What is the most likely type of gallstones in a patient with obesity, diabetes, and sickle cell trait undergoing laparoscopic cholecystectomy for chronic cholelithiasis?

Most Likely Type of Gallstones in a 44-Year-Old Woman with Obesity, Diabetes, and Sickle Cell Trait

The most likely type of gallstones in this 44-year-old woman with obesity, diabetes, and sickle cell trait is cholesterol gallstones. 1

Risk Factors and Pathophysiology

• Obesity is a significant risk factor for cholesterol gallstone formation, particularly in females. In studies of patients with gallstones, 36-64% of females with cholesterol gallstones were found to be obese 2
• Diabetes mellitus contributes to gallstone formation primarily through creating a functional deficit in the gallbladder, resulting in a large, flaccid, poorly emptying organ that promotes stone formation 3
• The combination of obesity and diabetes significantly increases the risk of cholesterol stone formation due to:
  • Increased biliary cholesterol saturation 4
  • Impaired gallbladder contractility 2
  • Altered bile acid composition 3

Epidemiological Evidence

• In patients undergoing gallstone surgery, cholesterol stones are the predominant type found in Western populations, accounting for approximately 47% of gallstones versus 41% pigment stones 1
• Female gender is associated with higher risk of cholesterol gallstones, with females representing 62% of patients with gallstones in clinical studies 1
• Age is a significant factor - 87-88% of patients with gallstones are over 40 years old 2

Clinical Implications

• Cholesterol gallstones are radiolucent and typically form when bile becomes supersaturated with cholesterol 5, 4
• Patients with rapid formation of cholesterol monohydrate crystals in bile (≤2 days) have higher risk of stone recurrence after treatment 6
• The patient's chronic cholelithiasis requiring laparoscopic cholecystectomy is consistent with the natural progression of cholesterol gallstone disease 1

Management Considerations

• Laparoscopic cholecystectomy is the first-line treatment for symptomatic gallstones, particularly appropriate for this patient with multiple risk factors 1
• For patients with confirmed common bile duct stones, additional procedures such as ERCP may be necessary, though this would be determined intraoperatively 1
• During surgery, care should be taken to avoid gallstone spillage, as this can lead to complications including abscesses, which occur in approximately 56.5% of cases with spilled stones 1

Pitfalls and Caveats

• While cholesterol stones are most likely, pigment stones should still be considered in the differential diagnosis, especially given the patient's sickle cell trait which can increase bilirubin production 1
• The presence of sickle cell trait may complicate the clinical picture, potentially increasing the risk of pigment stone formation, though cholesterol stones remain more likely given the patient's other risk factors 2
• Surgeons should document any gallbladder perforation or stone spillage during the procedure, as this occurs in approximately 27% of cases and can lead to future complications 1