Cholelithiasis, Cholecystitis,

Cholangitis and Pancreatitis:

Dr.dr. Fauzi Yusuf SpPD, KGEH, FACG, FINASIM

GastroenteroHepatologi Division, Medical Faculty
SyiahKuala University/Zainoel Abidin Hospital
Banda Aceh
Source: Bates Jane A; Pathology of Gallbladder and Biliary Tree; in Abdominal Ultrasound: How Why and When; Sec
Churchill Livingstone; China; 2004
 Gallstones
 Common worldwide
 Mostly asymptomatic
 Two main type : cholesterol and pigment
 In USA and Western countries,cholesterol
stones the majority (80-90%)
 East Asian contries pigment stone is
significant higher than Western contries
 Cholesterol stones

Mayor clinical associations :

 Aging

 Female gender

 Obesity

 Pregnancy

 Rapid weight loss

 Native American ethnicity

 Risk Factors associated With
Cholesterol Hypersecretion in Bile
 Clinical  Patogenesis

 Obesity   Increasehydroxymethyl-
glutaryl coenzyme A
 Contraceptives   Inhibition of hepatic acyl
oral coenzym A cholesterol

 Estrogens   Increase Lipoprotein

receptors B and C
 Age related decrease in 7
 Age  α-hydrolase activity
 Pigment stone
 Two types :Black pigment, Brown pigment
 Black pigment stones :
Associated with  - old age
- cirrhosis
- hemolysis
- possibly TPN
 Brown pigment stones : found mostly in
bile ducts
 SCHEMATIC REPRESENTATION
OF BILE ACID SYNTHESIS AND METABOLISM
Cholesterol

7 α Hydroxylase 12 α
Hydroxylase
7 α Hydroxycholesterol

26 α Hydroxylase 26 α Hydroxylase

Chenodeoxycholic Acid Cholic Acid

(unconjugated) (unconjugated)
Intestinal Bacteria Intestinal Bacteria

Lithocholic Acid Deoxycholic Acid

(unconjugated) (unconjugated)
 Role of the Gallbladder
 Gallbladder mucosal plays an important role in
pathogenic process.
 Gallbladder 
- absorb excess water and electrolyte and
concetrate bile
- secretes hydrogen ions and mucin.
 Normal : Balance proportion Cholesterol-Bile
Acid-Lecithin.
 Imbalance  Precipitacion Crystal Chlesterol
Chlesterol
Stone
 Diagnosis
 Ultrasonography
- Diagnosis of gallbladder stones(± 95%)
- Can also visualize the bile ducts, liver, and
pancreas.
- Stone in the bile ducts (± 30 %).
 ERCP

 MRCP

 EUS
 Other Radiologic Studies
 ± 15 % of gallstones are radio-opaque on
plain abdominal X-ray.
 CT scanning, for more information but
lower sensitivity than USG.
 Rarely, PTC, Oral cholecystography.
 Natural History
 Asymptomatic gallstones
 The majority of the patients with gallstones
are asymptomatic
 Asymptomatic  Symptomatic 1-2 1-2 %
 The consensus  asymptomatic patients with
gallstones Should not undergo prophylactic
cholecystectomi.
 Symptomatic Gallstones
 Cholesterol stone, not calcified
- < 5mm, patent cystic duct  oral bile acid
- Single stone, 5-20 mm, patent cystic duct

ESWL  oral bile acid
 Laparoscopic or Open cholecystectomi

 Endoscopic Sphincterotomy  Non

cholesterol stones or Calcified stones
 Differential Diagnosis
Many conditions  Right Upper Quadrant
pain
Epigastric pain
 Peptic Ulcer
 Choledocholithiasis
 Pancreatitis
 GERD
 Angina
 Liver-related conditions
 Natural History
 Once experiences a first episode of biliary
pain
  75 % attack within a 2 years period.
 Serious Complications :
- Acute cholecystitis
- Pancreatitis
- Cholangitis
 The risk of developing a serious
complications in patients with first
episode of biliary pain ± 1-2 % year
 Biliary pain
 1/3 patient with Gallstone are
Symptomatic
 Biliary pain is main complaint (70%-80%).
 The pain of Biliary  Functional spasm
around an obstructed Cystic Duct.
 Episodic and Severe
 Epigastric, right upper quadrant
 Acute cholecystitis
 The most common of acute complications
 The leading indication for emergency
cholecystectomy
 Pathogenesis :

- Cyst duct obstruction (stone, mucous,

sludge)
- Lysolecithin, prostaglandins and others
subtances  stasis  obstruct
gallbladder inflamation the gallbladder
wall.
 Acute cholecystitis (cont..)
 Clinical presentation
- Moderate pain in the epigastium or upper
right
quadrant which may radiate to right
sholder
and scapula.
- Nausea, vomiting, febrile
- Right upper quadrant tenderness,
- Murphy’s signs
 Acute cholecystitis (cont..)
 Laboratory findings
- Leukositosis
- AST,ALT, Alkaline phosphatase, bilirubin
levels  normal/slightly elevated
- If Alkaline phosphatase 
Choledocholithiasis?
 Diagnosis

Base on combination of characteristic

clinical findings and Radiologic studies.
 Diagnosis
 Hepatobiliary scanning
- Injecting radiolabeled HIDA or DISIDA
- Sensitivity 90%
 Ultrasonography

- Sign : Gallstone, dilated gallbladder,

thickened
gallbladder wall, edema within
gallbladder wall,
perycholecystic fluid, sludge.
 ULTRASOUND APPEARANCES
A B

Source: Bates Jane A; Pathology of Gallbladder and Biliary Tree; in Abdominal Ultrasound: How Why and When; Sec
Churchill Livingstone; China; 2004
 ULTRASOUND APPEARANCES

Source: Bates Jane A; Pathology of Gallbladder and Biliary Tree; in Abdominal Ultrasound: How Why and When; Sec
Churchill Livingstone; China; 2004
 Cholangitis
 Choledocholithiasis ( Common Bile Duct stones)
 obstructive jaundice, pruritus,acholic feces 
Cholangitis.
 Clinical picture : Charcot Triad (Biliary pain,
Jaundice, Chill and Rigor)
 Slight hepatomegali, tenderness.
 BloodCulture : E. Coli, Klebsiella, Proteus dan
Pseudomonas.
 Patogenesis : Biliary tract obstruction, Increase
intralumen pressure, Bile acid infection.
 ULTRASOUND APPEARANCES

Source: Bates Jane A; Pathology of Gallbladder and Biliary Tree; in Abdominal Ultrasound: How Why and When; Sec
Churchill Livingstone; China; 2004
 Cholangitis (cont..)
 Therapi  85 % response
- Antibiotic (7-10 days)  gram /-,
/-,
anaerob
- Fluid and Electrolyte
- Analgetic
Drainage  ERCP, sphingterotomi
 15 %  Directly Drainage (persistent fever,
abdominal pain, sign and symptom
septicemia)  ERCP, PTBD
 Acute Pancreatitis
 = Biliary Pancreatitis
 Precipitate by the passage of stones or
sludge in the common bile duct  sludge
or microscopic stones
 Fasting totally  Total Parenteral Nutrition
 Urgent ERCP  Sphincterotomi
 Antibiotic
 ULTRASOUND APPEARANCES

Endoscopic
cholangiopancreatography
(ERCP) of a stone in a normal-
calibre (5 mm) duct

Source: Bates Jane A; Pathology of Gallbladder and Biliary Tree; in Abdominal Ultrasound: How Why and When; Sec
Churchill Livingstone; China; 2004
 ULTRASOUND APPEARANCES

Source: Bates Jane A; Pathology of Gallbladder and Biliary Tree; in Abdominal Ultrasound: How Why and When; Sec
Churchill Livingstone; China; 2004
 Summary
 The Majority patient with Gallstones are
Asymptomatic
 Complication Gallstones symptomatic are :
Acute cholecystitis, Acute cholangitis,
Biliary Pancreatitis
 Therapy Gallstone are oral bile acid, ESWL,
ERCP, Laparoscopic/Open
Cholecystectomi, depend on characteristic
patients.