Cholelithiasis

Cholelithiasis is the presence of calculi within the gallbladder. Most gallstones are cholesterol stones, with pigment stones accounting for the remainder.

Gallstone formation is promoted by cholesterol supersaturation, gallbladder stasis and crystal nucleation. Pigment stones are associated particularly with chronic haemolysis, biliary infection and altered bilirubin metabolism.

Most gallstones remain asymptomatic. Clinically important disease begins when stones produce biliary pain or complications such as acute cholecystitis, choledocholithiasis, ascending cholangitis, gallstone pancreatitis, gallstone ileus or Mirizzi syndrome.

The presence of gallstones alone is not an indication for cholecystectomy.

Asymptomatic gallstones are commonly discovered incidentally.

Symptomatic cholelithiasis classically causes episodic right upper quadrant or epigastric pain after transient cystic duct obstruction. Pain may radiate to the right scapula or back and is often associated with nausea.

Persistent pain, fever or systemic inflammatory features suggest a complication rather than uncomplicated gallstones.

Jaundice is not a feature of isolated gallbladder stones and should prompt assessment for common bile duct obstruction, cholangitis or another hepatobiliary disorder.

Right upper quadrant ultrasound: first line investigation; demonstrates gallstones and simultaneously assesses the gallbladder and biliary tree.

Check liver biochemistry when symptoms suggest gallstone disease. Elevated bilirubin or cholestatic liver enzymes, a dilated common bile duct or pancreatitis should trigger assessment for choledocholithiasis.

MRCP or endoscopic ultrasound is appropriate when common bile duct stones remain clinically suspected despite inconclusive ultrasound.

Asymptomatic gallstones in a normal gallbladder generally require observation rather than prophylactic surgery.

Symptomatic gallstones should undergo elective laparoscopic cholecystectomy because recurrent biliary pain and future gallstone complications are common once symptoms begin.

Routine antibiotics are unnecessary for uncomplicated symptomatic cholelithiasis.

During laparoscopic cholecystectomy, obtain the critical view of safety before dividing the cystic duct or artery:

Clear fibrofatty tissue from the hepatocystic triangle
Separate the lower gallbladder from the cystic plate
Confirm that only two structures enter the gallbladder

Do not continue hazardous dissection when anatomy cannot be defined safely. A subtotal cholecystectomy is preferable to bile duct injury in a severely scarred or hostile hepatocystic triangle.

Suspected common bile duct stones require duct clearance, either by ERCP or operative bile duct exploration, combined with definitive cholecystectomy.

Gallstone dissolution therapy has a very limited role because treatment is slow, recurrence is common and most symptomatic surgical candidates are better treated definitively with cholecystectomy.

Hepatocellular Carcinoma

Also known as: HCC, Liver cancer

Primary malignancy of hepatocytes, arising overwhelmingly in the context of chronic liver disease, most commonly cirrhosis from chronic hepatitis B, chronic hepatitis C, alcohol related liver disease, and increasingly MASLD.

Hepatitis B carries a unique ability to cause hepatocellular carcinoma even without cirrhosis, through direct viral integration into the host genome, which is why surveillance in high risk hepatitis B carriers begins independent of fibrosis stage in some guidelines (for example, Asian men over 40 and African patients over 20, per the risk thresholds noted in the Hepatitis B entry).

Often detected through surveillance in an asymptomatic patient with known cirrhosis.
Symptomatic presentation reflects advanced disease: right upper quadrant pain, weight loss, worsening ascites, new or worsening jaundice, and decompensation of previously stable cirrhosis.
A palpable liver mass or bruit may be present. Rupture with intraperitoneal hemorrhage is a rare but recognized acute presentation, causing sudden severe abdominal pain and hypovolemic shock.

In a cirrhotic patient, hepatocellular carcinoma can be diagnosed radiologically without biopsy if a lesion above 1 cm shows the characteristic pattern of arterial phase hyperenhancement with portal venous or delayed phase washout on contrast enhanced CT or MRI (the LI-RADS classification formalizes this).

Biopsy is reserved for atypical imaging or a non-cirrhotic liver.

AFP (alpha-fetoprotein) supports diagnosis and is used for monitoring treatment response, though it lacks sufficient sensitivity to be used alone for surveillance or diagnosis.

Surveillance in at risk patients (cirrhosis of any cause, and high risk hepatitis B carriers as above) uses six monthly ultrasound with or without AFP.

Staging uses the Barcelona Clinic Liver Cancer (BCLC) system, which uniquely incorporates tumor burden, liver function (Child-Pugh class), and performance status together, since treatment options and prognosis in hepatocellular carcinoma depend as much on underlying liver reserve as on tumor stage.

Differentials include other focal liver lesions in a cirrhotic liver (regenerative or dysplastic nodules, hemangioma), intrahepatic cholangiocarcinoma, and metastatic disease to the liver.

Management follows BCLC staged treatment allocation.

Very early and early stage disease (BCLC 0 to A) in patients with preserved liver function is treated with surgical resection, liver transplantation (particularly attractive since it treats both the tumor and the underlying cirrhosis, using Milan criteria to select appropriate candidates), or percutaneous ablation (radiofrequency or microwave ablation) for small tumors unsuitable for resection.

Intermediate stage disease (BCLC B, multinodular, preserved liver function) is treated with transarterial chemoembolization (TACE), delivering chemotherapy directly to the tumor via its arterial supply while embolizing the vessel.

Advanced stage disease (BCLC C, vascular invasion or extrahepatic spread) is treated with systemic therapy, including tyrosine kinase inhibitors (sorafenib, lenvatinib) and, increasingly first-line, combination immunotherapy (atezolizumab with bevacizumab).

Terminal stage disease (BCLC D, poor liver function or performance status) receives best supportive and palliative care, since aggressive treatment offers no benefit and may cause harm in this group.

Referral: hepatobiliary surgery, hepatology, and oncology multidisciplinary team for all confirmed or suspected cases; liver transplant unit assessment where criteria may be met.

Cholelithiasis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management