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Forum Name: Surgery Topics

Question: MY USN SHOWS A 2.7-CM GALLSTONE


 BarBDoll - Mon Aug 23, 2010 1:47 pm

Hello,
I’m a 59-year-old Caucasian female in overall good general health, BMI of 23.5, status post TAH/BSO 18 years ago. After recently having some RUQ discomfort I was diagnosed by USN to have a solitary 2.7-cm gallstone. Am having surgical consult next week. I have been doing medical transcription for many years, including many op notes for cholcystectomies, and do not ever recall hearing of any gallstone that large! Not sure why I ended up with one big one instead of many tiny ones like most people, but I am somewhat concerned about how its size might affect treatment. Can I still have a lap chole, or will it have to be open because of the size, or might there be another alternative such as lithotripsy? Thank you in advance for your input.
 Dr.M.Aroon kamath - Sun Sep 05, 2010 3:14 am

User avatar Hi,
Gall stones come in several sizes. They can be
- solitary or
- multiple.

The multiple stones can be
- of uniform size (belong to the same generation), or
- may be of different sizes(belonging to different generations).

The multiple, small stones tend to pass down the biliary tract causing complications such as
- biliary colic,
- common bile duct obstruction,
- acute pancreatitis and
- cholangitis.

The larger gall bladder stones also can cause several problems including,
- acute or chronic calculus cholecystitis,
- they may get into the part of the gall bladder called as the neck of the gall bladder and cause obstruction leading to an empyema of the gall bladder,
- they may get lodged in the Hartmann's pouch, fistulate into the common bile duct and cause obstructive jaundice(Mirrizi's syndrome), or
- large solitary gall stones, sizes ranging from 2-5 cms may enter the bowel through a cholecystoduodenal fistula and cause small gut obstruction ("gall stone ileus"). Sometimes, a large stone may fistulate into the stomach and cause gastric outlet obstruction (Bouveret's syndrome).

For an overview on gall stone disease please click on the following URL.
viewtopic.php?f=84&t=50537&hilit=+gall+stones

A single large stone (>2cm) in the Hartmann's pouch can cause inflammatory changes and adhesions in that area and result in increased conversion rates (conversion to open cholecystectomy).
(Jansen S, Jorgensen J, Caplehorn J, et al. Preoperative ultrasound to predict conversions in laproscopic cholecystectomy. Surg Laparosc Endosc 1997;7:121-3).

Extracorporeal shock wave lithotripsy (ESWL) for gallstones may be appropriate when all of the following criteria are met:
- when the procedure is performed in conjunction with bile acid therapy, and
- the patient has symptomatic non-calcified solitary gallstone measuring 20 mm or less, and
- the small subset of symptomatic patients for whom surgical removal of the gallbladder is contraindicated for some reason
or the small subset of symptomatic, high-risk patients who actively refuse surgery.

The FDA approved use of biliary lithotripsy includes the administration of bile acid (ursodeoxycholic acid) 2 weeks prior to the procedure and continues up to 20 months after or until a stone-free state is achieved. The best results have been seen in patients with a single non-calcified gallstone measuring less than 20 mm in diameter. Patients with fragments of 3 mm or less 24 hours following lithotripsy have a higher probability of fragment disappearance than those with larger fragments.

However, cholecystectomy still represents the treatment of choice, due to the prompt resolution of symptoms in well selected patients and the absence of stone recurrence, which may recur at a rate of 10% per year in the absence of cholecystectomy.

In your case,a solitary stone of 2.7cms in itself, is not a contraindication for laparoscopic cholecystectomy, but conversion rates may be higher if it is in the Hartmann's pouch or if there have been many past episodes of acute cholecystitis. Lithotripsy may not be a suitable option based on the size.
Best wishes!

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