Good Research Paper About Gallstones

Gallstones are also called as cholelith and the development of gallstones is called as

cholelithiasis, these stones develop as a result of defect in the metabolism of the bile pigments and cholesterol which tend to form hard stones. Large population of the world now suffers from gallstones. It is the result of the lifestyle disorders nowadays. Number of factors may contribute to the formation of these stones; some of them are diet, genetics, obesity and decreased motility of the gall bladder. Gallstones form when there is an imbalance in the constituting elements of bile, if there is an excess of cholesterol then cholesterol stones may form. Pigment stones are commoner in patients suffering from some medical conditions like sickle cell anemia or cirrhotic liver.
(Webmd.com)
1.1. Risk factors
1.1.1. Genetics: If there is any other family member who has a history of gallstone then there is always an increased chance of developing gallstone.
1.1.2. Obesity: Obesity is a prime cause for development of gallstones. In obese people the cholesterol level is high; also the gall bladder emptying is delayed. This leads to the formation of gallstones. With increasing prevalence of obesity across the globe, the occurrence of gallstones has also increased.
1.1.3. Hormonal influence: Estrogen has a role in increasing blood cholesterol levels and decreasing gall bladder motility. Therefore, women taking oral contraceptive pills or those who are pregnant are at increased risk of gallstone formation as they are exposed to high levels of estrogen for prolonged period of time.
1.1.4. Ethnicity: Certain ethnic groups have a predisposition to develop gallstones. According to studies, it can be said that Native Americans and Mexican Americans are more likely to develop gallstones.
1.1.5. Age and Sex: Gallstones are commoner in the elderly age group and among females. There is a saying about gallstones which sums it up all, “fat female fertile forty”, which means the disease has a female preponderance who are likely of the middle or the elderly age group, being exposed to high levels of estrogen throughout their lives and along with all that, obese in body structure.
1.1.6. Diabetes: In patients who are diabetic, the triglyceride levels are higher than normal individuals, triglycerides being a fat, increases the risk of gallstones.
1.1.7. Losing weight at a fast pace: People attempting to lose weight tend to fast, thus the gall bladder motility is decreased. In these individuals the secretion of cholesterol from the liver is higher than normal individuals. Both the factors together contribute towards development of gallstones. As the incidences of obesity are increasing, simultaneously people are becoming more and more conscious about their health. Prolonged fasting leads to reduced gall bladder motility.
1.2. Clinical Presentation
1.2.1. Typical presenting complaints: Pain in right upper quadrant, radiating to right scapular tip and upper back, lasting for several hours. Nausea, vomiting, heartburn, flatulence etc. these symptoms are commonly found in almost all the gallstone patients. The intensity of the symptoms may vary (Webmd.com).
1.2.2. Atypical presenting complaint: In a case studied by Chatterjee et al, they observed a patient with gallstone impacted at the terminal ileum. The patient reported with vomiting and anuria. During intraoperative procedures, the gallstone was found at the duodeno- jejunal flexure (Chatterjee et al.).
1.3. DIAGNOSIS
1.3.1. X- ray: X- ray will help in visualizing the stone along with their site.
1.3.2. Ultrasonography: Ultrasonography is a better option than X-ray. It not just helps in visualizing the stone, but can also help in determining the type of stone.
1.3.3. MRCP or Magnetic Resonance Cholangeopancreatography: This test takes the pictures of the liver and gall bladder by the use of radio waves and magnetic energy.
1.3.4. HIDA Scan or cholescintigraphy: This test helps in determining the motility of the gall bladder.
1.3.5. ERCP or Endoscopic Retrograde Cholangiopancreatography: This test can be used for both diagnostic and therapeutic purpose.
1.4. MANAGEMENT
1.4.1. Conservative Management: Doctors may prescribe certain medications for the treatment of the gallstones. They aim at dissolving the stones. Two of those drugs are ursodiol or Actigall and chenodiol or Chenix. But conservative treatment has very little role to play. The medications may be needed to be taken for years. Also there are chances that the gallstones may reappear after few years.
1.4.2. Surgical Intervention: Open cholecystectomy is the treatment of choice when considering surgical intervention. The gall bladder is removed by making an upper abdominal incision.
1.4.3. Laparoscopic Cholecystectomy: This procedure is carried out by the use of lights and camera. The surgeon visualizes the interior of the abdomen and performs the cholecystectomy by making multiple incisions in the abdomen.
1.4.4. ERCP: As explained above, this procedure can be both diagnostic and therapeutic. If the gallstone is lodged in the bile duct then this method may help in its removal (Webmd.com).
1.5. COMPLICATIONS
1.5.1. Acute cholecystitis: A severe gallstone infection may occur in cases where the stones suddenly block the bile duct. Thus giving rise to acute symptoms and a medical emergency.
1.5.2. Jaundice: In almost one third patient of acute cholecystitis, jaundice has been found to be a common finding.
1.5.3. Acute Cholangitis: Obstruction of the bile duct also makes it susceptible to inflammation. Thus giving rise to acute cholangitis.
1.5.4. Acute Pancreatitis: This will happen if the gallstone moves out of the gall bladder and blocks the opening of the pancreatic duct. This is an emergency, life threatening condition.
1.5.5. Cancer of the Gall bladder: This is rare, but a serious complication. According to data, 660 new cases of gall bladder cancer are registered each year in UK.
1.5.6. Gallstone Ileus: In this the bowel becomes obstructed by a gallstone. Although considered rare, but good numbers of cases are recorded. In England in 2012- 13 almost 300 patients were hospitalized with the diagnosis of gallstone ileus (Nhs.uk).

DIVERTICULITIS

In order to understand diverticulitis first we need to know about diverticulosis. Diverticulosis is formation of pouches or sacs in the inner lining of the large intestine. It is a common occurrence in patients over 60. The cause of formation of this diverticulosis is not known exactly. But it is assumed that low intake of fiber could be a cause. Lower fibrous intake will lead to constipation, in an attempt to strain fro stool much pressure would be exerted on the walls of the intestine. Thus leading to the formation of these pouches. Impaction of stool in these pouches will make them prone to infections or inflammations. Therefore the inflammation of these pouches is called as diverticulitis.
(Medicinenet.com)

Clinical Presentation

Typical Presentation: Diverticulitis presents with severe and sudden symptoms, worsening within few days. The common symptoms are tenderness on the lower left quadrant of the abdomen, bloating, loss of appetite, nausea, vomiting and fever with chills. Some patients may present with diarrhea or constipation (Nlm.nih.gov).
Atypical Presentation: In certain complicated cases, the patients may present with abscess, phlegmon, obstruction, fistulization, bleeding, sepsis, generalized peritonitis, and/or stricture (Albrecht).

Differential Diagnosis

Carcinoma of the sigmoid colon: Both the diseases have certain similar manifestations. Patients with acute attack, previous history of diverticulitis attacks, dull lower abdominal pain, leukocytosis and fever mostly indicate towards diverticulitis; whereas gradual onset of symptoms, weight loss, bleeding per rectum and anemia points towards rectal carcinoma (Morton and Goldman).

Diagnosis

Blood test: Blood test may be required to diagnose if there is any underlying infection.
CT scan: Complete study of the abdomen may be carried out by this test.
Ultrasound: It will help in determining the exact nature of obstruction.
X- ray: This would give the very basic idea regarding the site of infection by showing air fluid levels.
Management
Management depends on the severity of the symptoms. At times the patient can be managed at home. The doctor will advise the following in that case:

Take proper rest and use a heating pad on the belly

Take prescribed pain killers
Take only liquid diet for a day or two, followed by slightly thicker fluids and gradually returning to solid food again.

Increase fiber intake

In severe cases surgery may be required (Nlm.nih.gov).

Complications and their Management

Abscess: Collection of pus in the pouches may occur as a result of infection. The pus will be required to be drained out under ultrasound or CT scan.
Peritonitis: If the abscess reaches the peritoneal wall then it may lead to peritonitis which is a fatal complication and requires immediate medical intervention.
Fistula: If a fistula forms between organs, then it may have to be cut open and the ends are to be sutured again.
Severe blood loss: Severe bleeding may require blood transfusion (Webmd.com).

APPENDICITIS

Appendicitis is inflammation of the appendix, more commonly seen in men than in women. Although in most of the people the appendix and associated pain occurs in the right lower quadrant, but in some patients the appendix may have a variable position giving rise to pain in some other region of the abdomen. Thus the case must be keenly observed in order to diagnose it correctly.
(Appendicitis)

Causes

Obstruction is considered to be the main cause of appendicitis. The cause of obstruction could be many. For example, the obstruction can occur due to impaction of fecal matter in the lumen of the appendix, enlargement of lymph nodes draining the appendix, worms, tumor on or near the appendix or trauma to the appendix. The pressure increases which ultimately leads to pain. In severe cases the blood vessels may get blocked thus stopping the flow of blood to the appendix. This may eventually lead to gangrene of the appendix. If the appendix ruptures, and the cause of obstruction was fecal matter, then the fecal matter may spread to the whole of abdomen leading to a fatal condition. Peritonitis may also occur upon rupture of the appendix. It would lead to inflammation of all the neighboring organs.

Clinical Presentation

The patient will present with the following symptoms: right lower abdominal pain, loss of appetite, nausea, vomiting, diarrhea or constipation, low grade fever, abdominal swelling, inability to pass flatus. Symptoms may start gradually with, mild intensity. But will increase in intensity with time.

Differential Diagnosis

Certain conditions may mimic similar symptoms as of appendicitis. They are as follows:
Urinary tract infection or kidney stone: A stone impacted in the right ureter may give rise to similar symptoms as that of appendicitis. To rule that out urinalysis is required.
Pelvic Inflammatory Disease: In females, pelvic inflammatory disease will also have the same location of pain and thus must be ruled out. It is basically the inflammation in the pelvic organs, thus any pelvic organ inflammation on the right side of the abdomen will also point towards appendicitis.
Ectopic Pregnancy: Implantation of the fetus in the right fallopian tube will be a very painful situation giving rise to symptoms as that of acute appendicitis. The pain will be sudden, driving the female to despair. Thus a pregnancy test must be conducted in females; also a proper history taking regarding the onset of last menstrual cycle may be helpful in differentiating ectopic pregnancy from appendicitis.
Right lower lobe pneumonia: This condition sometimes give rise to symptoms of appendicitis. Therefore an X- ray would be helpful in drawing the conclusion (Healthline).

Diagnosis

Blood test: On performing Complete blood count there will be leucocytosis present. But this is a very common finding; it can be seen in any form of infection.
Urinalysis: On undergoing routine urine examination in some patients there may be presence of white blood cells or red blood cells. This finding may relate to appendicitis, in cases where the inflamed appendix reaches the ureter it may lead to urinary symptoms. But mostly the urine reports are normal in appendicitis patients.
Abdominal X- Ray: Abdominal X- Ray may help in visualizing any impacted body in the appendix. Especially in cases of children a pea sized stool block may be seen to be present impacted in the appendix.
(Appendicitis)

Ultrasound: It not only gives a clear picture of the inflamed appendix, but also helps in refuting other diagnoses (Mark).

Management
Conservative Management: Although almost all the cases of appendicitis require surgical intervention, conservative treatment is rare. But can be considered. Conservative management will consist of prescribing antibiotics and a liquid only diet. Not much benefit can be obtained by this kind of treatment. The ultimate resort will be undergoing appendectomy surgery.
Surgical Management: Surgical intervention consists of removing the appendix completely, also called as appendectomy. The procedure can be carried out both as open surgical procedure or through laparoscopy (Healthline). The open surgical appendectomy can be performed by three different types of incisions; it depends on the performing surgeon which one opts for. The three types of incisions are McBurney-McArthur incision, Lanz incision and Para rectus (Jalaguier, Battle, Kammerer, Lennander, Senn) incision). In McBurney- McArthur incision, the point of incision is based on McBurney’s point which lies at the one third distance of the anterior superior iliac spine to the umbilicus (Ballehaninna). The incision is made exactly perpendicular to the line. This is also known as Gridiron incision. In Lanz incision the incision is made horizontally to the McBurney’s point, it gives better cosmetic results (Dastur).

Complications

Peritonitis: Rupture of the appendix can lead to spread of infection to nearby organs like peritoneum, giving rise to peritonitis. Treatment would consist of antibiotic administration and removal of appendix.
Abscess formation: Abscess may at times form around an already ruptured appendix. The collection of pus occurs as a protective mechanism of the body to fight against the invading infection. If formed, the abscess has to be drained out under ultrasound or CT scan (Nhs.uk).
Appendectomy in general reduces the risk of Inflammatory Bowel Disease. In patients who have undergone appendectomy tend to show decreased incidence of inflammatory disease or at least the risk of the occurrence of disease decreases markedly (Barclay). If performed before the onset of the inflammatory bowel disease, appendectomy can provide protection against both the forms of inflammatory bowel disease (Bronner). However in another study conducted by Andersson et al, with 212,218 patients they found that it is not always necessary that appendectomy will reduce the chances of inflammatory bowel disease, it largely depends on the age and sex of the patient (Andersson et al).

References

Albrecht, Suzanne. 'Management of Diverticular Disease: Signs and Symptoms'. Medscape.com. N.p., 2015. Web. 24 Mar. 2015.
Andersson, Roland E. et al. 'Appendectomy Is Followed By Increased Risk Of Crohn's Disease'.Gastroenterology 124.1 (2003): 40-46. Web. 24 Mar. 2015.
Appendicitis. 2015. Web. 24 Mar. 2015.
Appendicitis. 2015. Web. 24 Mar. 2015.
Ballehaninna, Umashankar K. 'Open Appendectomy'. Medscape. N.p., 2015. Web. 24 Mar. 2015.
Barclay, Laurie. 'Appendectomy Protects Against Inflammatory Bowel Disease'. Medscape.com. N.p., 2002. Web. 24 Mar. 2015.
Bronner, Mary P. 'Granulomatous Appendicitis And The Appendix In Idiopathic Inflammatory Bowel Disease'. Seminars in Diagnostic Pathology 21.2 (2004): 98-107. Web.
Chatterjee, Shamita et al. 'Gallstone Ileus – An Atypical Presentation And Unusual Location'.International Journal of Surgery 6.6 (2008): e55-e56. Web.
Dastur, Neville. 'Surgeonsnet - Open Appendicectomy | General-Surgery-Operation-Howto'.SurgeonsNet. N.p., 2007. Web. 24 Mar. 2015.
Healthline,. 'Appendicitis'. N.p., 2015. Web. 24 Mar. 2015.
Marks, Jay W. 'Appendicitis Symptoms, Causes, Treatment - Imaging Studies To Diagnosis Appendicitis - Medicinenet'. MedicineNet. N.p., 2015. Web. 24 Mar. 2015.
Medicinenet.com,. Diverticulitis. 2015. Web. 24 Mar. 2015.
MORTON, DONALD L., and LEON GOLDMAN. 'DIFFERENTIAL DIAGNOSIS OF DIVERTICULITIS AND CARCINOMA OF THE SIGMOID COLON'. Obstetrical & Gynecological Survey 17.3 (1962): 444-445. Web.
Nhs.uk,. 'Appendicitis - Complications - NHS Choices'. N.p., 2015. Web. 24 Mar. 2015.
Nhs.uk,. 'Gallstones - Complications - NHS Choices'. N.p., 2015. Web. 24 Mar. 2015.
Nlm.nih.gov,. 'Diverticulitis: Medlineplus Medical Encyclopedia'. N.p., 2015. Web. 24 Mar. 2015.
Webmd.com,. 'Diverticulitis (Acute And Chronic) Picture, Causes, Complications'. N.p., 2015. Web. 24 Mar. 2015.
Webmd.com,. Gallstones. 2015. Web. 24 Mar. 2015.
Webmd.com,. 'Gallstones Picture, Types, Causes, Risks, Symptoms, Treatments'. N.p., 2015. Web. 24 Mar. 2015.