Diseaseses of Gall Blader

Gallstone Disease
Aregawi kassa, MD
MU-CHS
Jan 16/2012G.C
Mx of cholelithiasis and
17/01/2012 G.C complications 1
Anatomy
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
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
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
Anatomy- Anomalies ? ~40%
inadvertent biliary tract injury
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
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.
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.
Types of stones
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
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.
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
17/01/2012 G.C cholecystitis cholecystitis complications 13
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.
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.
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.
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.
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.
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
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.
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.
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
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.
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.
Imaging Studies
Ultrasound and HIDA (99mTechnetium-labeled

derivatives of dimethyl iminodiacetic acid (HIDA) best.
Plain x-rays, CT scans ERCP are adjuncts.
CT Scan
For complications,
Ductal dilatation,
Surrounding organs.
Misses 20% of GS.
Get if diagnosis uncertain
Denotes the GB
wall thickening

denotes the fluid
around the GB
GB also appears
distended
Plain FilmsX-rays:
10-15% stones are

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

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.
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.
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
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
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
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
of cholelithiasis and
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
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
Tx: NPO, aggressive IV Fluids, broad spectrum IV
Antibiotics
Emergent decompression via ERCP or percutaneous

transhepatic cholangiogram (PTC)
Used to require emergency laparotomy
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
Tx: ABC, resuscitate, NPO/IVF, pain meds
Once pancreatitis resolving, ERCP with stone

extraction/sphincterotomy
Cholecystectomy before hospital discharge
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.
Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy
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
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
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
Causes inexperience
- aberrant anatomy
-inflammation
-bleeding
-injudious use of cautery
-large stone in Hartmans pouch
-wrong direction of traction of gall
bladder
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
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)
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 ,
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
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
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
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)
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
Post cholecystectomy syndrome cont
Mx. 1. Medical.
2. Surgical.
3. Psychiatric consultation
Safety
Always working close to the GB

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

Diseaseses of Gall Blader

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Gallstone Disease

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

Cystic artery passes through calots triangle in 90% of

venous drainage small veins into liver or

Cystic LNs at the insertion of the artery

Gallstones due to imbalance rendering cholesterol &

Pathogenesis involves 3 stages:

Three types of stones

Impaired motility can predispose to stones.

Sludge is crystals without stones.

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

Inflamed or perforated duodenal ulcer (PUD)

Also need to rule out:

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

Small stones more symptomatic.

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

Asymptomatic Gall Stone are not associated with

Every year 1-3% of Asymptomatic patients develop

Morbidity and mortality is associated with symptomatic

Highest in fair skinned people of northern European

Asians are more likely to have pigmented stones than

African descent with Sickle Cell Anemia.

More common in women.

Pregnant women more likely to have symptoms.

Women with multiple pregnancies at higher risk

Oral contraceptives, estrogen replacement therapy.

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

Fair, fat, female, fertile of course.

High fat diet

Rapid weight loss, Total Parentral Nutrition, Ileal

Diabetics have more complications.

A detailed history of pattern and characteristics of

Most patients develop symptoms before complications.

Once symptoms occur, severe symptoms develop in

Indigestion, bloating, fatty food intolerance occur in

Vital signs and physical findings in asymptomatic

Fever, tachycardia, hypotension, alert you to more

Murphys sign negative in uncomplicated cholelithiasis

Labs with asymptomatic cholelithiasis and biliary colic

WBC, elevated LFTS may be helpful in diagnosis of

ALT, AST, AP more suggestive of CBD stones

Amylase elevation may be Gall Stone pancreatitis.

Ultrasound and HIDA (99mTechnetium-labeled

Plain x-rays, CT scans ERCP are adjuncts.

Get if diagnosis uncertain

10-15% stones are

94% sensitive, 85%

CBD obstruction appears

ERCP is diagnostic and

Persistent cystic duct obstruction leads to GB distension,

Can lead to: empyema, gangrene, rupture

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

Palpable/tender or even visible RUQ mass

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

Surgery: Cholecystectomy usually within

Unstable patients may need more urgent interventions

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

In 5-10% of cases of acute cholecystitis

Seen in critically ill pts or prolonged TPN

More likely to progress to gangrene, empyema,

Tx: Emergent cholecystectomy usually open

If patient is too sick, percutaneouse cholecystostomy tube

Recurrent bouts of colic/acute cholecystitis leading to

Recurrent inflammatory process due to recurrent cystic