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COMPLICATIONS OF
GALLSTONE DISEASE
ShankarZanwar
Jewellery from gall stone
BACKGROUND
 Reports of gall stones in history dates back Babylonian era
before 2000 yrs
 Prevalence of gall stones in In...
NATURAL HISTORY OF GALLS STONE
DISEASE
COMPLICATIONS OF GALL
STONES
 Cholecystitis
 Cholangitis
 Mirrizi’s syndrome
 Gall stone ileus
 Emphysematous cholecy...
CHOLECYSTITIS
 Of all patients with gall stones 2% will become symptomatic
every year (for first 5 years and later decrea...
ACUTE CHOLECYSTITIS
 Pathogenesis
Stone
embedding in
cystic duct
Chr.
Obstruction
Stasis of bile in
GB
Mucosal
trauma by ...
CLINICAL FEATURES
 Nearly 75% have prior attacks of biliary pain
 Fever – but usually <102, higher – gangrene or perfora...
NATURAL HISTORY
 Untreated cholecystitis – pain relives in 7-10 days
 Sequelae
 Resolution – 83%
 Gangrenous cholecyst...
DIAGNOSIS
 Hemtological and biochemical alterations
 Mild amylase and lipase elevation may be seen in absence of
pancrea...
 Cholescintigraphy – HIDA/DISIDA scan
 Assesses patency of cystic duct
 Normal scan – GB seen within 30 min
 Non visua...
TREATMENT
 IV fluids, Electrolyte replacement, cultures.
 Broad spectrum antibiotic coverage, in complicated patient ext...
CHOLANGITIS
 Most serious and lethal of all complications
 All causes of cholangitis 85% are due to stones embedded in t...
CLINICAL FEATURES AND LABS
 Charcots triad – pain, fever and jaundice – 70% of patients
Pitt WB Ac. Cholangitis 1987
 Fe...
IMAGING
 Stones in CBD seen only in 50% cases, CBD dilatation >6mm may
give indirect evidence in remaining 25%
Yusuff, GE...
TREATMENT
 IV fluids, cultures, antibiotics in severe cases with shock cover
anerobes
 Decompression
 ERCP
 Failed PT...
MIRRIZI’S SYNDROME.
 First described in 1948 by Mirrizi
 Stone impacted in the neck or GB or cystic duct narrowing of
CH...
CLASSIFICATIONS
 Older – McSherry
 Type 1 – external compression of CHD by calculus in cystic
duct/Hartmanns’s pouch
 T...
DIAGNOSIS
 Symptoms and signs same as cholecystitis
 Lab parameters mimic cholecystitis or cholangitis
 USG – correct d...
TREATMENT -
 When preop diagnosis made – open preferred over lap chole
 When found intra-op during lap surgery – mandate...
 Type 2-4
 using remnant of GB to repair fistula withT-tube,
 Other safest alternative is Roux enY bilio- enteric anast...
CHOLECYSTO-ENTRIC FISTULA -
GALLSTONE ILEUS
 Not a true ileus – rather mechanical obstruction
 First description – Barth...
PATHOGENESIS
 Fistula formation from bile duct to the intestine due to pressure
necrosis by gall stone against the biliar...
CLINICAL PRESENTATION
 Gall stone ileus results when gallstone is large in size majority -
>2.5cm
 Commonest site of imp...
 Mean symptoms period before presentation – 5days
 Occasional hematemesis due to hemorrhage at the entry site of
the sto...
DIAGNOSIS
 Clinical diagnosis made infrequently
 Prep-op diagnosis is made only in 20-50% of cases
Chou WJG 2007
 Rigle...
TREATMENT
 Surgery after intial resuscitaion
 Ongoing debate – one stage vs 2 stage
 One stage – treating obs, cholecys...
 Largest review of 1000 cases by Reissner – mortality rate 16.9%
in one stage vs 11.7% for enterolithotomy alone
 But re...
 A study byTan (Singapore Med J 2004)
 Significantly increased operating time in one stage
 No significant morbidity an...
EMPHYSEMATOUS
CHOLECYSTITIS
 Acute infection of gall bladder by gas forming organisms
 Surgical emergency
 Seen in 1% o...
PATHOGENESIS
 Vascular compromise of the gall bladder – occlusion or stenosis
of vessels, usually arteriosclerotic cystic...
 Common causative agents
 Clostridum spp – 46%
 E. coli – 40%
 Klebsiella
 Enterococci
 Symptoms and presentation is...
IMAGING
 X- ray – air in side the GB – can be negative in
60% cases
 USG sensitivity 90-95%
 Stage 1 - gas in lumen
 S...
 CT confirms emphysematous cholecystitis, when USG is in doubt
 HPE shows full thickness necrosis of GB, gangrene seen i...
 In hemodynamically unstable patient and those who can not
tolerate GA percutaneous cholecystectomy can be done to
stabil...
GB PERFORATION
 Neimeier classification
 Type 1 – Acute
 Type 2 – Subacute
 Type 3 – Chronic
 Managed similarly as em...
GALL STONE PANCREATITIS
 Of all gall stone patients only 3-7% develop
pancreatitis
 But amongst the pancreatitis patient...
MANAGEMENT -TIMING OF
CHOLECYSTECTOMY
 mild pancreatitis – Review of studies with total of 998 patients
 no readmissions...
 Severe – of 187 patients
 78 had early and 109 late cholecystectomy
WilliamAnn Sur 2004
 Since the patients with acute...
THANKYOU
Complications of gall stone disease
Complications of gall stone disease
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Complications of gall stone disease

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Complications of gall stone disease

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Complications of gall stone disease

  1. 1. COMPLICATIONS OF GALLSTONE DISEASE ShankarZanwar Jewellery from gall stone
  2. 2. BACKGROUND  Reports of gall stones in history dates back Babylonian era before 2000 yrs  Prevalence of gall stones in India 4.3% half of the western world percentage RKTandon WJG 2000
  3. 3. NATURAL HISTORY OF GALLS STONE DISEASE
  4. 4. COMPLICATIONS OF GALL STONES  Cholecystitis  Cholangitis  Mirrizi’s syndrome  Gall stone ileus  Emphysematous cholecystitis  Perforation  Biliary pancreatitis  Carcinoma gall bladder
  5. 5. CHOLECYSTITIS  Of all patients with gall stones 2% will become symptomatic every year (for first 5 years and later decrease)  Of symptomatic gall stones 2% will develop complications per year Ranshoff Ann Int Med 1993  Acute cholecystitis is the most common complication of gall stone disease
  6. 6. ACUTE CHOLECYSTITIS  Pathogenesis Stone embedding in cystic duct Chr. Obstruction Stasis of bile in GB Mucosal trauma by gall stones Release of phospholipase A Conversion of lecithin  lysolecithin Luminal irritation Release of cytokinins cholecytitis
  7. 7. CLINICAL FEATURES  Nearly 75% have prior attacks of biliary pain  Fever – but usually <102, higher – gangrene or perforation  Jaundice – 20%, in 40 % elderly patients, usually <4mg/dl if >4 suspect CBD stone  Murphy’s sign – sensitivity – 97%, specificity 48% Singer Ann Int Med 1996  GB is palpable in 33% of pts. more if the attack is for first time.
  8. 8. NATURAL HISTORY  Untreated cholecystitis – pain relives in 7-10 days  Sequelae  Resolution – 83%  Gangrenous cholecystitis – 7%  Empyema – 6%  Perforation – 3%  Emphysematous – 1%
  9. 9. DIAGNOSIS  Hemtological and biochemical alterations  Mild amylase and lipase elevation may be seen in absence of pancreatitis  USG – Sonographic tenderness – 90% PPV  Non specific  GB wall thickening >4mm (in absence of hypoalbu)  Pericholecystitic fluid (in absence of ascites)
  10. 10.  Cholescintigraphy – HIDA/DISIDA scan  Assesses patency of cystic duct  Normal scan – GB seen within 30 min  Non visualisation – s/o cholecystitis  Sensitivity – 95%, specificity – 90 %  False positive – fasting,CLD,TPN, critically ill  False negative virtually absent  CT can useful when complications like – perforation, emphysema abscess, or pancreatitis suspected.
  11. 11. TREATMENT  IV fluids, Electrolyte replacement, cultures.  Broad spectrum antibiotic coverage, in complicated patient extend coverage for anerobes  Definitive therapy – cholecystectomy  Study from KMC, Manipal  Bile culture + ve in 70%  Aerobes - 56.8%  Anerobes – 13.6%
  12. 12. CHOLANGITIS  Most serious and lethal of all complications  All causes of cholangitis 85% are due to stones embedded in the CBD  Same organisms as in cholecystitis  Thus urgent decompression needed Obstruction biliary pressure regurg of bac. from bile in hep. venous sinuses Bacteremia fever and chills, sepsis & shock
  13. 13. CLINICAL FEATURES AND LABS  Charcots triad – pain, fever and jaundice – 70% of patients Pitt WB Ac. Cholangitis 1987  Fever – 95%, - usually > 102  RUQ tenderness – 90%  Jaundice – 80%  Leucocytosis – 80%, Bil >2mg – 80%.
  14. 14. IMAGING  Stones in CBD seen only in 50% cases, CBD dilatation >6mm may give indirect evidence in remaining 25% Yusuff, GE clinic of N Amer 2003  MRC for stones  Sensitivity 93%, specificity -94%  Recommended when low to moderate clinical probability  EUS  Sens – 95%, spec – 97%, NPV – 98%  Recommended when low to moderate clinical probability  ERCP – sens and spec – 95%  Recommended when high probability and therapeutic intent
  15. 15. TREATMENT  IV fluids, cultures, antibiotics in severe cases with shock cover anerobes  Decompression  ERCP  Failed PTBD  Cholecystectomy.
  16. 16. MIRRIZI’S SYNDROME.  First described in 1948 by Mirrizi  Stone impacted in the neck or GB or cystic duct narrowing of CHD.  Occurs in 0.1 -0.7% of patients with gall stones Hazzan Surg Endo 1999  Risk of GB ca. In these group of patients is higher then the rest – 25% Redaelli Surgery 1997
  17. 17. CLASSIFICATIONS  Older – McSherry  Type 1 – external compression of CHD by calculus in cystic duct/Hartmanns’s pouch  Type 2 – Cholecysto-choledochal fistula partial/ complete  Newer - Csendes classification Only external compression Cysto-biliary fistula <1/3rd of circumference of CHD Upto 2/3rd of CHD circum Complete destruction
  18. 18. DIAGNOSIS  Symptoms and signs same as cholecystitis  Lab parameters mimic cholecystitis or cholangitis  USG – correct diagnosis – 8-62%  Nearly 100% can be diagnosed with ERCP or EUS
  19. 19. TREATMENT -  When preop diagnosis made – open preferred over lap chole  When found intra-op during lap surgery – mandate open conversion  Though reported(and sparsely) lap should be avoided unless expert is available  Type 1 - cholecystectomy alone  If phlegmon or fibrous reaction at Calot’s triangle – stone extraction & partial cholecystectomy – safe
  20. 20.  Type 2-4  using remnant of GB to repair fistula withT-tube,  Other safest alternative is Roux enY bilio- enteric anastomosis  Prognosis of type – excellent  Higher types – poorer with complications like  Increased postop morbidity  Biliary fistulae – 10% or more  Strictures  Hepatic abscess
  21. 21. CHOLECYSTO-ENTRIC FISTULA - GALLSTONE ILEUS  Not a true ileus – rather mechanical obstruction  First description – Bartholin – 1654  Seen in 0.5% of gall stone patients  Occurs in nearly 1-3% of all small bowel mechanical obstructions Cooperman Ann Surg, 1986  Accounts for nearly 25% of all SB obstructions in elderly women (>65 y) Reisner RM Am J Surg 1994  Females more common - 3-16 times  Mortality – 15-18 %
  22. 22. PATHOGENESIS  Fistula formation from bile duct to the intestine due to pressure necrosis by gall stone against the biliary wall  Most common entry point into the bowel – duodenum followed by hepatic flexurestomachjejunum  Occur in 2-3% with cholecystitis  Mirrizi’s syndrome is associated in 90% of cases of cholecysto- enteric fistulae.
  23. 23. CLINICAL PRESENTATION  Gall stone ileus results when gallstone is large in size majority - >2.5cm  Commonest site of impact 50-70% – distal ileum, since narrowest  Presents as intermittent sub-acute obstruction  “Tumbling obstruction” – due to stone tumbling down the bowel lumen
  24. 24.  Mean symptoms period before presentation – 5days  Occasional hematemesis due to hemorrhage at the entry site of the stone.  Bouveret’s syndrome – Gastric outlet obstruction due to impacted gall stone in duodenum or pylorus
  25. 25. DIAGNOSIS  Clinical diagnosis made infrequently  Prep-op diagnosis is made only in 20-50% of cases Chou WJG 2007  Rigler’s triad on imaging  Partial or complete intestinal obs – 50%  Pneumobilia – 30-60%  Aberrant gall stones - <15%  X-ray – detects all 3 in 17-35% cases  USG + X-ray 74%  Plain CT – 93%
  26. 26. TREATMENT  Surgery after intial resuscitaion  Ongoing debate – one stage vs 2 stage  One stage – treating obs, cholecystectomy and fistula division withor without CBD exploration  Two stage – only explorative laparotomy and enterolithotomy first in second stage rest all.  Benefits of one stage operation – prevents further biliary complications, recurrent ileus and treats fistula
  27. 27.  Largest review of 1000 cases by Reissner – mortality rate 16.9% in one stage vs 11.7% for enterolithotomy alone  But recurrence of GS ileus is seen in only 5-9% of cases where enterolithotomy done  And only 10% require reoperation for biliary symptoms  Fistula may close spontaneously and unclosed fistula complicates rarely
  28. 28.  A study byTan (Singapore Med J 2004)  Significantly increased operating time in one stage  No significant morbidity and mortality differences in the 2 groups  Many authors conclude –  one stage procedure should be reserved for otherwise healthy patients and without serious fibrosis in RUQ  Two stage – be considered in younger patients with risk of further biliary complications
  29. 29. EMPHYSEMATOUS CHOLECYSTITIS  Acute infection of gall bladder by gas forming organisms  Surgical emergency  Seen in 1% of all cases of acute cholecystitis  Mortality rates between 15-25%
  30. 30. PATHOGENESIS  Vascular compromise of the gall bladder – occlusion or stenosis of vessels, usually arteriosclerotic cystic artery  More in male, DM(in up to 55%patients), elderly.  Vascular compromise facilitates growth of gas forming organisms  This is also reported in cases of pts. treated with sunitinib for GIST due toVEGF inhibition.
  31. 31.  Common causative agents  Clostridum spp – 46%  E. coli – 40%  Klebsiella  Enterococci  Symptoms and presentation is similar to acute cholecystitis except for higher degree of fever  Lab findings are similar to acute cholecystitis
  32. 32. IMAGING  X- ray – air in side the GB – can be negative in 60% cases  USG sensitivity 90-95%  Stage 1 - gas in lumen  Stage 2 - gas in wall  Stage 3 - gas in the pericholecystic tissue  Effervescent GB tiny foci floating on the nondependent wall  Curvilinear gaseous artifact, ring down effect, comet-tail sign - diagnostic
  33. 33.  CT confirms emphysematous cholecystitis, when USG is in doubt  HPE shows full thickness necrosis of GB, gangrene seen in 75% of cases.  Medical treatment same as for sever cholecystitis
  34. 34.  In hemodynamically unstable patient and those who can not tolerate GA percutaneous cholecystectomy can be done to stabilize the patient.  Interval cholecystectomy after 4-6week can be done  Adjuvant therapy with hyperbaric oxygen- rationale – anerobes is cause in majority  HBO is given within 8 hours of surgery for 5 days Kraljevic Hepatogastroenterology 1999
  35. 35. GB PERFORATION  Neimeier classification  Type 1 – Acute  Type 2 – Subacute  Type 3 – Chronic  Managed similarly as emphysematous cholecystitis  In a study by Hung stable patients can be taken up for early lap cholecystectomy with equal outcomes and lesser LOS as compared elective interval cholecystectomy after PTBD.
  36. 36. GALL STONE PANCREATITIS  Of all gall stone patients only 3-7% develop pancreatitis  But amongst the pancreatitis patients 40% are caused due to gall stones  In thesis – 17/53(32.07%) patients had biliary cause of pancreatitis, 3 severe, 3 moderate and rest 11 mild, no mortality  All underwent cholecystectomy except 2 severe ones
  37. 37. MANAGEMENT -TIMING OF CHOLECYSTECTOMY  mild pancreatitis – Review of studies with total of 998 patients  no readmissions if operated during index admission vs 18% readmission in patient with interval cholecystectomy(p<0.0001)  No difference in operative complications, conversion or mortality Ann Surg 2012
  38. 38.  Severe – of 187 patients  78 had early and 109 late cholecystectomy WilliamAnn Sur 2004  Since the patients with acute severe pancreatitis often have peripancreatitic complications and SIRS operating is challenging and may invite complications should be avoided till 4-6 weeks till pancreatitis settles Early(%) Late(%) Resolution of associated fluid collection 21 40 Percutaneous drainage required 50 18 Sepsis 47 6 Complications of cholecystectomy 44 5.5
  39. 39. THANKYOU

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