Dr Mohammed Kamal Uddin Sohel Bangladesh

1. A tale Of Biliary lithiasis
DR Md kamal uddin Sohel
MD(Medicine)
MACP(USA)
MO. Gastroenterology Deptt.

2. An echo from the past
RadioGraphics 2009; 29:1191–1194

3. Epidemiology
• Gallstones are a major public health problem in Europe & other
developed countries & affect up to 20% of population.
Gut and Liver, Vol:6,(2),April 2012, p. 172-187

4. Burden
“Hindustan Times” Tuesday, Apr 12, 2022

5. Remits of today’s talk
 Dx, medical & surgical Mx & prevention of GB stones
 Dx, Endoscopic & surgical Mx of bile duct stones
 Dx & therapy of intrahepatic stones

6. Gallstone types
Basis chemical composition & macroscopic appearance:
• Cholesterol stone(majority)
• Pigment stone
• Rare stone
 Cholesterol & black pigment stones: nearly always formed in
GB
 Brown pigment stones: primarily in main BD.

7. By location

8. RISK FACTORS
• Age & gender
• Diet
• Pregnancy & parity
• Rapid weight loss
• TNP
• Biliary sludge
• Drugs: Estrogen, clofibrate ,
octreotide, ceftriaxone
• Lipid abnormalities(TG)
• Obesity(>45 kg/m2)
• DM
• Diseases of ileum
• Spinal cord injury
• Cirrhosis of liver(CTP-c &
alcoholic)

9. Pathophysiology
• Venn diagram
Image courtesy: Sleisenger 10thedition,p;1109

10. Dx of GB stones
• 80% of carriers are asymptomatic.
• Symptoms develop with a rate of 1–4%/yr, 20% becoming
symptomatic within 20 yrs of Dx .
• Complications occur with a rate of 1–3%/yr after 1st colic
episode & 0.1–0.3% in asymptomatic pts.
J Hepatol,Vol:xxx,March 2016 p:1-20

11. Cont….

12. Complications Of GB stone
• Acute or chronic Cholecystitis
• Biliary pancreatitis
• Cholangitis
• Emphysematous cholecystitis
• Cholecysto-enteric fistula
• Mirrizzi’s syndrome
• Porcelain GB
Sleisenger & Fordtran's gastrointestinal and liver disease: 10th edition

13. When & what Investigation?
 Pt with recent H/O biliary pain, abdominal USG should be
performed.
 With strong clinical suspicion of GB stones & -ve abdominal
USG, EUS / MRCP may be performed.
 No role of lab test except complcation – cholangitis,
pancreatitis, cholecystitis.
J Hepatol,Vol:xxx,March 2016 p:1-20

14. Imaging

15. Acute cholecystitis
Suspected in pt with fever, severe pain in RUQ lasting for several
hrs & RUQ tenderness on palpation (Murphy’s sign).
• Investigation
 WBC count
 CRP
 USG (distended GB, thickened (>4 mm) GB wall,
pericholecystic fluid & a sonographic Murphy’s sign)
 CT scan (GB wall emphysema, abscess formation &
perforation)
 Radioisotope cholescintigraphy (Tc-HIDA scan)

16. Cont…………..

17. Cont….

18. Medical therapy of GB stones
Bile acid dissolution therapy :
Litholysis using bile acids alone /combination with ESWL : not
recommended for GB stones.
Although meta-analysis of studies on litholysis using UDCA showed
success in stones Of
 small(<10 mm)
 non-calcified
 functioning GB
** (63% of pts free from stones after > 6 mons).
J Hepatol,Vol:xxx,March 2016 p:1-20

19. Surgical therapy Of GB stones

20. Surgical therapy of GB stones
• Symptomatic GB stones: Cholecystectomy - Preferred
option.
• Approximately 1/2 of pts with symptomatic stone have
recurring colic.
• Risk of complications such as acute cholecystitis, biliary
pancreatitis, obstructive jaundice & cholangitis is 0.5–3%/yr.
J Hepatol,Vol:xxx, March 2016 p:1-20

21. Asymptomatic GB stones
• Routine Rx is not recommended.
• Reassured that life-threatening complications are
uncommon.
• Symptom related to stone develop only minority of pts.
• Most pts in whom complications of gallstone develop have
antecedent biliary pain.

22. Cont.
• Exception (Cholecystectomy needed)
 Asymptomatic porcelain GB
 GB polyps ≥1 cm without or with
GB stones regardless of their symptoms
 Asymptomatic pts with PSC & GB polyps irrespective of size
J Hepatol,Vol:xxx,March 2016 pp:1-20

23. • Cholecysyectomy in asymptomatic GB stone:
• Large stone > 2cm
• Non-functional GB
• Porcelin GB
• Pt with spinal cord inj./sensory neuropathy
affecting abdomen
• Pt with sickle cell anaemia
• Pt with medically complicated disese
(Cirrhosis,Portal HTN,) Harrison

24. Some recommedation of surgery
 Cholecystectomy : not recommended for asymptomatic stones
during abdominal surgery.
 Early phase after heart/lung transplantation with
symptomatic GB stones, cholecystectomy should be deferred.
 Cholecystectomy in asymptomatic gallstones:
• Hereditary spherocytosis & sickle cell disease during
splenectomy.
• During abdominal surgery for other reasons in sickle cell
disease to avoid diagnostic uncertainty in case of sickle cell
crises.
J Hepatol,Vol:xxx,March 2016 p:1-20

25. GB stone in pregnancy
• Lap chole can perform in any trimester.
• Asymptomatic GB & bile duct stones who are asymptomatic
after bile duct clearance should undergo cholecystectomy post
partum.
• Better in 2nd trimester : 3rd trimester better to avoid due to
abdominal crowding.
J Hepatol,Vol:xxx,March 2016 p:1-20

26. Type of cholecystectomy

27. Type of cholecystectomy
• Laparoscopic cholecystectomy : Standard method for
symptomatic GB stones (even with CTP- A & B liver
cirrhosis).
• Open cholecystestomy
 Strong suspicion of (advanced) GB carcinoma.
 Mirizzi II (fistula betw GM & hepatic duct)
 Gallstone ileus
J Hepatol,Vol:xxx,March 2016 p:1-20

28. Future : Man- machine symbiosis

30. Timing of cholecystectomy
• As early as possible for uncomplicated biliary Colic.
• Early lap chole (preferably within 72 hrs of admission) should be
done in acute cholecystitis.
• Simultaneous GB & bile duct stones : ERCP followed by Early
lap chole (within 72 hrs).
• Elderly with high anaesthetic risk with complications (acute
cholecystitis, gallstone pancreatitis/obstructive jaundice) lap chole
done as soon as general status allows surgery.
J Hepatol,Vol:xxx,March 2016 p:1-20

31. “It's so much easier to suggest
solutions when you don't know too
much about the problem.” ― Malcolm
Forbes.

32. Post-cholecystectomy syndrome (PCS)
Extra-biliary disorder:
 Reflux oesophagitis,
 peptic ulceration,
 IBS
 Chronic pancreatitis.
Biliary aetiologies :
• Biliary strictures/leakage
• Retained calculi
• Dropped calculi
• Chronic biloma/abscess
• Long cystic duct remnant
• SOD
• Bile salt-induced
diarrhea/gastritis
*For evaluation: EUS,MRCP
Jaunoo S et al. Inter J of surgery. 2010
Jan 1;8(1):15-7.

33. GB sludge
• Mixture of particulate solids that have precipitated from bile
consists of cholesterol crystals, Ca bilirubinate pigment & other Ca
salts.
• Resolve spontaneously: 50% , Stone develops: 5-15% cases.
Shaffer EA et al.Current gastroenterology reports. 2001 Mar;3(2):166-73.

34. Cont……
Shaffer EA et al.Current gastroenterology reports. 2001 Mar;3(2):166-73.

35. Prevention of GB stone
• Primary prevention
• Lifestyle: Healthy food, regular physical activity & ideal body wt
prevent cholesterol GB stones.
• Physical activity:70% decreased risk of symptomatic GB stones in
both sexes. Effect is seen after 5yrs.
• Diet:
• High fiber & calcium diets.Fruits ,Vegetables & vegetable oils,
• Vit C, Poly- & monounsaturated fats &
• Nut consumption
• ?? Controversial: Caffeine, alcohol,Statin,Ezetimide
J Hepatol,Vol:xxx,March 2016 p:1-20

36. Primary prevention of GB stones in
high risk groups
• Rapid wt loss temporary UDCA may be recommended until body wt
has stabilized.
• Prophylactic cholecytectomy not routinely indicated during
bariatric surgery.
• Long-term somatostatin/analogues, concomitant UDCA can
consider to prevent cholesterol stone.
• No indication for pharmacological/surgical stone prevention during
HRT, TPN & Prevention of recurrent bile duct stones.
J Hepatol,Vol:xxx,March 2016 p:1-20

37. GB Polyp
Foley KG et al. Mx & F/U of gallbladder polyps: updated joint guidelines between ESGAR,
EAES, EFISDS & ESGE. European radiology. 2021 Dec 17:1-1.

38. Cont…..
Indn of Cholecystectomy:
>1 cm
6-9 mm polyp with 1 of following risk of Mg-:
 Age> 60
 PSC
 Asian
 Sessile polypoid lesion with focal GB wall thickening > 4mm.
6-9 mm /< 5 mm without risk of Mg:
 F/U USG- 6 mons, 1 yr & 2 yrly
 Discontinue F/U > 2 yrs in absence of growth.
Foley KG et al. Mx & F/U of gallbladder polyps: updated joint guidelines between ESGAR,
EAES, EFISDS & ESGE. European radiology. 2021 Dec 17:1-1.

39. Dx of bile duct stones
• Like GB, stones in BD may remain asymptomatic for yrs.
• 3-10%% of pts with GB stones also have bile duct stone.
• Conversely 95% with BD stone have GB stones.
Common presentation:
 Biliary colic
 Ascending cholangitis
 Obstructive jaundice
 Acute biliary pancreatitis
CBD stones should search for pts with jaundice, acute
cholangitis/acute pancreatitis

40. Cont.
Laboratory Dx & imaging
 Abdominal US (CBD sometimes not dilated)
 EUS (< 5mm stone can detected)
 MRCP
 Liver biochemical test
 ERCP- If concomitant endoscopic therapy is envisaged (high SEN)
** LFTs & Abdominal US – as initial steps (ESGE, Endoscopy,2019)

41. CBD stone images

42. Mx of BD stones
Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy
(ESGE) guideline. Endoscopy. 2019 May;51(05):472-91.

43. Rx of BD stones without
Complications
 Choledocholithiasis warrants Rx in nearly all cases.
 Endoscopic sphincterotomy & stone extraction : Recommended Rx
of bile duct stones.
 Balloon & basket catheters : equally effective & safe for CBDs.
 Temporary biliary plastic stent in irretrievable stones.
 Plastic stent should be removed/ exchanged within 3 – 6 mons to
avoid infectious complications.
ESGE guideline. Endoscopy. 2019 May;51(05):472-91.

44. Cont…
• Intra-operative ERCP / laparoscopic bile duct exploration
with cholecystectomy : alternatives if adequate expertise
available
• Laparoscopic cholecystectomy within 2 wks from ERCP.
• Percutaneous stone extraction with acute cholangitis : ERCP
is not feasible/ successful within recommended timeframes.
• ERCP : Safe & effective in pregnancy

45. ERCP stone extraction
Courtesy: Dr Royes Uddin ,
Gastroenterolgy dptt.SSMC Mitford Hospital

46. Cont.
 Failed standard stone extraction ESWL, electrohydraulic or
laser lithotripsy may perform.
 In altered anatomy (e.g. previous Roux-en-Y anastomosis,
bariatric surgery) percutaneous or endoscopic (balloon
endoscopy-assisted) Rx of bile duct stones can consider.

47. ESWL by lithotripsy basket

48. Cholangioscope assisted ESWL

49. Altered anatomy ERCP

50. Cont.
 Failed endoscopic therapy : cholecystectomy combined with
BD exploration /intraoperative ERCP(Rendezvous) should
perform.
 Intraoperative detection of BD stones : bile duct
exploration& transcystic stone extraction/ endoscopic
clearance represent alternative Rx options.
 In postoperative Dx of BD stones, endoscopic sphincterotomy
& stone extraction are recommended.
 Simultaneous GB & BD stones : ERCP followed by early lap
chole ( within 72 hrs).

51. Rx of acute cholangitis
 Immediate broad spectrum antibiotics
 Biliary decompression within 24 hrs.
Endoscopic Rx with sphincterotomy - preferred mode. Or
Biliary stenting with stone removal
If failed - percutaneous bile duct drainage is choice.

52. Rx of acute biliary pancreatitis
• Biliary pancreatitis with suspected coexistent acute
cholangitis antibiotics should be initiated & ERCP with
sphincterotomy and stone extraction should perform with
timing depends on the severity of cholangitis, better within
24 hr.
• Early ERCP not recommeded in absence of
Cholangitis
Obstructed bile duct

53. Cont.
 Suspected biliary pancreatitis without cholangitis,
EUS
or
MRCP may prevent potential ERCP & its risks.
 Cholecystectomy during the same hospital admission is the
preferred option in mild acute biliary pancreatitis.

54. Dx & Rx of intrahepatic BD stones
Hepatolithiasis typically occur in
 Bile duct strictures & after bile duct injury
 primary /secondary sclerosing cholangitis
 recurrent pyogenic cholangitis
Ix:
Abdominal US-1st choice
MRCP - 2nd
J Hepatol,Vol:xxx,March 2016 p:1-20

55. Cont….

56. Cont.
Rx options:
Asymptomatic intra-hepatic BD stones do not always need to treat.
 Partial hepatectomy (unilateral disease,biliary stricture &lobar
atrophy )
 Peroral cholangioscopic lithotripsy (POCSL) or
 Percutaneous transhepatic cholangioscopic
Lithotripsy (PTCSL)
# Rx decision should made individually for each pt & inter-
disciplinarily for symptomatic intrahepatic BD stones.
J Hepatol,Vol:xxx,March 2016 p:1-20