its important info about gallbladder stone.

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Nangarhar University Teaching Hospital
General Surgery Word
Chlolelithiasis
Prepared by : Dr Abdullah ihsaas
General Surgery Trainee Specialist

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Cholelithiasis

3. DEFINITION
 The presence of stones in the gallbladder is referred to
As cholelithiasis :-
from the Greek chol- (bile) + lith- (stone) + -iasis (process).
 If gallstones migrate or (primary ,Rare) into the ducts
of the biliary tract, the condition is referred to
As choledocholithiasis
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4. INCIDENCE & PREVALENCE
 Occur at any age
 Uncommon in children & young adults but become more
prevalent with increasing age have.
 Gall stones incidence increase with every decades
 Or after 50 -65 y suffer 20% women and 5 % of men.
There is no specific data at Afghanistan
In America :-
 20 million have GB stones
 300000 Operations for GB stones done per year
 6000 deaths every year
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5. RISK FACTORS
 Women (Gender )
 Mutiparity
 Birth control pills
 Pregnancy (Fertile)
 A family history
 Flatulent
 Obesity (Fat)
 Diabetes
 Sedentary life style
 Biliary sys inflammatory
disease L.C ,HBS HCV
 Rapid weight loss.
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6. • Flatulent
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1. Fat
2. Forty
3. Female
4. Fertile
5. Flatulent
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7. TYPES OF GALLSTONES
 There are three types of gall stone-
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8. Cholesterol stones
 Made of cholesterol
 Very large
 Single and soft
 Made 6% of GB stones
Pigment stones
 Made of bilirubin pigment
 Small
 Multiple and soft
 Black or black green colored
 Made 4% of GB stones
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9. Mixed stones
 Most common type 90 % of GB stones.
 It may be combination of cholesterol & pigment stones
or other substances like
 Calcium carbonate, phosphate, bile salts, & palmitate
make up more common minor constituents.
 Multiple , Hard and Radiopaque 15 % (Due to more Ca)
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10. Etiology and pathogenesis
No specific and clear mechanism for stones formation
But there is some factors which is involved in formation of GB
stones
1. Metabolic causes
2. Infection
3. Bile stasis
4. Pigment stones formation theory
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11. 1. Metabolic causes :
 Cholesterol increases then bile acids
 Cholesterol become precipitated
 First foci of stone formed
 Or we can say all causes which increase cholesterol production:
 Old age
 Fat
 Oral contraceptive drugs
 Or all causes which decreases Bile acid formations:
 Ilium resection
 Bypass
 Estrogen
 Ilial disease
 Cholestyramine use 11

12. 2. Infections:
80 % Role in GB stones formation ( Mostly Mixed type stones )
 Ecoli – proteus – anaerobic organism – streptococci
 Damage wall of Gall bladder
 Change at permeability
 Bile salt and lecithin spread to circulatory system and
decreased
 Cholesterol precipitated or segmented
 Foci of stone formed
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13. 3. Bile stasis:
 Mechanical causes
Mostly cause mixed type stones
 Spasm of oddi sphincter
 Congenital anomalies
 Bile ducts fibrosis
 Local tumors
 Non mechanical causes
Decrease contraction of gall bladder which cause bile stasis ( bile salt ,
phospholipids precipitation ) occur which causes formation of stone firs foci
 Estrogen
 Pregnancy
 truncal vagotomy
 Long term parenteral nutrition 13

14. 4. Pigmented stones formation theory
There is three causes for pigmented stone formation
 Hemolytic disorders:-
 Hereditary spherocytosis
 Sickle cell anemia
 Thalassemia
 Malaria
 Mechanical destruction of RBCs by prostatic heart valve
 Bile ducts benign and malignant strictures , cirrhosis ,
ascaris:-
 oddi sphincter obstruction
 E. coli infection:-
Beta.Glucuronidase enzyme change soluble bilirubin to
insoluble unconjugated bilirubin
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15. Clinical presentation
Asymptomatic or silent Gall stone
 10 % in male
 20 % in female
 As we mentioned before 10 % is radiopaque thus it diagnose
accidentally while we do radiography for other problems
Mostly its single and cholesterol stone.
It don’t need treatment with out some Exceptions
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16. Symptomatic gallstones clinic
 Flatulent dyspepsia
 Gall stone colic
 Clinic due to complications
Flatulent dyspepsia :
 Abdominal distention
 Epigastric area discomfort
 Lipid intolerance
 Oral bloating
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Clinical presentation

17. Gall stone colic :
due to contraction or spasm of obstructed gall bladder
RUQ colic pain ( mostly at night after eating heavy and fatty foods.
Pain increase at supine position ( due to gall bladder and cystic duct
spasm)
Radiated to chest and inter scapular area or right shoulder
Duration of pain ( from minutes up to hour )
Pain is periodic
Associated with :
Nausea/vomiting discomfort and other dyspeptic symptoms due to
reflex pylorospasm
Tenderness of Right hypo chondrium.
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Murphy sign- It is indicator of gall bladder inflammation (acute cholecystitis).
Pain on deep breath when the finger on under the liver border at the bottom
of the rib cage. The inspiration causes the gallbladder to descend onto the
fingers

19.  Clinic due to complications :-
Some time stones present at biliary ducts and intestines
Gall bladder stones show complication at three sites
1. Gall bladder
 Acute cholicystitis
 Chronic cholicystits
 Empyema gall bladder
 Perforation causing biliary peritonitis or peri cholicystic abscess
 Mucocele of gallbladder
 Lime gall bladder
 Carcinoma gall bladder
2. At CBD :
 Secondary CBD stones
 Cholangitis
 pancreatitis
 Mirizzi syndrome
3. At intestine :
 Cholicystoduodenal fistula causing gall stone ileus 19

20. VITAMIN DEFICIENCY
 Obstruction of bile flow also interferes with absorption of
the fat soluble vitamins A, D, E, & K.
 May exhibit deficiencies of these vitamins.
 If biliary obstruction has been prolonged (eg,
bleeding caused by vitamin K deficiency, which
interferes with normal blood clotting)
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21. Diagnosis
 Clinical feature
 Complete Detailed history tacking
 Physical examination
 Laboratory and imagining tests
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ERCP

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27. MANAGEMENT
1. Of Asymptomatic gall bladder stone
2. Of Symptomatic gall bladder stone
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28. Management of gall stones
1. Asymptomatic or silent stones :
No need for surgery, Except below conditions :-
1. Silent stones + Diabetes and Poor immunity patients
2. If there is increase chance of gall bladder CA
3. Increased Gall bladder wall thickness.
4. Multiple stones and stone Beggar then 2,5 cm size
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29. 2. Symptomatic gall stones :
Treated by two methods
A. Non surgical treatment :
 Conservative treatment
90% of inflammatory symptoms with gall stone cure with
conservative treatment
 Stop oral diet for 2- 3 days, start iv nutrition.
 For pain relief use :
 Analgesics
 Antispasmodic
 Morphine 8-10 mg sever pain
 Atropine 1ml or Hyoscin butyl bromide to reduce Oddi
spasm
 Broad spectrum antibiotic
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30.  Medical dissolution of gall stones
when stones are radiolucent and gall bladder function is
normal
 Chenodeoxy cholic acid 15 mg / kg for 6 months
 Ursodeoxy cholic acid 10 mg/kg for 6 month
Side effect  poor compliance due to diarrhea
 Methyl ter butyl ether (MTBE) :-
Which dissolve cholesterol stone at several hours.
Pigtail catheter U/S or CT Guided inter to GB  (MTBE) put into GB  after
dissolve stones  suction it.
 Lithotripsy :-
ESWL various types use ((wolf system, Dornier system, Siemens system))
Use for GB stones which is 1 – 3 and normal function GB.
Broken stones find way to duodenum
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32. B. Surgical treatment or cholecystectomy :
For cholecystectomy we use two operative methods
 Laparoscopic cholecystectomy
 Open cholecystectomy
Before procedures we should prepare patient for
operation
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34. Preparation for operation
 Taking detailed history and assessment of patient for
operation. To do or not to do operation
 Complete blood routine exams to assess liver and kidney
function ….?
 Prothrombin time, chest X ray, ECG,
 Pre operative antibiotics ( 2nd generation cephalosporin )
 Sub cutaneous heparin or anti embolic specific socks to
reduce Deep vein thrombosis
 Explain procedure and its complication to patient and
take constant
 Intra operative cholangiography may be needed
 Premedication before operation
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35. Indication of cholecystectomy
Indication for cholecystectomy are the same whether
it is performed by laparoscopic or by open
techniques.
1. Symptomatic gall stone
2. Acute and chronic cholicystitis
3. A calculus cholicystitis
4. Empyema – gall bladder
5. Mucocele – gall bladder
6. Preventively cholecystectomy done at diabetics and
hemolytic anemia.
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37. LAPAROSCOPIC CHOLECYSTECTOMY
 Cholecystectomy is the most common major abdominal
procedure
 Open cholecystectomy was a safe and effective
treatment for both acute and chronic cholecystitis now
its (uncommon)
 Bcz In 1987 laparoscopic cholecystectomy was
introduced today laparoscopic cholecystectomy is the
treatment of choice for symptomatic gallstone.
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38.  The patient is placed supine on the operating table.
 Head of table should be upward up to 20 degree.
 The patient is placed in a revers Trendelburg position
slightly rotated to the left.
 The patient is covered and colored under general
anesthesia.
And at first pneumoperitoneum is established :
1. Use open sub umbilical cut down with direct visualization of
the peritoneum.
2. With closed technique verres needle.
pressure should be reached up to 12 – 14 mm
 laparoscopic cholecystectomy procedure :
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39. 1. Sub umbilical 10 mm longest  insert the initial port
( camera or telescope ) to peritoneal cavity
2. Anterior auxiliary line at subcostal area 5mm L to insert
first gallbladder grasper forceps by which we pull fundus
toward diaphragm.
3. Mid clavicular linear subcostal area 5mm L  to insert 2nd
gall bladder grasper forceps by which we pull Hartmann's
pouch toward the RIF to Expose the calot’s Triangle
4. Mid line at sub xiphoid 10mm L  to insert dissector by
which we dissect calot’s triangle and ligate or clipping
cystic duct and cystic artery
4 incisions done at abdomen for laparoscopic
cholecystectomy
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40. At this procedure The key as in open surgery, is the
identification and safe dissection of calot,s triangle.
Dissection of calot,s
Triangle
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41. Calot’s triangle
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42.  Once the anatomy is clearly defined and the triangle of calots
has been laid widely open the cystic duct and artery are
clipped
 and divided the gall bladder
 is then removed from the gall bladder bed by sharp or
cautery dissection and once free
 removed via the umbilicus
After hemostasis ports of laparoscope is out from peritoneum.
Reaper of incision done plan by plan
Continue ..
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43. Note:
if there was oozing – infected gall bladder or raptured
at procedure then we put sub hepatic tube drain from
lateral incision.
 Allow the patient to eat after 24 Hr.
 Hospital stay will be 24 or 48 Hr.
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44. Complication of cholecystectomy
1. Bile duct injury 0.05 %
2. Bleeding
3. Bile leakage
4. Infection, cholangitis, septicaemia
5. Sub phrenic abscess
6. Injury to colon, duodenum or mesentry
7. Walt man – Walter syndrome
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45. Advantages of laparoscopic
cholecystectomy
1. Less hospital stay one or two days
2. Patients will rapidly mobilized bcz of less pain sensation
3. Good cosmetically
4. Less chance of adhesions and incisional hernia
 Contraindication of laparoscopic
cholecystectomy:
1. Sever contracted and fibrosis gall bladder
2. Difficult gall bladder
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47. Open cholecystectomy
For patient in whom a laparoscopic approach is not indicated or
in whom conversion from a laparoscopic approach is required
an open cholecystectomy is performed.
Patient is placed supine under general anesthesia,
covered and colored.
And one of below incisions made for this procedure :
1. Right sub costal incision ( right Kocher's)
2. Right paramedium
3. Horizontal incision
4. Myo – rob son incision
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48. Procedure
After incision released all adhesions between
Gall bladder – omentum – and duodenal ampulla.
 For removing gall bladder we use two methods :
1. Retrograde or Duct – first method
2. Fundus – first cholecystectomy
At both methods two points should be conceders :
• Cut down cystic duct near to CBD, stump should be not
remained .
• Try to protect CBD from injury's
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49. PERCUTANEOUS
CHOLECYSTOSTOMY
 Used in the treatment & diagnosis of acute cholecystitis
in patients who are poor risks for any surgical procedure
or for general anesthesia.
 Under local anesthesia, a fine needle is inserted
through the abdominal wall & liver edge into the
gallbladder under the guidance of ultrasound or
computed tomography.
 Bile is aspirated to ensure adequate placement of the
needle & a catheter is inserted into the gallbladder to
decompress the biliary tract.
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51. References :
1. Bailey & love’s
SHORT
PRACTICE of
SURGERY 27th Edition.
2. Schwartz's
MANUAL OF
SURGERY 8th Edition.
3. GRAY’S
ANATOMY
FOR STUDENTS3rd EDITION 51