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Gallstones Causes and Management -Dr Kedar Patil Pune
1. Dr Kedar Patil
D.N.B-Gen. Surgery, F.N.B-Minimal Access Surgery,
Fellow Bariatric and Metabolic Surgery -Taiwan,
Fellow G.I Oncosurgery, Tata Memorial Hospital, Mumbai
Bariatric and Metabolic, G.I Onco surgeon and Advanced Laparoscopic Surgeon
Poona Hospital ,Bharati Hospital Pune and Sangli
8888655455,presizeclinic@gmail.com,www.lifedocsindia.com
2. Bile Contents
Bile Pigments
Bile Salts –Cholic and Chenodexoycholic acid
Phospholipids and Cholesterol –Serves absorption of
dietary lipids and avoids toxic effect of bile on
hepatocytes
Bilirubin –End products of globin and myoglobin
excreted with bile salts
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3. Physiology of bile
Bile fills in Gall bladder
retrograde method due
to Sphicter Of Oddi
CCK and Vagi influence
on Sphicter Of Oddi
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5. Pathogenesis of Gallstone
formation
Supersaturation of Secreted Bile
Concentration of bile in GB
Crystal nucleation
Gallbladder dysmotility
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6. Types Of Stones
Pigment Stones – Black or brown
Black-Hemoglobinopathies or cirrhosis,usually in bile
duct and GB
Brown –Bacterial infections and motility disorders
,Found anywhere
Pure Chlolesterol stones (10%)-Yellow
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7. Natural history of Stones
Asymptomatic –When free floating in GB
Symptomatic –When obstructs a Cystic Duct or passes
in CBD
20-30% Asymptomatic stone patient develop
symptoms
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8. Factors affecting Gallstone
formation
Gall stone Promoting Gallstone Preventing
Higher Cholesterol and Lipid
Increased Hemoglobin
processing –
hemoglobinopathies
Fasting ,Burns TPN
Glycoproteins and Ig-
Pronucleating agents
Gall bladder dysmotility
Bile salts
CCK
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9. Clinical features
Biliary Colic –Misnomer ,since it’s a constant pain in
right upper quadrant or epigastrium
Due to incomplete emptying of G.B
Pain –associated with food in epigastrium
Fever –Systemic response to inflammation
Jaundice – 2.5 gm/dl Scleral Icterus ,5 gm/dl- Skin
manifestation
Pain ,Fever and jaundice –Charcots triad
Pain ,Fever,Jaundice,Hypotension and Altered
mentation –Reynolds Pentad (Indicates sepsis)
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10. Clinical Features
Acute Cholecystitis –Pain >24 hours .May progress to
gangrene
‘Murphys sign’- Tenderness in right upper quadrant
Jaundice –Seen in cases of choledocholithiasis or
Mirrizzis Syndrome .
Most common presentation is ‘Dyspepsia’-belching or
bloating after food or discomfort
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11. Investigations
LFTs – Raised Direct S.Bilirubin and Alkaline
Phosphatase indicate an Obstructive Pattern
S.Amylase and S.Lipase- Raised in Gallstone
pancreatitis
Ultrasound - Sensitive than CT for gallstones .
Gallstones,CBD Stones,CBD Diameter,Wall thickening
of G.B,Pericholecystic fluid etc can be known
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13. Investigations
CT Abdomen –when malignancy is suspected or to
rule out CBD calculi
Evaluation of CBD Injury and collections
MRCP- Most sensitive for biliary pathologies
HIDA Scan – Biliary excretion and level of leak or
obstruction,useful in biliary dyskinesia
ERCP- Diagnostic-for strictures
Therapeutic ERCP for stones / malignant obstruction
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14. MRCP for Biliary tract
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15. Investigations
PTC-Percutanpercutaneous transhepatic
cholangiography (PTC) is an invasive procedure used
to evaluate the biliary tree. Useful for patients with
intrahepatic biliary disease or in whom ERCP is not
technically feasible, PTC can decompress biliary
obstruction, stent obstructions nonoperatively, and
provide anatomic information for biliary
reconstruction.
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16. Other Modalities Of Investigation
Endoscopic Ultrasound (EUS )-Biliary strictures and
malignancy ,Sludge
Intraoperaative Cholangiogram –For
Choledocholithiasis ,Injury , Anatomy Unclear
PET Scan –Malignancy suspected
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17. Management
Medical –Not much role except UDCA -300 mg twice
daily for 6 months ,review with USG.Only
recommended in high risk and asympromatic
individuals
Surgical –Laparoscopic Cholecystectomy is the Gold
standard
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18. Laparoscopic Cholecystectomy
Who require it –Symptoms of Gallstones-Bloating
,Dyspepsia
High risk individuals even if asymptomatic –
Hemolytic anemia/Sickle cell anemia
Porcelian gall bladder
Large stones >2.5 cm
Few Bariatric Surgeries and transplant surgeries
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19. Laparoscopic Cholecystectomy
One of the most common surgery done worldwide
Erich Muhe from Germany performed first
Laparoscopic Cholecystectomy in 1982
1-3% Complication rate in acute setting
Subtotal Cholecystectomy or Cholecystostomy
(Draining the Gall bladder ) alternatives in high risk
individuals
In Acute Cholecystitis – Operated within first 7 days or
delayed upto 6 weeks to prevent CBD Injury
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20. Complications of Gallstones
Acute Cholecystitis and its sequale
Gangrene,Emphysematous
Gallstone Pancreatitis
Gallstone Ileus –Passing into small bowel through
duodenal fistula
Obstructive Jaundice
GB Malignancy –Porcelian GB and stones >3cms has
greater risk
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21. Choledocholithiasis
Means –Stones in the CBD
Primary –Brown stones ; associated with infection
Secondary –Black –retained or migrated from GB
Can cause Pancreatitis as well
Specific Investigations-S.Biirubin ,S.Alkaline
Phosphate ,ERCP,MRCP
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22. Choledocholithiasis
Treatment – ERCP /Lap
or Open CBD
Exploration with
Cholecystsectomy
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23. Thanks for your Patient listening !
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presizeclinic@gmail.com.
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