Medical management is contraindicated in gallstone:
|A||< 15mm stone|
|D||Stone of 5 mm|
a. Pigment stones contain less than 20% cholesterol and are dark owing to the presence of calcium bilirubinate.
b. Otherwise, black and brown pigment stones have little in common and should be considered as separate entities.
c. Black pigment stones are small and tarry, and are frequently associated with hemolytic conditions such as hereditary spherocytosis and sickle cell disease or cirrhosis.
d. In hemolytic states, the bilirubin load and concentration of unconjugated bilirubin increases.
e. Cirrhosis may lead to increased secretion of unconjugated bilirubin. These stones are usually not associated with infected bile and are located almost exclusively in the gallbladder.
f. Ursodeoxycholic acid (UDCA) decreases cholesterol saturation of bile and also appears to produce a lamellar liquid crystalline phase in bile that allows a dispersion of cholesterol from stones by physical-chemical means.
g. UDCA may also retard cholesterol crystal nucleation.
h. The advantages and success of laparoscopic cholecystectomy have largely reduced the role of gallstone dissolution to patients who wish to avoid or are not candidates for elective cholecystectomy.
i. Patients with cholesterol gallstone disease who develop recurrent choledocholithiasis after cholecystectomy should be on long-term treatment with ursodeoxycholic acid.