Gallstones in patients with liver cirrhosis: Incidence, etiology, clinical and therapeutical aspects

Abstract

Gallstones occur in about one third of the patients having liver cirrhosis. Pigment gallstones are the most frequent type, while cholesterol stones represent about 15% of all stones in cirrhotics. Increased secretion of unconjugated bilirubin, increased hydrolysis of conjugated bilirubin in the bile, reduced secretion of bile acids and phospholipds in bile favor pigment lithogenesis in cirrhotics. Gallbladder hypomotility also contributes to lithogenesis. The most recent data regarding risk factors for gallstones are presented. Gallstone prevalence increases with age, with a ratio male/female higher than in the general population. Chronic alcoholism, viral C cirrhosis, and non-alcoholic fatty liver disease are the underlying liver diseases most often associated with gallstones. Gallstones are often asymptomatic, and discovered incidentally. If asymptomatic, expectant management is recommended, as for asymptomatic gallstones in the general population. However, a closer follow-up of these patients is necessary in order to earlier treat symptoms or complications. For symptomatic stones, laparoscopic cholecystectomy has become the therapy of choice. Child-Pugh class and MELD score are the best predictors of outcome after cholecystectomy. Patients with severe liver disease are at highest surgical risk, therefore gallstone complications should be treated using noninvasive or minimally invasive procedures, until stabilization of the patient condition.

Liver cirrhosis

“…[13,14,16–18] Specifically, Conte et al [19] followed 618 cirrhotic patients and found that the probability of developing gallstones increased in a time-dependent manner. Moreover, Fornari et al [20] determined that cirrhosis is a risk factor for gallstones in males.…”

Index admission cholecystectomy for acute biliary pancreatitis favorably impacts outcomes of hospitalization in cirrhosis

“…[1][2][3] Mortality from acute biliary pancreatitis (ABP) in the general population is 1-3%. [5][6][7] In addition, there is an increasing prevalence of gallstones as liver disease worsens within these patients. [5][6][7] In addition, there is an increasing prevalence of gallstones as liver disease worsens within these patients.…”

Short‐term outcome of total clipless laparoscopic cholecystectomy for complicated gallbladder stones in cirrhotic patients

“…Only a small proportion of cirrhotic patients harbour cholesterol stones. The factors leading to gallstone formation are the changes in bile composition (supersaturation of the bile with calcium bilirubinate for pigment stones or supersaturation with cholesterol for cholesterol stones), enhanced crystal nucleation in the presence of mucin and its congeners and gallbladder (GB) hypomotility (stasis) that allows crystals to grow into gallstones …”

“…Since laparoscopy was introduced in the late 1980s, it has been generally approved as the standard approach for cholecystectomies with the exception of end‐stage cirrhosis which was declared by NIH consensus statement in 1992 to be a contraindication . It was thought that the NIH came out with this concept because in the era prior to laparoscopic cholecystectomy (LC), published postoperative mortality in cirrhotic patients undergoing OC was 7.5–25.5% and patients with the most advanced liver disease were at the greatest risk.…”