Gallstone surgery by Dr Dhaval Mangukiya https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Gallstone Disease
Dr. Dhaval Mangukiya

2. His career started as
•Policeman
•Cricketer
•Umpire
•Banker

3. Overview
• Gallstone pathogenesis
• Definitions
• Differential Diagnosis of RUQ pain

4. Gallstone Pathogenesis
• Bile = bile salts, phospholipids, cholesterol
– Also bilirubin which is conjugated b4 excretion
• Gallstones due to imbalance rendering
cholesterol & calcium salts insoluble
• Pathogenesis involves 3 stages:
– 1. cholesterol supersaturation in bile
– 2. crystal nucleation
– 3. stone growth

5. Types of stones
•Cholesterol stones (20%)
•Pigment stones (5%)
–Black (hemolysis)
–Brown (infection)
•Mixed stones (75%)

6. Risk factors – 5 F
•Forty
•Female
•Fertile
•Fatty
•Family History or genetics

7. Risk factors
•OC pills/Estrogen
•DM
•Rapid weight loss
•Cirrhosis
•GB stasis (TPN/Somatostatin)
•Other drugs
•Decreased physical activity
•Crohn’s disease
•Hemolysis

8. Protective factors
•Statins
•Ascorbic acid
•Coffee
•Vegetable proteins and nuts
•Poly and monounsaturated fats

10. Que
Most common presenting symptoms for GB
stones
•Pain
•Fever
•Dyspepsia
•Jaundice

11. Asymptomatic Gall Stones
•Most individuals with gallstones are
asymptomatic throughout their life and are
referred to as having "incidental"
gallstones
•"Uncomplicated" gallstone disease is
present if the gallstones cause symptoms
(eg, biliary colic)

12. Asymptomatic Gall Stones
•Leave it alone
•Dissolution therapy (UDCA)
•Regular follow up
•Surgery

13. Lithotripsy/dissolution

14. Asymptomatic Gall stones
Indication for Surgery
•Increased risk of gallbladder cancer
–Anomalous pancreatic ductal drainage
–Gallbladder adenomas
–Porcelain gallbladder
–Large gallstones (particularly if larger than 3 cm)
•Hemolytic disorder
–Hereditary spherocytosis
–Sickle cell anaemia
•Gastric bypass

15. Definitions
Symptomatic
cholelithiasis
Wax/waning postprandial epigastric/RUQ pain
due to transient cystic duct obstruction by stone,
no fever/WBC, normal LFT
Acute
cholecystitis
Acute GB inflammation due to cystic duct
obstruction. Persistent RUQ pain +/- fever,
↑WBC, ↑LFT, +Murphy’s sign
Chronic
cholecystitis
Recurrent bouts of colic/acute chol’y leading to
chronic GB wall inflamm/fibrosis. No fever/WBC.
Acalculous
cholecystitis
GB inflammation due to biliary stasis(5% of time)
and not stones(95%). Seen in critically ill pts
Choledocho-
lithiasis
Gallstone in the common bile duct (primary
means originated there, secondary = from GB)
Cholangitis Infection within bile ducts usu due to obstrux of
CBD. Charcot triad: RUQ pain, jaundice, fever
(seen in 70% of pts), can lead to septic shock

16. Que
What is Murphy’s sign
•Punch at Scapular angle
•Inspiration arrest while deep palpation at
RHC
•Bluish discoloration at umbilicus
•Right shoulder pain while deep palpation at
RHC

17. Differential Diagnosis of RUQ pain
• Biliary disease
– Acute chol’y, chronic chol’y, CBD stone,
cholangitis
• Inflamed or perforated duodenal ulcer
• Hepatitis
• Also need to rule out:
– Appendicitis, renal colic, pneumonia or
pleurisy, pancreatitis

18. Symptomatic cholelithiasis
• aka “biliary colic”
• 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
• Ultrasound reveals evidence at the crime
scene of the likely etiology: gallstones
• Exam, WBC, and LFT normal in this case
• Treatment: Laparoscopic cholecystectomy

19. Que
•Which is the nature of pain in biliary colic
•Colicky/spasmodic
•Vague
•Sharp shooting
•Burning

20. Chronic calculous cholecystitis
• 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

21. Acute calculous cholecystitis
• Persistent cystic duct obstruction leads to
GB distension, wall inflammation & edema
• Can lead to: empyema, gangrene, rupture
• Pain usu. persists >24hrs & a/w 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, Abx (GNR & enterococcus)
• Sg: Cholecystectomy usu within 48hrs

22. HIDA scan
•99-mTc Hepatic Iminodiacetic Acid
•Injected IV
•Normally, visualization of contrast within
the common bile duct, gallbladder, and
small bowel occurs within 30 to 60 minutes
•The test is positive if the gallbladder does
not visualize

23. Que
Which is best investigation to detect gall
stones
•X – Ray
•USG Abdomen
•CT Scan
•MRI

24. Que
How many % of Gall stones are radio
opaque
•10
•20
•50
•90

25. Acute acalculous cholecystitis
• 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 usu open
• If pt is too sick, perc cholecystostomy tube
and interval cholecystectomy later on

26. Complications of acute cholecystitis
Empyema of
gallbladder
Pus-filled GB due to bacterial proliferation in
obstructed GB. Usu. more toxic, high fever
Emphysematous
cholecystitis
More commonly in men and diabetics. Severe
RUQ pain, generalized sepsis. Imaging
shows air in GB wall or lumen
Perforated
gallbladder
Occurs in 10% of acute chol’y, usually
becomes a contained abscess in RUQ
Less commonly, perforates into adjacent
viscus = cholecystoenteric fistula & the stone
can cause SBO (gallstone ileus)

27. Choledocholithiasis
• Can present similarly to cholelithiasis,
except with the addition of jaundice
• DDx: cholelithiasis, hepatitis, sclerosing
cholangitis, less likely CA with pain
• Tx: Endoscopic retrograde
cholangiopancreatography (ERCP)
– Stone extraction and sphincterotomy
• Interval cholecystectomy after recovery
from ERCP

28. Interval Cholecystectomy
•Explaination
•Preparation
•Timing
•Approach

30. Cholangitis
• Infection of the bile ducts due to CBD
obstruction 2ndary to stones, strictures
• Charcot’s triad seen in 70% of pts
• May lead to life-threatening sepsis and
septic shock (Raynaud’s pentad)
• Tx: NPO, IVF, IV Abx
• Emergent decompression via ERCP or
perc transhepatic cholangiogram (PTC)

31. Que
Which is not component Raynaud’s pentad
•Fever
•Jaundice
•Altered mental status
•Bluish finger tips

32. 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 w stone
extraction/sphincterotomy
• Cholecystectomy before hospital discharge