not an absolute contraindication to bile acid dissolution therapy. Cystic duct patency can be documented by hepatobiliary scintigraphy or, occasionally, by oral cholecystography. Some experts recommend evaluating stones by computed tomography to be sure they are buoyant and isodense or hypodense...

Long Acting Somatostatin Analogues

The side effects of treatment with synthetic somatostatin analogues include cramping or nausea, which usually resolve with continued treatment, and pain at the subcutaneous injection site, which may be reduced by slow injection and warming the vial. Worsening of glucose tolerance develops in some patients, and it is advisable to obtain a serum glucose determination when beginning the medication. A small percentage of patients may develop fat malabsorption. Long term, the principal side effect is the development of biliary sludge or gallstones, thought to be due to the ability of somatostatin to inhibit gallbladder emptying. In various studies with long-term treatment, 10 to 50 of patients have developed biliary sludge or gallstones, but in only 1 to 10 is it symptomatic. With long-term treatment, an ultrasound examination of the gallbladder before the treatment and every 6 to 12 months should be considered (Redfern and Fortuner, 1995).

Indications and Evaluation

Currently, the Centers for Disease Control and Prevention estimates 600,000 to 750,000 cholecystectomies are performed annually in the United States. Cholecystectomy is classically indicated to treat signs, symptoms, and complications of gallstones. Despite the relatively low risks associated with laparoscopic cholecystectomy, the procedure should be limited to symptomatic patients. These patients are at increased risk of developing complications including acute cholecystitis, common bile duct obstruction, cholangitis, and pancreatitis. Evidence exists that these complications seldom develop at initial presentation, so asymptomatic patients are generally treated with watchful waiting. Laparoscopic chole-cystectomy is also indicated for patients without gallstones but typical biliary colic. These patients may have acalculous cholecystitis or biliary dyskinesia diagnoses made by quantitative gallbladder emptying or radio-nucleotide study. patients to undergo gallbladder surgery, leading...

Acute Pancreatitis

The endoscopic approach to a patient with acute pancreatitis most commonly is in the setting of acute gallstone-induced pancreatitis. Acute pancreatitis related to bile duct stones is suspected in patients with gallstones, elevated liver function tests, particularly those with alanine amino-transferase levels greater than three times the upper limit of normal, and a dilatated common bile duct (CBD) by ultrasonography or computed tomography (CT) scan. Biliary sphincterotomy of the major papilla affords removal of stones in the bile duct, if present, and also affords a patent biliary sphincter to allow for future stone passage in the setting of gallbladder stones or microlithiasis. The challenge to endoscopists is to determine which patients with suspected acute gallstone pancreatitis would benefit from ERCP and biliary sphincterotomy. Four prospective studies have addressed early ERCP within 72 hours of admission in patients with gallstone pancreatitis (Fogel and Sherman, 2003). ERCP,...

Early Complications

Although, complications such as pancreatitis, or bowel perforations from cautery injuries can occur after cholecystectomy, bile leaks and bile duct obstruction are the notorious perioperative procedure-related complications. The most threatening morbidity of cholecystectomy comes from damaging the main bile duct. Patients who present with abdominal pain, fever, chills, leukocytosis, or jaundice should be evaluated for either of these complications. Liver function tests and ultrasound are chosen to determine if the etiology is caused by biliary obstruction or leak. A bile leak on ultrasound will manifest as a fluid collection in the right upper quadrant while an obstruction is diagnosed by dilated intrahepatic or extrahepatic bile ducts. Whereas in-depth management of complications following cholecystectomy is beyond the scope of this chapter, several tests and procedures are undertaken in each of these circumstances. Abdominal bile collections are drained percutaneously under...

Open Cholecystectomy

Cholecystectomy is one of the most commonly performed operations, with over 700,000 performed annually in the United States. Cholecystectomy is the only definitive therapy for symptomatic gallstones. Elective cholecystectomy is usually safe, with mortality rates of less than 0.1 to 0.2 . The TABLE 132-1. Management Options for Symptomatic Gallstones Open cholecystectomy Symptomatic gallstones Laparoscopic Symptomatic gallstones 100 Retained common bile duct stones Severe acute pancreatitis Bile leak after cholecystectomy Acute cholangitis Symptomatic gallstones Unwilling or unable to undergo patent cystic duct-cholecystectomy Functioning gallbladder Floating radiolucent stones, 10 mm in diameter Symptomatic gallstones Unwilling or unable to undergo cholecystectomy or without oral bile Patent cystic duct functioning acid supplementation gallbladder Requires general anesthesia Definitive treatment for gallstones Possible bile duct injury Requires general anesthesia Definitive treatment...


The prevalence of cholelithiasis in patients with cirrhosis is higher than in the general population. In a series that included 23 patients with PBC, 39 were found to have gallstones. There are specific recommendations on the management of gallstones associated with symptoms, which will not be reviewed in this section however, it is important to state that in patients with cirrhosis gallbladder surgery carries an important risk for complications. The effect of UDCA, the treatment approved for PBC, on the incidence of gallstones in this disease has not been published.


(surgeon, anesthesia, and consultant fees) are approx 3600. However, the overall costs for the management of symptomatic gallstones appears to have been increased by this technology because a greater percentage of patients and physicians have been opting for surgical management than they did when open surgery was their only option (27).


Approximately 15 of Americans have gallstones, with roughly 20 of the patients developing symptoms over their lifetime. Bile duct stones are classified as primary if they form within the bile ducts, or secondary if associated with gallstones (cholecystolithiasis). The majority of bile duct stones in Western society are secondary, and composed of almost pure cholesterol (yellow stones). Primary bile duct stones are less common in Western countries and contain higher concentrations of bilirubin. Bacterial infection and biliary stasis have been postulated as important factors in the formation of primary bile duct stones. Common bile duct (CBD) stones are seen in 15 of patients undergoing cholecystectomy for symptomatic gallbladder disease. Choledocholithiasis may be asymptomatic or present with acute cholangititis, pancreatitis, and, rarely, with hepatic abscesses. In most cases, the obstruction is incomplete, but in a minority of cases the obstruction may be complete and persistent,...


Excess weight shortens life expectancy and increases a person's risk of atherosclerosis, hypertension, diabetes mellitus, joint pain and degeneration, kidney stones, and gallstones cancer of the breast, uterus, and liver in women and cancer of the colon, rectum, and prostate gland in men. The excess thoracic fat in obese people interferes with breathing and results in increased blood Pco2, sleepiness, and reduced vitality. Obesity is also a significant obstacle to successful surgery.


Somatostatinomas typically occur in the pancreas or small bowel. The mean age of onset is 50 years. Most are solitary and large (average size 5 cm) and have metastases to lymph nodes or liver.28 This hormonal syndrome typically presents with mild diabetes, gallbladder disease, weight loss, anemia, diarrhea, steatorrhea, and hypochlorhydria.29 The clinical effects are more common in tumors located in the pancreas compared with tumors in the duodenum. These tumors are typically first noticed incidentally during intra-abdominal imaging. The diagnosis is then made by an increase in somatostatin-like immunoreactivity in plasma and or an increase in the number of D cells defined by immunohistochemical stains of the tumor.

Late Complications

The possibility of a relationship between increased colon cancer risk and gallstone disease has been entertained for years. It is believed that the same environmental, dietary and genetic factors that predispose to gallstones may also increase risk for colorectal cancer. The postcholecystectomy state itself, however, does not appear to change the risk of colon cancer (23). Patients who have persistent pain after cholecystectomy often did not have histories consistent with symptomatic gallstone disease in the first place, even though they had gallstones on ultrasound. In such patients, there has probably been a failure of proper patient selection rather than a complication of the operation. Overall, cholecystectomy is a very reliable and safe procedure. Moreover, the addition of laparoscopy has significantly reduced postoperative pain and shortened the recovery period.

HELLP Syndrome

Periportal Lymph Breast Cancer

The definitive diagnosis of HELLP syndrome requires clinical suspicion as well as timely and appropriate laboratory screening. The differential diagnosis includes other causes of hematologic and or liver abnormalities, such as AFLP, appendicitis, viral hepatitis, gallbladder disease, gastroenteritis, ulcer disease, idiopathic thrombocytopenia purpura, hemolytic-uremic syndrome, or thrombotic thrombocytopenic purpura. Microangiopathic hemolytic anemia, thrombocytopenia, and elevated serum aminotransferase activity are essentially always seen in the HELLP syndrome. Liver biopsy is rarely needed to establish the diagnosis, and women with the HELLP syndrome may not have evidence of hepatic synthetic dysfunction (see Figure 120-2).

Short Bowel Syndrome

Patients with SBS not only have an inadequate absorptive surface but also have an increased intestinal transit time. These patients have an elevated serum gastrin level and the excess gastric acid that is produced exacerbates the diarrhea (1,8). The mechanism for the hypergastrinemia is not known and this state is usually transient (1,8). In addition, the loss of brush border hydrolases causes inadequate carbohydrate breakdown, contributing to osmotic diarrhea. If the terminal ileum has been resected, bile acids are not well absorbed, which results in sodium and water secretion in the colon, again adding to diarrhea. Loss of the bile acid pool will cause steatorrhea and malabsorption of fat-soluble vitamins (A, D, E, and K). This disruption of the enterohepatic circulation of bile can lead to both cholesterol gallstones and oxalate kidney stones. Thirty-five to forty percent of patients with SBS have been found to develop gallstones (10). Risk factors for the development of...

Abdominal Pain

An initial examination by ultrasonography should be performed to assess for the presence of gallstones and a thickened gallbladder wall, suggestive of inflammation. If this is equivocal, biliary scintigraphy should be performed to rule out acute cholecystitis. If the gallbladder fills and CCK fails to elicit gallbladder emptying this suggests chronic cholecystitis. The sensitivity of biliary scintigraphy is preserved as long as hepatic bilirubin metabolism is intact. A total bilirubin 10 mg dL makes this diagnostic test less useful. Once acute or chronic cholecystitis is diagnosed, surgical therapy should be considered even in the SCT patient. Because thrombocytopenia frequently coexists, surgery is delayed until platelet counts can be maintained over 100 K mm3 with or without platelet transfusions. Such patients require triple antibiotic therapy until the cholecys-tectomy can be safely performed. Another option to consider is endoscopic gallbladder stenting, which has been...

Get Rid of Gallstones Naturally

Get Rid of Gallstones Naturally

One of the main home remedies that you need to follow to prevent gallstones is a healthy lifestyle. You need to maintain a healthy body weight to prevent gallstones. The following are the best home remedies that will help you to treat and prevent gallstones.

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