10/13/2015

Gallstones(Cholelithiasis):PracticeEssentials,Background,Pathophysiology

Gallstones(Cholelithiasis)
Author:DouglasMHeuman,MD,FACP,FACG,AGAFChiefEditor:JulianKatz,MDmore...
Updated:Jan20,2015

PracticeEssentials
Cholelithiasisinvolvesthepresenceofgallstones(seetheimagebelow),whichare
concretionsthatforminthebiliarytract,usuallyinthegallbladder.
Choledocholithiasisreferstothepresenceof1ormoregallstonesinthecommon
bileduct(CBD).Treatmentofgallstonesdependsonthestageofdisease.

Magneticresonancecholangiopancreatography(MRCP)showing5gallstonesinthecommon
bileduct(arrows).Inthisimage,bileintheductappearswhitestonesappearasdarkfilling
defects.Similarimagescanbeobtainedbytakingplainradiographsafterinjectionof
radiocontrastmaterialinthecommonbileduct,eitherendoscopically(endoscopicretrograde
cholangiography)orpercutaneouslyunderfluoroscopicguidance(percutaneoustranshepatic
cholangiography),buttheseapproachesaremoreinvasive.

Signsandsymptoms
Gallstonediseasemaybethoughtofashavingthefollowing4stages:
1.
2.
3.
4.

Lithogenicstate,inwhichconditionsfavorgallstoneformation
Asymptomaticgallstones
Symptomaticgallstones,characterizedbyepisodesofbiliarycolic
Complicatedcholelithiasis

Symptomsandcomplicationsresultfromeffectsoccurringwithinthegallbladderor
fromstonesthatescapethegallbladdertolodgeintheCBD.
Characteristicsofbiliarycolicincludethefollowing:
Sporadicandunpredictableepisodes
Painthatislocalizedtotheepigastriumorrightupperquadrant,sometimes
radiatingtotherightscapulartip
Painthatbeginspostprandially,isoftendescribedasintenseanddull,
typicallylasts15hours,increasessteadilyover1020minutes,andthen
graduallywanes
Painthatisconstantnotrelievedbyemesis,antacids,defecation,flatus,or
positionalchangesandsometimesaccompaniedbydiaphoresis,nausea,
andvomiting
Nonspecificsymptoms(eg,indigestion,dyspepsia,belching,orbloating)
Patientswiththelithogenicstateorasymptomaticgallstoneshavenoabnormal
findingsonphysicalexamination.
Distinguishinguncomplicatedbiliarycolicfromacutecholecystitisorother
complicationsisimportant.Keyfindingsthatmaybenotedincludethefollowing:
UncomplicatedbiliarycolicPainthatispoorlylocalizedandvisceralan
essentiallybenignabdominalexaminationwithoutreboundorguarding
absenceoffever
AcutecholecystitisWelllocalizedpainintherightupperquadrant,usually
withreboundandguardingpositiveMurphysign(nonspecific)frequent
presenceoffeverabsenceofperitonealsignsfrequentpresenceof
tachycardiaanddiaphoresisinseverecases,absentorhypoactivebowel
sounds
Thepresenceoffever,persistenttachycardia,hypotension,orjaundicenecessitates
asearchforcomplications,whichmayincludethefollowing:
Cholecystitis
Cholangitis
Pancreatitis
Othersystemiccauses
SeePresentationformoredetail.

Diagnosis
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Patientswithuncomplicatedcholelithiasisorsimplebiliarycolictypicallyhave
normallaboratorytestresultslaboratorystudiesaregenerallynotnecessaryunless
complicationsaresuspected.Bloodtests,whenindicated,mayincludethe
following:
Completebloodcount(CBC)withdifferential
Liverfunctionpanel
Amylase
Lipase
Imagingmodalitiesthatmaybeusefulincludethefollowing:
Abdominalradiography(uprightandsupine)Usedprimarilytoexclude
othercausesofabdominalpain(eg,intestinalobstruction)
UltrasonographyTheprocedureofchoiceinsuspectedgallbladderorbiliary
disease
Endoscopicultrasonography(EUS)Anaccurateandrelativelynoninvasive
meansofidentifyingstonesinthedistalCBD
LaparoscopicultrasonographyPromisingasapotentialmethodforbile
ductimagingduringlaparoscopiccholecystectomy
Computedtomography(CT)Moreexpensiveandlesssensitivethan
ultrasonographyfordetectinggallbladderstones,butsuperiorfor
demonstratingstonesinthedistalCBD
Magneticresonanceimaging(MRI)withmagneticresonance
cholangiopancreatography(MRCP)Usuallyreservedforcasesinwhich
choledocholithiasisissuspected
ScintigraphyHighlyaccurateforthediagnosisofcysticductobstruction
Endoscopicretrogradecholangiopancreatography(ERCP)
Percutaneoustranshepaticcholangiography(PTC)
SeeWorkupformoredetail.

Management
Thetreatmentofgallstonesdependsuponthestageofdisease,asfollows:
LithogenicstateInterventionsarecurrentlylimitedtoafewspecial
circumstances
AsymptomaticgallstonesExpectantmanagement
SymptomaticgallstonesUsually,definitivesurgicalintervention(eg,
cholecystectomy),thoughmedicaldissolutionmaybeconsideredinsome
cases
Medicaltreatments,usedindividuallyorincombination,includethefollowing:
Oralbilesalttherapy(ursodeoxycholicacid)
Contactdissolution
Extracorporealshockwavelithotripsy
Cholecystectomyforasymptomaticgallstonesmaybeindicatedinthefollowing
patients:
Thosewithlarge(>2cm)gallstones
Thosewhohaveanonfunctionalorcalcified(porcelain)gallbladderon
imagingstudiesandwhoareathighriskofgallbladdercarcinoma
Thosewithspinalcordinjuriesorsensoryneuropathiesaffectingthe
abdomen
Thosewithsicklecellanemiainwhomthedistinctionbetweenpainfulcrisis
andcholecystitismaybedifficult
Patientswiththefollowingriskfactorsforcomplicationsofgallstonesmaybe
offeredelectivecholecystectomy,eveniftheyhaveasymptomaticgallstones:
Cirrhosis
Portalhypertension
Children
Transplantcandidates
Diabeteswithminorsymptoms
Surgicalinterventionstobeconsideredincludethefollowing:
Cholecystectomy(openorlaparoscopic)
Cholecystostomy
Endoscopicsphincterotomy
SeeTreatmentandMedicationformoredetail.

Background
Cholelithiasisisthemedicaltermforgallstonedisease.Gallstonesareconcretions
thatforminthebiliarytract,usuallyinthegallbladder(seetheimagebelow).

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Gallstones(Cholelithiasis):PracticeEssentials,Background,Pathophysiology

Excisedgallbladderopenedtoshow3gallstones

Gallstonesdevelopinsidiously,andtheymayremainasymptomaticfordecades.
Migrationofaagallstoneintotheopeningofthecysticductmayblocktheoutflow
ofbileduringgallbladdercontraction.Theresultingincreaseingallbladderwall
tensionproducesacharacteristictypeofpain(biliarycolic).Cysticductobstruction,
ifitpersistsformorethanafewhours,mayleadtoacutegallbladderinflammation
(acutecholecystitis).
Choledocholithiasisreferstothepresenceofoneormoregallstonesinthecommon
bileduct.Usually,thisoccurswhenagallstonepassesfromthegallbladderintothe
commonbileduct(seetheimagebelow).

Commonbileductstone(choledocholithiasis).Thesensitivityoftransabdominal
ultrasonographyforcholedocholithiasisisapproximately75%inthepresenceofdilatedducts
and50%fornondilatedducts.ImagecourtesyofDTSchwartz.

AgallstoneinthecommonbileductmayimpactdistallyintheampullaofVater,
thepointwherethecommonbileductandpancreaticductjoinbeforeopeninginto
theduodenum.Obstructionofbileflowbyastoneatthiscriticalpointmayleadto
abdominalpainandjaundice.Stagnantbileaboveanobstructingbileductstone
oftenbecomesinfected,andbacteriacanspreadrapidlybackuptheductalsystem
intothelivertoproducealifethreateninginfectioncalledascendingcholangitis.
ObstructionofthepancreaticductbyagallstoneintheampullaofVateralsocan
triggeractivationofpancreaticdigestiveenzymeswithinthepancreasitself,leading
toacutepancreatitis. [1,2]
Chronically,gallstonesinthegallbladdermaycauseprogressivefibrosisandlossof
functionofthegallbladder,aconditionknownaschroniccholecystitis.Chronic
cholecystitispredisposestogallbladdercancer.
Ultrasonographyistheinitialdiagnosticprocedureofchoiceinmostcasesof
suspectedgallbladderorbiliarytractdisease(seeWorkup).
Thetreatmentofgallstonesdependsuponthestageofdisease.Asymptomatic
gallstonesmaybemanagedexpectantly.Oncegallstonesbecomesymptomatic,
definitivesurgicalinterventionwithexcisionofthegallbladder(cholecystectomy)is
usuallyindicated.Cholecystectomyisamongthemostfrequentlyperformed
abdominalsurgicalprocedures(seeTreatment).Complicationsofgallstonedisease
mayrequirespecializedmanagementtorelieveobstructionandinfection.
GotoPediatricCholelithiasisforcompleteinformationonthistopic.

Pathophysiology
Gallstoneformationoccursbecausecertainsubstancesinbilearepresentin
concentrationsthatapproachthelimitsoftheirsolubility.Whenbileisconcentrated
inthegallbladder,itcanbecomesupersaturatedwiththesesubstances,whichthen
precipitatefromsolutionasmicroscopiccrystals.Thecrystalsaretrappedin
gallbladdermucus,producinggallbladdersludge.Overtime,thecrystalsgrow,
aggregate,andfusetoformmacroscopicstones.Occlusionoftheductsbysludge
and/orstonesproducesthecomplicationsofgallstonedisease.
The2mainsubstancesinvolvedingallstoneformationarecholesterolandcalcium
bilirubinate.

Cholesterolgallstones
Morethan80%ofgallstonesintheUnitedStatescontaincholesterolastheirmajor
component.Livercellssecretecholesterolintobilealongwithphospholipid(lecithin)

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intheformofsmallsphericalmembranousbubbles,termedunilamellarvesicles.
Livercellsalsosecretebilesalts,whicharepowerfuldetergentsrequiredfor
digestionandabsorptionofdietaryfats.
Bilesaltsinbiledissolvetheunilamellarvesiclestoformsolubleaggregatescalled
mixedmicelles.Thishappensmainlyinthegallbladder,wherebileisconcentrated
byreabsorptionofelectrolytesandwater.
Comparedwithvesicles(whichcanholdupto1moleculeofcholesterolforevery
moleculeoflecithin),mixedmicelleshavealowercarryingcapacityforcholesterol
(about1moleculeofcholesterolforevery3moleculesoflecithin).Ifbilecontainsa
relativelyhighproportionofcholesteroltobeginwith,thenasbileisconcentrated,
progressivedissolutionofvesiclesmayleadtoastateinwhichthecholesterol
carryingcapacityofthemicellesandresidualvesiclesisexceeded.Atthispoint,bile
issupersaturatedwithcholesterol,andcholesterolmonohydratecrystalsmayform.
Thus,themainfactorsthatdeterminewhethercholesterolgallstoneswillformare
(1)theamountofcholesterolsecretedbylivercells,relativetolecithinandbile
salts,and(2)thedegreeofconcentrationandextentofstasisofbileinthe
gallbladder.

Calcium,bilirubin,andpigmentgallstones
Bilirubin,ayellowpigmentderivedfromthebreakdownofheme,isactivelysecreted
intobilebylivercells.Mostofthebilirubininbileisintheformofglucuronide
conjugates,whicharequitewatersolubleandstable,butasmallproportionconsists
ofunconjugatedbilirubin.Unconjugatedbilirubin,likefattyacids,phosphate,
carbonate,andotheranions,tendstoforminsolubleprecipitateswithcalcium.
Calciumentersbilepassivelyalongwithotherelectrolytes.
Insituationsofhighhemeturnover,suchaschronichemolysisorcirrhosis,
unconjugatedbilirubinmaybepresentinbileathigherthannormalconcentrations.
Calciumbilirubinatemaythencrystallizefromsolutionandeventuallyformstones.
Overtime,variousoxidationscausethebilirubinprecipitatestotakeonajetblack
color,andstonesformedinthismanneraretermedblackpigmentgallstones.Black
pigmentstonesrepresent1020%ofgallstonesintheUnitedStates.
Bileisnormallysterile,butinsomeunusualcircumstances(eg,aboveabiliary
stricture),itmaybecomecolonizedwithbacteria.Thebacteriahydrolyzeconjugated
bilirubin,andtheresultingincreaseinunconjugatedbilirubinmayleadto
precipitationofcalciumbilirubinatecrystals.
Bacteriaalsohydrolyzelecithintoreleasefattyacids,whichalsomaybindcalcium
andprecipitatefromsolution.Theresultingconcretionshaveaclaylikeconsistency
andaretermedbrownpigmentstones.Unlikecholesterolorblackpigment
gallstones,whichformalmostexclusivelyinthegallbladder,brownpigment
gallstonesoftenformdenovointhebileducts.Brownpigmentgallstonesare
unusualintheUnitedStatesbutarefairlycommoninsomepartsofSoutheast
Asia,possiblyrelatedtoliverflukeinfestation.

Mixedgallstones
Cholesterolgallstonesmaybecomecolonizedwithbacteriaandcanelicit
gallbladdermucosalinflammation.Lyticenzymesfrombacteriaandleukocytes
hydrolyzebilirubinconjugatesandfattyacids.Asaresult,overtime,cholesterol
stonesmayaccumulateasubstantialproportionofcalciumbilirubinateandother
calciumsalts,producingmixedgallstones.Largestonesmaydevelopasurfacerim
ofcalciumresemblinganeggshellthatmaybevisibleonplainxrayfilms.

Etiology
Cholesterolgallstones,blackpigmentgallstones,andbrownpigmentgallstones
havedifferentpathogenesesanddifferentriskfactors.

Cholesterolgallstones
Cholesterolgallstonesareassociatedwithfemalesex,EuropeanorNative
Americanancestry,andincreasingage.Otherriskfactorsincludethefollowing:
Obesity
Pregnancy
Gallbladderstasis
Drugs
Heredity
Themetabolicsyndromeoftruncalobesity,insulinresistance,typeIIdiabetes
mellitus,hypertension,andhyperlipidemiaisassociatedwithincreasedhepatic
cholesterolsecretionandisamajorriskfactorforthedevelopmentofcholesterol
gallstones.
Cholesterolgallstonesaremorecommoninwomenwhohaveexperiencedmultiple
pregnancies.Amajorcontributingfactoristhoughttobethehighprogesterone
levelsofpregnancy.Progesteronereducesgallbladdercontractility,leadingto
prolongedretentionandgreaterconcentrationofbileinthegallbladder.
Othercausesofgallbladderstasisassociatedwithincreasedriskofgallstones
includehighspinalcordinjuries,prolongedfastingwithtotalparenteralnutrition,
andrapidweightlossassociatedwithseverecaloricandfatrestriction(eg,diet,
gastricbypasssurgery).
Anumberofmedicationsareassociatedwithformationofcholesterolgallstones.
Estrogensadministeredforcontraceptionorfortreatmentofprostatecancer
increasetheriskofcholesterolgallstonesbyincreasingbiliarycholesterolsecretion.
Clofibrateandotherfibratehypolipidemicdrugsincreasehepaticeliminationof
cholesterolviabiliarysecretionandappeartoincreasetheriskofcholesterol
gallstones.Somatostatinanaloguesappeartopredisposetogallstonesby

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decreasinggallbladderemptying.
About25%ofthepredispositiontocholesterolgallstonesappearstobehereditary,
asjudgedfromstudiesofidenticalandfraternaltwins.Atleastadozengenesmay
contributetotherisk. [3]Araresyndromeoflowphospholipidassociated
cholelithiasisoccursinindividualswithahereditarydeficiencyofthebiliarytransport
proteinrequiredforlecithinsecretion. [4]

Blackandbrownpigmentgallstones
Blackpigmentgallstonesoccurdisproportionatelyinindividualswithhighheme
turnover.Disordersofhemolysisassociatedwithpigmentgallstonesincludesickle
cellanemia,hereditaryspherocytosis,andbetathalassemia.Incirrhosis,portal
hypertensionleadstosplenomegaly.This,inturn,causesredcellsequestration,
leadingtoamodestincreaseinhemoglobinturnover.Abouthalfofallcirrhotic
patientshavepigmentgallstones.
Prerequisitesforformationofbrownpigmentgallstonesincludeintraductalstasis
andchroniccolonizationofbilewithbacteria.IntheUnitedStates,thiscombination
ismostoftenencounteredinpatientswithpostsurgicalbiliarystricturesor
choledochalcysts.
InricegrowingregionsofEastAsia,infestationwithbiliaryflukesmayproduce
biliarystricturesandpredisposetoformationofbrownpigmentstonesthroughout
intrahepaticandextrahepaticbileducts.Thiscondition,termedhepatolithiasis,
causesrecurrentcholangitisandpredisposestobiliarycirrhosisand
cholangiocarcinoma.

Othercomorbidities
Crohndisease,ilealresection,orotherdiseasesoftheileumdecreasebilesalt
reabsorptionandincreasetheriskofgallstoneformation.
Otherillnessesorstatesthatpredisposetogallstoneformationincludeburns,useof
totalparenteralnutrition,paralysis,ICUcare,andmajortrauma.Thisisdue,in
general,todecreasedenteralstimulationofthegallbladderwithresultantbiliary
stasisandstoneformation.

Epidemiology
Theprevalenceofcholelithiasisisaffectedbymanyfactors,includingethnicity,
gender,comorbidities,andgenetics.

UnitedStatesstatistics
IntheUnitedStates,about20millionpeople(1020%ofadults)havegallstones.
Everyyear13%ofpeopledevelopgallstonesandabout13%ofpeoplebecome
symptomatic.Eachyear,intheUnitedStates,approximately500,000people
developsymptomsorcomplicationsofgallstonesrequiringcholecystectomy.
Gallstonediseaseisresponsibleforabout10,000deathsperyearintheUnited
States.About7000deathsareattributabletoacutegallstonecomplications,such
asacutepancreatitis.About20003000deathsarecausedbygallbladdercancers
(80%ofwhichoccurinthesettingofgallstonediseasewithchroniccholecystitis).
Althoughgallstonesurgeryisrelativelysafe,cholecystectomyisaverycommon
procedure,anditsrarecomplicationsresultinseveralhundreddeathseachyear.

Internationalstatistics
TheprevalenceofcholesterolcholelithiasisinotherWesternculturesissimilarto
thatintheUnitedStates,butitappearstobesomewhatlowerinAsiaandAfrica.
ASwedishepidemiologicstudyfoundthattheincidenceofgallstoneswas1.39per
100personyears. [5]InanItalianstudy,20%ofwomenhadstones,and14%of
menhadstones.InaDanishstudy,gallstoneprevalenceinpersonsaged30years
was1.8%formenand4.8%forwomengallstoneprevalenceinpersonsaged60
yearswas12.9%formenand22.4%forwomen.
TheprevalenceofcholedocholithiasisishigherinternationallythanintheUnited
States,mainlybecauseoftheadditionalproblemofprimarycommonbileduct
stonescausedbyparasiticinfestationwithliverflukessuchasClonorchissinensis.

Race,sex,andagerelateddemographics
PrevalenceofgallstonesishighestinpeopleofnorthernEuropeandescent,andin
HispanicpopulationsandNativeAmericanpopulations. [6]Prevalenceofgallstones
islowerinAsiansandAfricanAmericans.
Womenaremorelikelytodevelopcholesterolgallstonesthanmen,especially
duringtheirreproductiveyears,whentheincidenceofgallstonesinwomenis23
timesthatinmen.Thedifferenceappearstobeattributablemainlytoestrogen,
whichincreasesbiliarycholesterolsecretion. [7]
Riskofdevelopinggallstonesincreaseswithage.Gallstonesareuncommonin
childrenintheabsenceofcongenitalanomaliesorhemolyticdisorders.Beginningat
puberty,theconcentrationofcholesterolinbileincreases.Afterage15years,the
prevalenceofgallstonesinUSwomenincreasesbyabout1%peryearinmen,the
rateisless,about0.5%peryear.Gallstonescontinuetoformthroughoutadultlife,
andtheprevalenceisgreatestatadvancedage.Theincidenceinwomenfallswith
menopause,butnewstoneformationinmenandwomencontinuesatarateof
about0.4%peryearuntillateinlife.
Amongindividualsundergoingcholecystectomyforsymptomaticcholelithiasis,8
15%ofpatientsyoungerthan60yearshavecommonbileductstones,compared
with1560%ofpatientsolderthan60years.

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Prognosis
Lessthanhalfofpatientswithgallstonesbecomesymptomatic.Themortalityrate
foranelectivecholecystectomyis0.5%withlessthan10%morbidity.Themortality
rateforanemergentcholecystectomyis35%with3050%morbidity.
Followingcholecystectomy,stonesmayrecurinthebileduct.
Approximately1015%ofpatientshaveanassociatedcholedocholithiasis.The
prognosisinpatientswithcholedocholithiasisdependsonthepresenceandseverity
ofcomplications.Ofallpatientswhorefusesurgeryorareunfittoundergosurgery,
45%remainasymptomaticfromcholedocholithiasis,while55%experiencevarying
degreesofcomplications.

PatientEducation
Patientswithasymptomaticgallstonesshouldbeeducatedtorecognizeandreport
thesymptomsofbiliarycolicandacutepancreatitis.Alarmsymptomsinclude
persistentepigastricpainlastingforgreaterthan20minutes,especiallyif
accompaniedbynausea,vomiting,orfever.Ifpainissevereorpersistsformore
thananhour,thepatientshouldseekimmediatemedicalattention.
Forpatienteducationinformation,seetheLiver,Gallbladder,andPancreasCenter
andCholesterolCenter,aswellasGallstones.
ClinicalPresentation

ContributorInformationandDisclosures
Author
DouglasMHeuman,MD,FACP,FACG,AGAFChiefofHepatology,HunterHolmesMcGuireDepartmentof
VeteransAffairsMedicalCenterProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,
VirginiaCommonwealthUniversitySchoolofMedicine
DouglasMHeuman,MD,FACP,FACG,AGAFisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofPhysicians,AmericanGastroenterological
Association
Disclosure:Receivedgrant/researchfundsfromNovartisforotherReceivedgrant/researchfundsfromBayerfor
otherReceivedgrant/researchfundsfromOtsukafornoneReceivedgrant/researchfundsfromBristolMyers
SquibbforotherReceivednonefromScynexisfornoneReceivedgrant/researchfundsfromSalixforother
Receivedgrant/researchfundsfromMannKindforother.
Coauthor(s)
JeffAllen,MDAssistantProfessor,DepartmentofSurgery,UniversityofLouisville
Disclosure:Nothingtodisclose.
AnastasiosAMihas,MD,DMSc,FACP,FACGProfessor,DepartmentofMedicine,Divisionof
Gastroenterology,VirginiaCommonwealthUniversitySchoolofMedicineConsultingStaff,Virginia
CommonwealthUniversityHospitalsandClinicsChiefofGIClinicalResearch,DirectorofGIOutpatientService,
AssociateDirectorofHepatology,HunterHolmesMcGuireVeteransAffairsMedicalCenter
AnastasiosAMihas,MD,DMSc,FACP,FACGisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeof
Physicians,AmericanGastroenterologicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,Sigma
Xi,SouthernSocietyforClinicalInvestigation,AmericanFederationforClinicalResearch,Gastroenterology
ResearchGroup
Disclosure:Nothingtodisclose.
ChiefEditor
JulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine
JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,
Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocial
Responsibility
Disclosure:Nothingtodisclose.
Acknowledgements
FirassAbiad,MDHeadofDivision,GeneralandLaparoscopicSurgery,SpecializedMedicalCenterHospital,
SaudiArabia
Disclosure:Nothingtodisclose.
BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeof
Medicine
BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,andAmerican
SocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
DavidEricBernstein,MDDirectorofHepatology,NorthShoreUniversityHospitalProfessorofClinical
Medicine,AlbertEinsteinCollegeofMedicine
DavidEricBernstein,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyof
LiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,American
GastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,

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Gallstones(Cholelithiasis):PracticeEssentials,Background,Pathophysiology

ProgramDirector,EmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracic
Society,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolVice
Chair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital
DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
WilliamKChiang,MDAssociateProfessor,DepartmentofEmergencyMedicine,NewYorkUniversitySchool
ofMedicineChiefofService,DepartmentofEmergencyMedicine,BellevueHospitalCenter
WilliamKChiang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofClinicalToxicology,
AmericanCollegeofMedicalToxicology,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AlfredCuschieri,MD,ChM,FRSE,FRCS,Head,Professor,DepartmentofSurgeryandMolecularOncology,
UniversityofDundee,UK
Disclosure:Nothingtodisclose.
ImadSDandan,MDConsultingSurgeon,DepartmentofSurgery,TraumaSection,ScrippsMemorialHospital
ImadSDandan,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheSurgeryof
Trauma,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanTraumaSociety,California
MedicalAssociation,andSocietyofCriticalCareMedicine
Disclosure:Nothingtodisclose.
DavidGreenwald,MDAssociateProfessorofClinicalMedicine,FellowshipProgramDirector,Departmentof
Medicine,DivisionofGastroenterology,MontefioreMedicalCenter,AlbertEinsteinCollegeofMedicine
DavidGreenwald,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanSociety
forGastrointestinalEndoscopy,andNewYorkSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
FayeMaryannLee,MDStaffPhysician,DepartmentofEmergencyMedicine,NewYorkUniversity/Bellevue
HospitalCenter
FayeMaryannLee,MDisamemberofthefollowingmedicalsocieties:PhiBetaKappa
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AssaadMSoweid,MD,FASGE,FACGAssociateProfessorofClinicalMedicine,Endosonographyand
AdvancedTherapeuticEndoscopy,Director,EndoscopyBronchoscopyUnit,DivisionofGastroenterology,
DepartmentofInternalMedicine,AmericanUniversityofBeirutMedicalCenter,Lebanon
AssaadMSoweid,MD,FASGE,FACGisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternal
Medicine,AmericanGynecologicalandObstetricalSociety,andAmericanMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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