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.

Keywords: Liver cirrhosis, Pigment gallstones, Cholesterol gallstones, Lithogenesis, Risk factors, Asymptomatic gallstones, Laparoscopic cholecystectomy

Core tip: Gallstones often occur in patients with liver cirrhosis. Their prevalence increases with age and with disease severity. In most cases, stones are of pigment type; in about 15% of cases, they are cholesterol stones. This review presents new data on pathogenesis and risk factors for gallstones in patients with liver cirrhosis. An evidence-based approach to gallstones in these patients is described. Patients with liver cirrhosis and asymptomatic gallstones should be followed-up closely and offered laparoscopic cholecystectomy once symptoms develop. In patients with advanced liver disease, noninvasive or mini-invasive procedures should be used to treat the complications of gallstones.