A. Definisi

In cholelithiasis, calculi (gallstones) usually form in the gallbladder from solid

constituents of bile and vary greatly in size, shape, and composition. There are two major

types of gallstones: pigment stones, which contain an excess of unconjugated pigments in the

bile, and cholesterol stones (the more common form), which result from bile supersaturated

with cholesterol due to increased synthesis of cholesterol and decreased synthesis of bile

acids that dissolve cholesterol.

B. Faktor Resiko

Risk factors for pigment stones include cirrhosis, hemolysis, and infections of the biliary

tract. These stones cannot be dissolved and must be removed surgically. Risk factors for

cholesterol stones include gender (women are two to three times more likely to develop

cholesterol stones); use of oral contraceptives, estrogens, and clofibrate; age (usually older

than 40 years); multiparous status; and obesity. There is also an increased risk related to

diabetes, GI tract disease, T-tube fistula, and ileal resection or bypass.

C. Gejala dan Tanda

1. May be silent, producing no pain and only mild GI symptoms

2. May be acute or chronic with epigastric distress (fullness, abdominal distention, and

vague upper right quadrant pain); may follow a meal rich in fried or fatty foods

3. If the cystic duct is obstructed, the gallbladder becomes distended, inflamed, and

eventually infected; fever and palpable abdominal mass; biliary colic with

excruciating upper right abdominal pain, radiating to back or right shoulder with

nausea and vomiting several hours after a heavy meal; restlessness and constant or

colicky pain

4. Jaundice, accompanied by marked itching, with obstruction of the common bile duct,

in a small percentage of patients

5. Very dark urine; grayish or clay-colored stool

6. Deficiencies of vitamins A, D, E, and K (fat-soluble vitamins)

D. Patofisiologi

Gallstones are formed because of abnormal bile composition. They are divided into two

major types: cholesterol stones account for more than 80% of the total, with pigment stones

comprising less than 20%. Cholesterol gallstones usually contain >50% cholesterol

monohydrate plus an admixture of calcium salts, bile pigments, and proteins. 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 stones and biliary sludge

It is not known why the hepatocytes secrete bile that is supersaturated with

cholesterol. Proposed mechanisms include: (1) an enzymatic defect that increases the

hepatocytes’ synthesis of cholesterol; (2) diminished secretion of bile acids, which normally

promote cholesterol solubility; (3) decreased resorption of bile salts from the ileum, which

decrease the bile acid pool; (4) gallbladder smooth muscle hypomotility and stasis; (5)

genetic predisposition; and (6) some combination of these mechanisms.295 In obese

individuals the mechanism appears to involve cholesterol synthesis, whereas in nonobese

individuals, it appears to involve decreased secretion ofbile acids.

Pigment stones

Pigmented stones are black (hard) or brown (soft). Black pigmented stones are formed

in a sterile environment and consist primarily of calcium bilirubinate polymer. They are

associated with hyperbilirubinbilia (biliary hypersecretion of bilirubin conjugates) and

hemolytic diseases, such as sickle cell anemia and Gilbert syndrome (hereditary

hyperbilirubinemia). The formation of brown stones is associated with bacterial infection of

the bile ducts with formation of stone composed of calcium soaps, unconjugated bilirubin,

cholesterol, fattyacids, and mucin. They are more common in East Asia.

E. Pemeriksaan Diagnostik

1. Cholecystogram, cholangiogram; celiac axis arteriography2. Laparoscopy3. Ultrasonography; EUS4. Helical CT scans and MRI; ERCP

5. Serum alkaline phosphatase; gamma-glutamyl (GGT), gamma-glutamyl transpeptidase (GGTP), LDH

6. Cholesterol levelsF. Penatalaksanaan Medis

Major objectives of medical therapy are to reduce the incidence of acute episodes of

gallbladder pain and cholecystitis by supportive and dietary management and, if possible,

to remove the cause by pharmacotherapy, endoscopic procedures, or surgical

intervention.