Metabolisme batu empedu

Epidemiologi
the third National Health and Nutrition
Examination Survey (NHANES III) has revealed
an overall prevalence of gallstones of 7.9% in
men and 16.6% in women. The prevalence
was high in Mexican Americans (8.9% in men,
26.7% in women), intermediate for non-
Hispanic whites (8.6% in men, 16.6% in
women), and low for African Americans (5.3%
in men, 13.9% in women).

Epidemiologi

Patogenesis
Gallstones are formed because of abnormal bile
composition.
They are divided into two major types:
cholesterol stones (80%) : Cholesterol gallstones usually
contain >50% cholesterol monohydrate plus an
admixture of calcium salts, bile pigments, and proteins.
pigment stone (20%) : Pigment stones are composed
primarily of calcium bilirubinate; they contain <20%
cholesterol and are classified into "black" and "brown"
types, the latter forming secondary to chronic biliary
infection

cholesterol gallstone disease occurs because of
several defects, which include (1) bile
supersaturation with cholesterol, (2)
nucleation of cholesterol monohydrate with
subsequent crystal retention and stone
growth, and (3) abnormal gallbladder motor
function with delayed emptying and stasis
Pigment stones
Black pigment stones are composed of either pure
calcium bilirubinate or polymer-like complexes
with calcium and mucin glycoproteins.
Brown pigment stones are composed of calcium
salts of unconjugated bilirubin with varying
amounts of cholesterol and protein.
Pigment stone formation is especially prominent in
Asians and is often associated with infections in
the gallbladder and biliary tree
Table 311-1 Predisposing Factors for Cholesterol and Pigment Gallstone Formation


Cholesterol Stones
1. Demographic/genetic factors: Prevalence highest in North American Indians, Chilean Indians, and Chilean Hispanics, greater in Northern Europe and North
America than in Asia, lowest in Japan; familial disposition; hereditary aspects
2. Obesity, metabolic syndrome: Normal bile acid pool and secretion but increased biliary secretion of cholesterol
3. Weight loss: Mobilization of tissue cholesterol leads to increased biliary cholesterol secretion while enterohepatic circulation of bile acids is decreased
4. Female sex hormones
a. Estrogens stimulate hepatic lipoprotein receptors, increase uptake of dietary cholesterol, and increase biliary cholesterol secretion
b. Natural estrogens, other estrogens, and oral contraceptives lead to decreased bile salt secretion and decreased conversion of cholesterol to cholesteryl esters
5. Increasing age: Increased biliary secretion of cholesterol, decreased size of bile acid pool, decreased secretion of bile salts
6. Gallbladder hypomotility leading to stasis and formation of sludge
a. Prolonged parenteral nutrition
b. Pregnancy
c. Fasting
d. Drugs such as octreotide
7. Clofibrate therapy: Increased biliary secretion of cholesterol
8. Decreased bile acid secretion
a. Primary biliary cirrhosis
b. Genetic defect of the CYP7A1gene
9. Decreased phospholipid secretion: Genetic defect of the MDR3 gene
10. Miscellaneous
a. High-calorie, high-fat diet
b. Spinal cord injury
Pigment Stones
1. Demographic/genetic factors: Asia, rural setting
2. Chronic hemolysis
3. Alcoholic cirrhosis
4. Pernicious anemia
5. Cystic fibrosis
6. Chronic biliary tract infection, parasite infections
7. Increasing age
8. Ileal disease, ileal resection or bypass
Diagnostic Evaluation of the
Gallbladder
Diagnostic Advantages Diagnostic
Limitations
Comment
Gallbladder Ultrasound
Rapid
Accurate identification of gallstones
(>95%)
Simultaneous scanning of GB, liver, bile
ducts, pancreas
"Real-time" scanning allows assessment of
GB volume, contractility
Not limited by jaundice, pregnancy
May detect very small stones
Bowel gas
Massive obesity
Ascites
Procedure of choice for
detection of stones
Diagnosis advantages Diagnosis limitations comments
Plain Abdominal x-ray
Low cost Relatively low yield Pathognomonic findings in: calcified
gallstones
Readily available ? Contraindicated in pregnancy Limey bile, porcelain GB
Emphysematous cholecystitis
Gallstone ileus
Radioisotope Scans (HIDA, DIDA, etc.)
Accurate identification of cystic
duct obstruction
? Contraindicated in pregnancy Indicated for confirmation of suspected
acute cholecystitis; less sensitive and
less specific in chronic cholecystitis;
useful in diagnosis of acalculous
cholecystopathy, especially if given with
CCK to assess gallbladder emptying
Simultaneous assessment of bile
ducts
Serum bilirubin >103205
mol/L (612 mg/dL)

Cholecystogram of low
resolution
Diagnostic Evaluation of the
Gallbladder
Examples of ultrasound and radiologic studies of the biliary tract. A. An ultrasound study showing a distended
gallbladder containing a single large stone (arrow), which casts an acoustic shadow. B. Endoscopic retrograde
cholangiopancreatogram (ERCP) showing normal biliary tract anatomy. In addition to the endoscope and large
vertical gallbladder filled with contrast dye, the common hepatic duct (CHD), common bile duct (CBD), and
pancreatic duct (PD) are shown. The arrow points to the ampulla of Vater. C. Endoscopic retrograde cholangiogram
(ERC) showing choledocholithiasis. The biliary tract is dilatated and contains multiple radiolucent calculi. D. ERCP
showing sclerosing cholangitis. The common bile duct shows areas that are strictured and narrowed.
Symptoms of Gallstone Disease
biliary colic (a constant and often long-lasting pain, colic begins quite
suddenly and may persist with severe intensity for 15 min to 5 h,
subsiding gradually or rapidly)
Nausea and vomiting
epigastric fullness, dyspepsia, eructation, or flatulence, especially
following a fatty meal
jaundice
Jaundice, or icterus, is a yellowish
discoloration of tissue resulting from the
deposition of bilirubin. Tissue deposition of
bilirubin occurs only in the presence of serum
hyperbilirubinemia and is a sign of either liver
disease or, less often, a hemolytic disorder
Production and Metabolism of
Bilirubin
heme
Enzym
heme
oxygenase
biliverdin
Enzym
biliverdin
reduktase
Unconjugated
bilirubin (insoluble
in water)
Bound to albumin
Transported
to liver
bilirubin is
solubilized by
conjugation to
glucuronic acid
Excreted into bile
drains into
duodenum
hydrolyzed to
unconjugated
bilirubin by
bacterial -
glucuronidases.
Unconjugated
bilirubin
reduced
by
normal
gut
bacteria
urobilinoge
n
hiperbilirubinemia
The bilirubin present in serum represents a
balance between input from production of
bilirubin and hepatic/biliary removal of the
pigment. Hyperbilirubinemia may result from
(1) overproduction of bilirubin; (2) impaired
uptake, conjugation, or excretion of bilirubin;
or (3) regurgitation of unconjugated or
conjugated bilirubin from damaged
hepatocytes or bile ducts