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 arteriography
2. Laparoscopy
3. Ultrasonography; EUS
4. Helical CT scans and MRI; ERCP
5. Serum alkaline phosphatase; gamma-glutamyl (GGT),
transpeptidase (GGTP), LDH

gamma-glutamyl

6. Cholesterol levels
F. 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.