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Gallstone Disease

Aregawi kassa, MD
MU-CHS
Jan 16/2012G.C

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Anatomy

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Anatomy

In the inferior
surface of the liver
Pear shaped
7-10cm long
30-50ml capacity
Has four parts;
Fundus, Body,
Infundibulum and
neck
Calots triangle
bounded medially
by CHD, superiorly
the liver surface
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Anatomy
Vascular supply

cystic artery may arise from R. hepatic, L. hepatic,


common hepatic, gastroduodenal, Lt.gastric or
superior mesenteric artery

Cystic artery passes through calots triangle in 90% of


cases

venous drainage small veins into liver or


large cystic vein to portal vein

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Anatomy
Lymphatic drainage

Cystic LNs at the insertion of the artery

Innervations
Vagus motor supply
Sympathetic nerves that pass through the celiac and
splanchnic nerves then into the spinal cord

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Anatomy- Anomalies ? ~40%
inadvertent biliary tract injury

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Gallstone Pathogenesis
Bile = water, bile salts, phospholipids, cholesterol
Also bilirubin which is conjugated before excretion

Gallstones due to imbalance rendering cholesterol &


calcium salts insoluble

Pathogenesis involves 3 stages:


1. cholesterol super saturation in bile
2. crystal nucleation
3. stone growth

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Pathophysiology

Three types of stones


Cholesterol- most common in the western countries
Pigment
Mixed
Bile consists of lethicin, bile acids, phospholipids in a fine
balance.

Impaired motility can predispose to stones.

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Pathophysiology

Sludge is crystals without stones.


It may be a first step in stones, or be independent of it.

Pigment stones (10-15%) are from calcium bilirubinate.


Diseases that increase RBC destruction will cause these.
Also in cirrhotic patients, parasitic infections.

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Types of stones

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Differential Diagnosis of RUQ pain

Biliary disease
Acute cholecystitis, chronic cholecystitis, CBD stone,
cholangitis

Inflamed or perforated duodenal ulcer (PUD)

Hepatitis

Also need to rule out:


Appendicitis, renal colic, pneumonia or pleurisy,
pancreatitis
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Symptomatic cholelithiasis

Definition
On and off postprandial epigastric/RUQ pain due to
transient cystic duct obstruction by stone, no fever/WBC,
normal LFT
The pain occurs due to a stone obstructing the cystic
duct, causing wall tension; pain resolves when stone
passes

Pain usually lasts 1-5 hrs, rarely > 24hrs

Small stones more symptomatic.

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Spectrum of Gallstone Disease

Cholelithiasis Symptomatic
cholelithiasis can be a
herald to:
an attack of acute
cholecystitis
Asymptomatic Symptomatic or ongoing chronic
cholelithiasis cholelithiasis cholecystitis
May also resolve

Chronic Acute
calculous calculous Mx of cholelithiasis and
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Frequency

US: affected by race, ethnicity, sex, medical conditions,


fertility.
Internationally: 20% of women, 14% of men. Patients
over 60 prevalence was 12.9% for men, 22.4% for
women.

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Morbidity/Mortality

Asymptomatic Gall Stone are not associated with


fatalities.

Every year 1-3% of Asymptomatic patients develop


symptoms.

Morbidity and mortality is associated with symptomatic


stones.

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Race

Highest in fair skinned people of northern European


descent and in Hispanic populations.

Asians are more likely to have pigmented stones than


other populations.

African descent with Sickle Cell Anemia.

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Sex

More common in women.


estrogen causing increased cholesterol secretion
progesterone causing bile stasis.

Pregnant women more likely to have symptoms.

Women with multiple pregnancies at higher risk

Oral contraceptives, estrogen replacement therapy.

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Age

It is uncommon in children.
If they do, its more likely that they have congenital
biliary anomalies, or hemolytic pigment stones.

Incidence of Gall bladder Stone increases with age 1-3%


per year.

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Risk factors

Fair, fat, female, fertile of course.

High fat diet


Obesity

Rapid weight loss, Total Parentral Nutrition, Ileal


disease/resection, NPO.
Increases with age, alcoholism.

Diabetics have more complications.


Hemolytics
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History

3 clinical stages:
Asymptomatic - Most (~80%)

Symptomatic, and
With complications (cholecystitis, cholangitis,
CBD stones).
A history of epigastric pain with radiation to shoulder
may suggest it.

A detailed history of pattern and characteristics of


symptoms as well as Ultrasound make the diagnosis.

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History

Most patients develop symptoms before complications.

Once symptoms occur, severe symptoms develop in


3-9%, with complications in 1-3% per year.

Indigestion, bloating, fatty food intolerance occur in


similar frequencies in patients without gallstones, and
are not commonly cured with cholecystectomy.

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Physical

Vital signs and physical findings in asymptomatic


cholelithiasis are completely normal.

Fever, tachycardia, hypotension, alert you to more


serious infections, including cholangitis, cholecystitis.

Murphys sign negative in uncomplicated cholelithiasis

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Workup

Labs with asymptomatic cholelithiasis and biliary colic


should all be normal.

WBC, elevated LFTS may be helpful in diagnosis of


acute cholecystitis, but normal values do not rule it out.

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Workup

In retrospective study,
60% of patients with cholecytitis had a WBC > 11,000.
WBC greater than 15,000 may indicate perforation or
gangrene.

ALT, AST, AP more suggestive of CBD stones

Amylase elevation may be Gall Stone pancreatitis.

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Imaging Studies

Ultrasound and HIDA (99mTechnetium-labeled


derivatives of dimethyl iminodiacetic acid (HIDA) best.

Plain x-rays, CT scans ERCP are adjuncts.

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CT Scan

For complications,
Ductal dilatation,
Surrounding organs.
Misses 20% of GS.

Get if diagnosis uncertain

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Denotes the GB
wall thickening

denotes the fluid
around the GB

GB also appears
distended

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Plain FilmsX-rays:

10-15% stones are


radiopaque,
porcelain GB may be seen.
Air in biliary tree,
emphysematous GB wall.

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Imaging

Ultrasound
95% sensitive for stones,
80% specific for cholecystitis.
It is 98% sensitive and specific for simple stones.
Wall thickening (2-4mm)
Distension
Pericholecystic fluid, sonographic Murphys.
Dilated CBD (7-8mm).

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Ultrasound

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Imaging
Hida scan documents
cystic duct patency.

94% sensitive, 85%


specific

GB should be visualized
in 30 min.

CBD obstruction appears


as non visualization of
small intestine.

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Imaging-ERCP

ERCP is diagnostic and


therapeutic.
Provides radiographic and
endoscopic visualization of
biliary tree.
Do when CBD dilated and
elevated LFTs.
Complications include
bleeding, perforation,
pancreatitis, cholangitis.

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Acute calculous cholecystitis
Defnition
Acute GB inflammation due to cystic duct obstruction.
Persistent RUQ pain +/- fever, WBC, LFT, +Murphys
= inspiratory arrest

Persistent cystic duct obstruction leads to GB distension,


wall inflammation & edema

Can lead to: empyema, gangrene, rupture

Pain usu. persists >24hrs & N/V/Fever

Palpable/tender or even visible RUQ mass


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Nuclear HIDA scan shows nonfilling of GB
If U/S non-diagnostic, obtain HIDA

Tx: NPO, IVF, Antibiotics (GNR & enterococcus)

Surgery: Cholecystectomy usually within


48hrsCholecystectomy can be performed after the first
24-48h or after the inflammation has subsided.

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Lap cholecystectomy very effective
with few complications (4%).
5% convert to open.
In acute setting up to 50% open.

Unstable patients may need more urgent interventions


with ERCP, percutaneous drainage, or cholecystectomy.

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Acute acalculous cholecystitis

GB inflammation due to biliary stasis(5% of time) and


not stones (95%).

In 5-10% of cases of acute cholecystitis

Seen in critically ill pts or prolonged TPN

More likely to progress to gangrene, empyema,


perforation due to ischemia

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Caused by gallbladder stasis from lack of enteral
stimulation by cholecystokinin

Tx: Emergent cholecystectomy usually open

If patient is too sick, percutaneouse cholecystostomy tube


and interval cholecystectomy later on

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Chronic cholecystitis

Recurrent bouts of colic/acute cholecystitis leading to


chronic GB wall inflammation/fibrosis. No fever/WBC.

Recurrent inflammatory process due to recurrent cystic


duct obstruction, 90% of the time due to gallstones

Overtime, leads to scarring/wall thickening

Treatment: laparoscopic cholecystectomy

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Complications of acute cholecystitis
Empyema of Pus-filled GB due to bacterial proliferation
gallbladder in obstructed GB. Usually more toxic, high
fever

Emphysematous More commonly in men and diabetics.


cholecystitis Severe RUQ pain, generalized sepsis.
Imaging shows air in GB wall or lumen

Perforated Occurs in 10% of acute cholecystitis,


gallbladder usually becomes a contained abscess in
RUQ

Less commonly, perforates into adjacent


viscus = cholecystoenteric fistula & the
stone can cause SBO (gallstone ileus) with
~20% Mxmortality rate
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Choledocholithiasis
Gallstone in the common bile duct (primary means
originated there, secondary = from GB)

Can present similarly to cholelithiasis, except with the


addition of jaundice

Tx: Endoscopic retrograde cholangiopancreatography


(ERCP)-current modality of therapy
Stone extraction and sphincterotomy

Interval cholecystectomy after recovery from ERCP or at


the same time

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Cholangitis

Infection within bile ducts usually due to obstruction of


CBD 2ndary to stones, strictures.
Charcot triad: can lead to septic shock
RUQ pain,
jaundice,
fever (seen in 70% of pts),
Raynauds pentad = Charcots triad + altered mentation
and hypotension

May lead to life-threatening sepsis and septic shock

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Tx: NPO, aggressive IV Fluids, broad spectrum IV
Antibiotics

Emergent decompression via ERCP or percutaneous


transhepatic cholangiogram (PTC)

Used to require emergency laparotomy

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Gallstone pancreatitis

35% of acute pancreatitis 2ndary to stones

Pathophysiology
Reflux of bile into pancreatic duct and/or obstruction
of ampulla by stone

ALT > 150 (3-fold elevation) has 95% PPV for


diagnosing gallstone pancreatitis

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Tx: ABC, resuscitate, NPO/IVF, pain meds

Once pancreatitis resolving, ERCP with stone


extraction/sphincterotomy

Cholecystectomy before hospital discharge

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Prognosis

Uncomplicated cholecystitis has low mortality.

Emphysematous GB mortality is 15%

Perforation of GB occurs in 3-15% with up to 60%


mortality.

Gangrenous GB 25% mortality.

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Laparoscopic Cholecystectomy

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Laparoscopic Cholecystectomy

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Laparascopic cholecystectomy

Advantages Disadvantages
Less pain Lack of depth perception
Small incisions View controlled by camera
Better cosmesis operator
Short hospitalization Difficult to control hemorrage
Eariler return to full CO2 insufflation
activity complications
Decreased total costs

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Postoperative complications
1. Bleeding inadvertent vascular injury
liver cirrhosis
portal HTN
Rx apply pressure with hot packs 5 min
identify bleeder and ligate
- Hogarth Pringle maneuver

In LC introduce good suctioning identify bleeder and


apply clip bleeding continues conversion

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Postoperative complications

2. Bile duct injury open~ 0.1% - 0.2%


LC ~ 0.5% - 0.6%
only of bile duct injuries are noticed intraoperativelly

of them in the 1st mo,

rest present in months or yrs

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Causes inexperience
- aberrant anatomy
-inflammation
-bleeding
-injudious use of cautery
-large stone in Hartmans pouch
-wrong direction of traction of gall
bladder

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Classifications or grading

Bismuth grading system-


Grade 1->2cm from confluence
Grade 2-<2cm from the confluence
Grade 3-at the hilium
Grade 4-ducts are separated
Grade 5-involvement of intrahepatic
ducts

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Strasberg classification-
class A-injury to small ducts
class B-injury to the sectoral duct with
stricture
class c-injury to sectoral duct with leak
class d-lateral injury to extrahepatic
duct
classes E1-5 (Bismuth)

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Bile duct injury cont

Presentations Diagnosis
-obstructive jaundice -CBC
-evidence of bile leak -LFT
-cholangitis -serum Albumin and
coagulation profile
-Abd u/s
-MRCP,PTC
-ERCP ,

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Operative treatment Bile duct injury
Immediate repair
simple ligation of ducts
-closure over a T-tube
-end to end anastomosis with a T tube
-Roux-en-Y anastomosis with transhepatic bilary
stents

Elective repair
-hepaticojejunostomy with Roux-en y limb
usually after 2 months

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Postoperative complications cont

3. Retained stone
In 1% of cholecystectomies

T-tube Cholangiogram or ERCP may be necessary

Rx Dormia extraction
Endoscopic sphinicterotomy and extraction
T-tube flashing
Reoperation

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Postoperative complications cont
4. Post cholecystectomy syndrome.
Persistent or recurrent signs and symptoms after
cholecystectomy excluding early post op. complications

10% of patients
common in middle aged

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DDx of Post cholecystectomy syndrome cont

Retained or recurrent stones in the bile duct.


Stump cholelithiasis and bile duct stricture
Pancreatic or liver disease.
PUD or Bile gastritis.
Diverticular disease and irritable bowel syndrome.
Psychiatric problems (anxiety or depression)

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Post cholecystectomy syndrome cont
1. Hx & P/E.
2. Lab. CBC, serum amylase, LFT, PT.
3. Imaging. CXR , US , CT , PTC MRCP
Upper GI & SB follow through ,
Ba enema
Endoscopy. ERCP , Total colonoscopy

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Post cholecystectomy syndrome cont
Mx. 1. Medical.
2. Surgical.
3. Psychiatric consultation

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Safety

Always working close to the GB


Clamping, ligation and cutting of identified structures
Gentle traction
Good relaxation
No cautery around CBD

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Thank u

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