CHOLELITHIASIS

Shoofii Dzakiyyah Ulhaq

Preceptor:
dr. Liza Nursanty, Sp.B, M.Kes, FinaCS
BASIC SCIENCE
 ANATOMY OF GALLBLADDER
 The gallbladder is a pear-shaped sac, about 7 to 10
cm long, with capacity of 30 to 50 mL.
 Location in a fossa on the inferior surface of the liver.
 The gallbladder is divided into four anatomic areas:
 the fundus  (rounded, 1-2 cm long, contains
smooth muscles)
 the corpus (body)  (the main storage area and
contains most of the elastic tissue. extends from the
fundus and tapers into the neck that connects with
the cystic duct. )
 the infundibulum,
 the neck  a gentle curve, the convexity of which
may be enlarged to form the infundibulum or
Hartmann’s pouch that extends into the free portion
of the hepatoduodenal ligament
Vascularization
 Venous Drainage
• Cystic veins join
the right branch of the
portal vein.
• The veins of
the fundus and body of
the gallbladder pass
directly into the liver.
Lymphatic Drainage
Gallbladder
lymph node

Cystic lymph
node

Hepatic
lymph node

Coeliac
lymph node
Innervation
• Sympathic  Celliac
plexus nerve
• Parasympathic  CN-X
HISTOLOGY OF GALL BLADDER
• Mucosa
• Simple columnar epithelium
• Lamina propria  the
tubuloalveolar glands
• Muscularis
 Thin, contains circular
longitudinal and oblique
fibers muscle
• Serosa
• External adventitia
• Perimuscular subserosa
contains connective tissue,
nerves, vessels, lymphatics,
and adipocytes
PHYSIOLOGY OF BILE
• Bile formed in the hepatic lobules
is secreted into a complex network
of canaliculi, small bile ductules,
and larger bile ducts with total
daily secretion is 500-600
ml/day.
• Major salute components of bile:
• Bile acids (80%),
• Lecithin and traces of phospholipids
(16%),
• Unesterified cholesterol (4.0%),
• Conjugated bilirubin,
• Proteins,
• Electrolyte,
• Mucus,
• Drugs and their metabolites.
• Function of bile:
• Digestion and absorption
Because bile acids can:
• Emulsification large fat
particles into small
particles
• Absorption of last fat
product which ingested
from intestine mucosal
membrane
• Waste product excretion
 bilirubin and
cholesterol ↑
PHYSIOLOGY OF BILE
• Secretion
Hepatocyte secreting bile  1st secretion: bile acid, cholesterol, others
organic components  secreted into bile canaliculi  bile ductules  bile
ducts  hepatic duct  common bile duct  gallbladder  duodenum
• Storage
Bile secretion  storage in gallbladder because water, natrium, chloride,
small electrolyte absorbed in gallbladder  remnant concentrations: bile
salt, cholesterol, lechitin, bilirubin
• Emptying gallbladder
Fatty foods reach the duodenum (30 minutes after eat) small intestine gets
stimulation to secreting CCK hormones  gallbladder wall contracts
ritmically which helped by ACh from vagal nerve  ↑ bile flow to common
bile duct  Sphincter of Oddi is relaxation  ↑ bile flow to duodenum
CHOLELITHIASIS
DEFINITION
 Cholelithiasis is the
disease presence of
stones (gallstones) in
the gallbladder and /
or in the ductus
 Cholecystolithiasis is
stone that formed in
gallbladder
 Primer
 Sekunder
EPIDEMIOLOGY
• Worldwide prevalences  11-36%.
• Quite prevalent in most Western countries.

• Women has 3x greater prevalence than Men.

• 1st degree relatives of patients with gallstones have

2x greater prevalence.
• Peak incidence  > 40 years old.
ETIOLOGY
 Imbalance of bile salts, lecithin (stabilizer), diluted
substances (cholesterol, calcium carbonate, bilirubin),
and gallbladder stasis.
RISK FACTORS
• Chronic hemolytic
Fat anemias
• Crohn disease
Family Female
history
• Terminal ileal resection

6Fs • Gastric surgery

Fair- Fertile • Genetics

skinned
• Activity
Forty
• Food
 PATHOGENESIS

Cholesterol
(80%) Black
Gallstone (10%)
Pigmented
(20%) Brown
(10%)
 Cholesterol Gallstone
 Shaped oval, multifocal or
mulberry contains more than
70%
 Cholesterol gallstone > 90%
are cholesterol, 10%
(calcium carbonat, calciu
palmitrat, and calcium
bilirubinar)
 Pure cholestrol stones are
rare
 Pigmented Gallstone (BROWN)
 BROWN GALLSTONE
 Colored brown / dark
brown, soft, easy to
destroy and contains
calcium-bilirubinat (main
component)
 Due to  stasis factor +
bile duct infection
 Stasis: Oddi sphincter dysfunction, stricture,
biliary surgery, and parasitic infections
 Bile duct infections, (E. Coli), glucoronidase
(bacterial) enzyme levels  hydrolysis 
free bilirubin & glucoronic acid. Calcium +
bilirubin  calcium bilirubinate (not
soluble)
Pigmented Gallstone (BLACK)

 BLACK GALLSTONE
 Black / brownish black
powder and rich in
unextracted black
residues
 Many are found in
patients with chronic
hemolysis or cirrhosis
of the liver
PATHOGENESIS
• Abnormal hepatic cholesterol metabolism  ↑ cholesterol
concentration in bile + ↓ bile salts & lecithin  ...
• Hypersaturated bile  biliary sludge  cholesterol stone or mixed stones
• Bile acids malabsorption  cholesterol precipitation
• Gallbladder hypomotility & bowel rest  bile stasis
• Other stone type:
• Black pigmented stone
↑ hemolysis  hypersaturation of bilirubin  bilirubin precipitation &
stone formation
• Brown pigmented stone  calcium carbonate stone
Caused by bacteria, biliary parasites, and stasis
 Post prandial or
night
Biliary colic
May radiate to
the epigastrium,
right shoulder
Nausea
Assymptomatic
(60-80%)
Clinical Vomiting
Features
Symptomatic
Feelings of
satiety

Bloating

Dyspepsia
 DIAGNOSTICS

Assymptomatic Mild RUQ Laboratory

DIAGNOSTICS
HISTORY TAKING

PHYSICAL EXAMINATION
Symptomatic tenderness • WBC, liver function
during an test  normal (in
• Biliary colic episode of pain uncomplicated
• Nausea gallstones)
• Vomiting Radiographic
• Feelings of • USG  shows
gallstones with
satiety posterior accoustic
• Bloating shadow, possible
sludge
• Dyspepsia
 Cholecystography

Contrast for standard diagnostics  look

gallbladder under USG/CT
Principle :
Patient don’t eat fatty food or any food
for 6 hours. Than, patient took a contrast
tablet  dissolved and absorption in
liver  secretion to bile duct

Purpose :
1. Clinical Patology of Gallbladder
2. Condition ofcystic duct & common
bile duct
 CT Scan

CT Scan Examination

• Location of Stoness
• Existence of obstruction
• Dilatation of cystic duct and
common bile duct
• Complication  Ruptur of
gallbladder
 ERCP (Endoscopic Retrograde Cholangio
Pancreatography)
Prosedur: sebuah kanul yang
dimasukan ke dalam duktus
koledukus dan duktus pancreatikus
→ bahan kontras disuntikkan ke
dalam duktus tsb.

 Function:
1. Facilitates direct visualization of biliary structures and facilitates access to the distal bile
ducts to remove gallstones
2. Distinguish jaundice-induced jaundice, jaundice of cellular hepato & jaundice induced
biliary obsInvestruction
3. Investigate gastro intestinal symptoms in patients whose gall bladder has been removed
TREATMENTS

CONSERVATIVE SURGICAL

• Fasting or dietary • Laparoscopic

modification (decreased cholecystectomy
fat intake) • Gold standard treating
• Spasmolytics
symptomatic cholelithiasis
• Indications:
• Analgesia
• Presence of symptoms
• Presence of prior complication
• Presence of underlying condition
predisposing complication
 CONSERVATIVE TREATMENT
Lisis batu dengan obat-obatan
Terapi disolusi dengan asam
ursodeoksilat untuk melarutkan
batu empedu kolesterol
dibutuhkan waktu pemberian obat
6-12 bulan dan diperlukan
monitoring hingga dicapai disolusi.
Terapi efektif pada ukuran <1 cm
dengan angka kekambuhan 50%
dalam 5 tahun
Disolusi kontak
Prinsip :
PTC (Percutaneous transhepatic
cholangiogram) pelarut kolesterol
langsung kekandung empedu.
Melalui kateter yang diletakkan
perkutan langsung ke kantung
empedu
Prosedur ini invasif dan kerugian
utamanya adalah angka
kekambuhan yang tinggi.
 Litotripsi (Extarcorporeal Shock
Wave Lithotripsy = ESWL)

 Indication
 Stones larger than 5 mm + Persistent pain
not resolved with adequate anelgetic
treatment
 The presence of persistent obstruction with
the risk of kidney damage
 Infection of the urinary tract,
 Bilateral obstruction
 OPERATIVE TREATMENT
 Indication
Urgency (within 24-72 hours)
 Acute cholecystitis
Open cholecystectomy
 Cholecystitis emphysema

 Empyema of the gallbladder

 Perforation of the gallbladder

 History of Choledocholithiasis

 Elective
 Diskinesia biliaris
 Chronic cholecystitis
 Symptomatic cholelithiasis
Laparoscopic Cholecystectomy
CBD Exploration with T Tube Insertion
Transduodenal Sphincterotomy

Indication

 Impacted stone in
ampulla
 Papillary stenosis
 Multiple stone with
nondilatated duct
 COMPLICATIONS

Chronic
Inflammatory Mechanical Gallbladder
Inflammation
• Cholecystitis • Gallbladder • Formation of
• Cholangitis perforation porcelain
• Gallbladder • Gallstone ileus gallbladder
empyema • Gallstone • Shrunken
• Gallbladder pancreatitis gallbladder
gangrene • Mirrizi syndrome • Gallbladder
• Liver abscess cancer
PROGNOSIS
• Quo ad vitam: ad bonam
• Quo ad sanationam: dubia ad bonam
• Quo ad functionam: ad bonam
REFERENCES
• Moore, Keith L, dkk. 2010. Clinically Oriented Anatomy Sixth
Edition. Philadelphia: Lippincot Williams & Wiskins.
• Mescher, Anthony L. Junqueira’s Basic Histology: Text and
Atlas, 12e. Mc-Graw-Hill Companies.
• Guyton, Arthur C., John E. Hall. 2006. Textbook of Medical
Physiology, 11e. Philadelphia: Elsevier Saunders.
• Kasper, Denis L, dkk. Harrison’s Principle of Internal Medicine
16th e. 2005. USA: Mc-Graw-Hill Companies, Inc.
• Brunicardi, Charles, dkk. 2006. Schwartz’s Manual of Surgery
8th Edition. USA: McGraw-Hill Companies.
• Sjamsuhidajat, R., Wim de Jong. 2010. Buku Ajar Ilmu Bedah.
Jakarta: EGC.
THANKS FOR YOUR
ATTENTION