Gallstone disease is common, affecting 11-36% of people based on autopsy reports. Gallstones can be asymptomatic or cause biliary colic, acute cholecystitis, or other complications. The document discusses the epidemiology, types, natural history, complications, clinical features, diagnosis, and treatment of gallstone disease and acute cholecystitis. Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones and acute cholecystitis to prevent future attacks or complications.

1. Gallstone disease
Yonas Ademe
August, 2017
1

2. Introduction
2

3. Epidemiology
• Gallstone disease is one of the most common problems
affecting the digestive tract
• Autopsy reports have shown a prevalence of gallstones
from 11% to 36%
• The prevalence of gallstones is related to many factors,
including age, gender, and ethnic background
– Women are 3 times more likely to develop gallstones than
men
– First-degree relatives of patients with gallstones have a
twofold greater prevalence
3

4. Cont.
• Certain conditions predispose to the development
of gallstones
– Obesity
– Pregnancy
– Dietary factors
– Gastric surgery
– Terminal ileal resection
– Crohn’s disease
– Hereditary spherocytosis, sickle cell disease, and
thalassemia
4

5. Natural History
• Most patients will remain asymptomatic from
their gallstones throughout life
• For unknown reasons, some patients progress
to a symptomatic stage, with biliary colic
caused by a stone obstructing the cystic duct
• Symptomatic gallstone disease may progress to
complications related to the gallstones
5

6. Cont.
• Over a 20-year period, about two thirds of
asymptomatic patients with gallstones remain
symptom free
• 3% of asymptomatic individuals become
symptomatic per year (i.e., develop biliary colic)
– Once symptomatic, patients tend to have recurring
bouts of biliary colic
• Complicated gallstone disease develops in 3% to
5% of symptomatic patients per year
6

7. Cont.
• Because few patients develop complications without
previous biliary symptoms, prophylactic cholecystectomy
in asymptomatic persons with gallstones is rarely
indicated
– The rare indications
• Elderly patients with diabetes
• Populations with increased risk of GB cancer
– Porcelain gallbladder, a rare premalignant condition in which the wall of the
gallbladder becomes calcified, is an absolute indication for cholecystectomy
• Individuals who will be isolated from medical care for extended
periods of time
• HIV
• Hemolytic anemia
• Bariatric surgery
7

8. Gallstone Formation
• Gallstones form as a result of solids settling out of
solution
– The major organic solutes in bile are bilirubin, bile salts,
phospholipids, and cholesterol
• Gallstones are classified by their cholesterol content as
either cholesterol stones or pigment stones
– Pigment stones can be further classified as either black or
brown
• In Western countries, about 80% of gallstones are
cholesterol stones and about 15% to 20% are black
pigment stones
– Brown pigment stones account for only a small percentage
• Both types of pigment stones are more common in
Asia 8

9. Types
• Cholesterol Stones
– These stones are usually multiple, of variable size, and
may be hard and faceted or irregular, mulberry-shaped,
and soft
• They usually occur as single large stones with smooth surfaces
– Colors range from whitish yellow and green to black
– Pure cholesterol stones are uncommon and account for
<10% of all stones
• Most other cholesterol stones contain variable amounts of bile
pigments and calcium, but are always >70% cholesterol by
weight
– Most cholesterol stones are radiolucent (<10% are
radiopaque) 9

10. Cont.
• Cont.
– Whether pure or of mixed nature, the common primary
event in the formation of cholesterol stones is
supersaturation of bile with cholesterol
– Cholesterol is highly nonpolar and insoluble in water
and bile
– Cholesterol solubility depends on the relative
concentration of cholesterol, bile salts, and lecithin (the
main phospholipid in bile)
• Supersaturation almost always is caused by cholesterol
hypersecretion rather than by a reduced secretion of
phospholipid or bile salts
10

11. Cont.
• Cont.
– Cholesterol is held in solution by bile salt-phospholipid-
cholesterol micelles and cholesterol-phospholipid
vesicles
– The presence of vesicles and micelles in the same
aqueous compartment allows the movement of lipids
between the two
– Vesicular maturation occurs when vesicular lipids are
incorporated into micelles
– Vesicular phospholipids are incorporated into micelles
more readily than vesicular cholesterol
• Therefore, vesicles may become enriched in cholesterol,
become unstable, and then nucleate cholesterol crystals
11

12. Cont.
• Pigment Stones
– Pigment stones contain <20% cholesterol and are
dark because of the presence of calcium bilirubinate
– Black and brown pigment stones have little in
common and should be considered as separate
entities
12

13. Cont.
• Cont.
– Black pigment stones are usually small, brittle, black, and
sometimes spiculated
– They are formed by supersaturation of calcium
bilirubinate, carbonate, and phosphate, most often
secondary to hemolytic disorders such as hereditary
spherocytosis and sickle cell disease, and in those with
cirrhosis
• Unconjugated bilirubin is much less soluble than conjugated
bilirubin in bile
– Like cholesterol stones, they almost always form in the GB
13

14. Cont.
• Cont.
– Brown stones are usually <1 cm in diameter, brownish
yellow, soft, and often mushy
– They may form either in the GB or in the bile ducts, usually
secondary to bacterial infection caused by bile stasis
• Bacteria such as Escherichia coli secrete β-glucuronidase that
deconjugates bilirubin
• Precipitated calcium bilirubinate and bacterial cell bodies compose
the major part of the stone
– The stones are typically found in the biliary tree of Asian
populations and are associated with stasis secondary to
parasite infection
• In Western populations, they occur in patients with biliary strictures
or other CBD stones that cause stasis and bacterial contamination
14

15. Complications
• Acute cholecystitis
• Chronic cholecystitis
• Choledocholithiasis with or without cholangitis
• Gallstone pancreatitis
• Cholecystocholedochal fistula
• Cholecystoduodenal or cholecystoenteric fistula
leading to gallstone ileus
• Gllbladder carcinoma
15

16. Clinical features
16

17. Chronic Cholecystitis (Biliary Colic)
• About two thirds of patients with gallstone
disease present with chronic cholecystitis
characterized by recurrent attacks of pain, often
inaccurately labeled as biliary colic
• The pain develops when a stone obstructs the
cystic duct, resulting in a progressive increase
of tension in the gallbladder wall
17

18. Cont.
• The pathologic changes, which often do not
correlate well with symptoms, vary from an
apparently normal GB with minor chronic
inflammation in the mucosa, to a shrunken,
nonfunctioning GB with gross transmural fibrosis
and adhesions to nearby structures
– The mucosa is initially normal or hypertrophied, but
later becomes atrophied, with the epithelium protruding
into the muscle coat, leading to the formation of the so-
called Aschoff-Rokitansky sinuses
18

19. Cont.
• The chief symptom associated with symptomatic
gallstones is pain
– The pain is located in the epigastrium or RUQ and frequently
radiates to the right upper back or between the scapulae
– It is constant and increases in severity over the first half hour
or so and typically lasts 1 to 5 hours
– It is severe and comes on abruptly, typically during the night
or after a fatty meal
• Association with meals is present in only about 50% of patients
– It is episodic
• The patient suffers discrete attacks of pain, between which they feel
well
– It often is associated with nausea and sometimes vomiting
19

20. Cont.
• Cont.
– When the pain lasts >24 hours, an impacted stone in the
cystic duct or acute cholecystitis should be suspected
– An impacted stone without cholecystitis will result in
what is called hydrops of the gallbladder
• The bile gets absorbed, but the GB epithelium continues to
secrete mucus, and the GB becomes distended with mucinous
material
• The GB may be palpable but usually is not tender
• It may result in edema of the GB wall, inflammation, infection,
and perforation
– Early cholecystectomy is generally indicated to avoid complications
20

21. Cont.
• Physical examination may reveal mild RUQ
tenderness during an episode of pain
– If the patient is pain free, the physical examination is
usually unremarkable
• Laboratory values, such as WBC count and liver
function tests, are usually normal in patients
with uncomplicated gallstones
21

22. Cont.
• Atypical presentation of gallstone disease is
common
– Some patients report milder attacks of pain, but
relate it to meals
– The pain may be located primarily in the back or the
left upper or lower right quadrant
– Bloating and belching may be present and
associated with the attacks of pain
22

23. Cont.
• The diagnosis depends on the presence of typical
symptoms and the demonstration of stones on
diagnostic imaging
– An abdominal ultrasound is the standard diagnostic test
for gallstones
• Occasionally, patients with typical attacks of biliary pain have
no evidence of stones on ultrasonography
– Gallstones are occasionally identified on abdominal
radiographs or CT scans
• In these cases, if the patient has typical symptoms, an
ultrasound of the GB and the biliary tree should be added
before surgical intervention
23

24. Cont.
• Sometimes only sludge in the GB is demonstrated
on ultrasonography
– If the patient has recurrent attacks of typical biliary pain
and sludge is detected on two or more occasions,
cholecystectomy is warranted
• Cholesterolosis and adenomyomatosis of the GB
may cause typical biliary symptoms and may be
detected on ultrasonography
– In symptomatic patients, cholecystectomy is the
treatment of choice
24

25. Cont.
• Treatment
– Patients with symptomatic gallstones should be
advised to have elective laparoscopic
cholecystectomy
– While waiting for surgery, or if surgery has to be
postponed, the patient should be advised to avoid
dietary fats and large meals
25

26. Cont.
• Cont.
– Cholecystectomy, open or laparoscopic, offers
excellent long-term results
• About 90% of patients with typical biliary symptoms and
stones are rendered symptom free after cholecystectomy
– For patients with atypical symptoms or dyspepsia (flatulence,
belching, bloating, and dietary fat intolerance), the results are
not as favorable
26

27. Cont.
• Cont.
– Diabetic patients with symptomatic gallstones
should have a cholecystectomy promptly, as they
are more prone to develop acute cholecystitis that
is often severe
– Pregnant women with symptomatic gallstones who
cannot be managed expectantly with diet
modifications can safely undergo laparoscopic
cholecystectomy during the second trimester
27

28. Acute Cholecystitis
• Acute cholecystitis is secondary to gallstones in
90% to 95% of cases
– In <1% of acute cholecystitis, the cause is a tumor
obstructing the cystic duct
• Obstruction of the cystic duct by a gallstone is
the initiating event that leads to GB distention,
inflammation, and edema of the GB wall
28

29. Cont.
• In most cases, the GB wall becomes grossly
thickened and reddish with subserosal
hemorrhages
– Pericholecystic fluid often is present
– The mucosa may show hyperemia and patchy necrosis
• In severe cases (5% to 10%), the inflammatory
process progresses and leads to ischemia and
necrosis of the gallbladder wall
– More frequently, the gallstone is dislodged and the
inflammation resolves
29

30. Cont.
• If perforation occurs, it is usually contained in
the subhepatic space by the omentum and
adjacent organs
– However, free perforation with peritonitis,
intrahepatic perforation with intrahepatic
abscesses, and perforation into adjacent organs
(duodenum or colon) with cholecystoenteric fistula
may occur
30

31. Cont.
• Initially, acute cholecystitis is an inflammatory
process, probably mediated by the mucosal toxin
lysolecithin, a product of lecithin, as well as bile
salts and platelet-activating factor
– Secondary bacterial contamination is documented in
15% to 30% of patients undergoing cholecystectomy for
acute uncomplicated cholecystitis (?more than one half
will have positive cultures)
• When the GB remains obstructed and secondary bacterial
infection supervenes, an acute gangrenous cholecystitis
develops, and an abscess or empyema forms within the GB
31

32. Cont.
• When gas-forming organisms are part of the
secondary bacterial infection, gas may be seen
in the GB lumen and in the wall of the GB on
abdominal radiographs and CT scans, an entity
called an emphysematous gallbladder
32

33. Cont.
• About 80% of patients with acute cholecystitis give
a history compatible with chronic cholecystitis
• Acute cholecystitis begins as an attack of biliary
colic, but in contrast to biliary colic, the pain is
more severe and does not subside; it is
unremitting and may persist for several days
– The pain is typically in the RUQ or epigastrium and may
radiate to the right upper part of the back or the
interscapular area
– The patient is often febrile, complains of anorexia,
nausea, and vomiting, and is reluctant to move
33

34. Cont.
• Physical examination
– Focal tenderness and guarding are usually present
in the RUQ
– A Murphy’s sign, an inspiratory arrest with deep
palpation in the right subcostal area, is
characteristic
– A mass is occasionally palpable
• However, guarding may prevent this
34

35. Cont.
• In elderly patients and in those with diabetes
mellitus, acute cholecystitis may have a subtle
presentation resulting in a delay in diagnosis
– The incidence of complications is higher in these
patients, who also have approximately 10-fold the
mortality rate compared to that of younger and
healthier patients
35

36. Cont.
• CBC
– A mild to moderate leukocytosis (12,000–15,000
cells/mm3) is usually present
• However, some patients may have a normal WBC
– A high WBC count (above 20,000) is suggestive of a
complicated form of cholecystitis
• LFT
– They are usually normal, but a mild elevation of serum
bilirubin (<4 mg/mL) may be present along with mild
elevation of ALP, transaminases, and amylase
– Severe jaundice is suggestive of CBD stone or Mirizzi’s
syndrome
36

37. Cont.
• Diagnosis
– Ultrasonography is the most useful radiologic test for
diagnosing acute cholecystitis
• It has a sensitivity and specificity of 95%
• Findings
– Stones
– Thickening of the GB wall
– Pericholecystic fluid
– Sonographic Murphy ‘s sign
– HIDA scan
• May be of help in the atypical case
• A normal scan excludes acute cholecystitis
• Finding
– Lack of filling of the GB after 4 hours indicates an obstructed cystic duct
and, in the clinical setting of acute cholecystitis, is highly sensitive and
specific for acute cholecystitis
37

38. Cont.
• Cont.
– CT scan
• It demonstrates thickening of the GB wall, pericholecystic
fluid, and the presence of gallstones as well as air in the
gallbladder wall, but is less sensitive than
ultrasonography
38

39. Cont.
• Treatment
– IV fluids
– Analgesia
– Antibiotics
• The antibiotics should cover gram-negative aerobes as
well as anaerobes
– A third generation cephalosporin with good anaerobic coverage
OR
– A second-generation cephalosporin combined with
metronidazole OR
– For patients with allergies to cephalosporins, an aminoglycoside
with metronidazole
39

40. Cont.
• Cont.
– Cholecystectomy is the definitive treatment for
acute cholecystitis
• Unless the patient is unfit for surgery, early
cholecystectomy performed within 2 to 3 days of the
illness is preferred over interval or delayed
cholecystectomy that is performed 6 to 10 weeks after
initial medical treatment
– Definitive solution in one hospital admission
– Quicker recovery times
– Earlier return to work
– Similar complication rate with delayed operation
40

41. Cont.
• Cont.
– Laparoscopic cholecystectomy is the procedure of
choice for acute cholecystitis
• Drawbacks
– The conversion rate to an open cholecystectomy is higher (10%–
15%) in the setting of acute cholecystitis than with chronic
cholecystitis
– The procedure is more tedious and takes longer than in the
elective setting
41

42. Cont.
• Cont.
– When patients present late, after 3 to 4 days of
illness, or if they are unfit for surgery, they can be
treated medically with laparoscopic
cholecystectomy scheduled for approximately 2
months later
• Approximately 20% of patients will fail to respond to
initial medical therapy and require an intervention
– Laparoscopic cholecystectomy could be attempted, but the
conversion rate is high and some prefer to go directly for an open
cholecystectomy
42

43. Cont.
• Cont.
– For those unfit for surgery, a percutaneous
cholecystostomy or an open cholecystostomy under
local analgesia can be performed
• For those who respond after cholecystostomy, the tube can be
removed once cholangiography through it shows a patent
ductus cysticus
– Laparoscopic cholecystectomy may then be scheduled in the near
future
• Failure to improve after cholecystostomy usually is due to
gangrene of the gallbladder or perforation
– For these patients, surgery is unavoidable
• For the rare patients who can’t tolerate surgery, the stones can
be extracted via the cholecystostomy tube before its removal
43

44. Acalculous Cholecystitis
• Acute inflammation of the GB can occur without gallstones
• It typically develops in critically ill patients in the ICU
– Patients on parenteral nutrition with extensive burns, sepsis,
major operations, multiple trauma, or prolonged illness with
multiple organ system failure
• The cause is unknown
– GB distention with bile stasis and ischemia has been implicated as
causative factors
• Pathologic examination of the GB wall reveals edema of the
serosa and muscular layers, with patchy thrombosis of
arterioles and venules
44

45. Cont.
• The symptoms and signs depend on the condition
of the patient, but in the alert patient, they are
similar to acute calculous cholecystitis
– RUQ pain and tenderness, fever, and leukocytosis
• In the sedated or unconscious patient, the clinical
features are often masked
– Fever, elevated WBC count, and elevated ALP and
bilirubin are indications for further investigation
45

46. Cont.
• Diagnosis
– Ultrasonography is usually the diagnostic test of choice
• Distended gallbladder
• Thickened GB wall
• Pericholecystic fluid
• Biliary sludge
• The presence or absence of abscess formation
– Abdominal CT scan can aid in the diagnosis
– HIDA scan can be useful
• But it’s non-specific test in patients who are fasting, on total
parenteral nutrition, or have liver disease
46

47. Cont.
• Treatment
– Acalculous cholecystitis requires urgent intervention
– Options
• Percutaneous cholecystostomy
– Ultrasound- or CT-guided
– It is the treatment of choice for these patients, as they are
usually unfit for surgery
– About 90% of patients will improve with this
• Open cholecystostomy
• Cholecystectomy
47

48. Choledocholithiasis
• Found in 6% to 12% of patients with stones in the GB
– The incidence increases with age
• About 20% to 25% in patients above the age of 60
• The vast majority of ductal stones in Western countries
are secondary stones; formed within the GB and migrate
down the cystic duct to the CBD
– These are usually cholesterol stones
• The primary stones are associated with biliary stasis and
infection and are more commonly seen in Asian
populations
48

49. Cont.
• Choledochal stones:
– May be silent and often are discovered incidentally
– They may cause obstruction (complete or incomplete)
• May manifest with cholangitis or gallstone pancreatitis
• The pain caused by a stone in the bile duct is very similar to
that of biliary colic caused by impaction of a stone in the
cystic duct
– Nausea and vomiting are common
– Jaundice
• The symptoms may be intermittent
– The stones may become completely impacted, causing severe
progressive jaundice
49

50. Cont.
• Physical examination may be normal, but mild
epigastric or RUQ tenderness as well as mild
icterus are common
• Elevation of serum bilirubin, alkaline
phosphatase, and transaminases are commonly
seen in patients with bile duct stones
– However, in about one third of patients with CBD
stones, the liver chemistries are normal
50

51. Cont.
• Ultrasonography
• A dilated common bile duct (>8 mm in diameter) in a patient with
gallstones, jaundice, and biliary pain is highly suggestive of CBD stones
• ERCP
– The gold standard for diagnosing CBD stones
• MRCP
• Endoscopic ultrasound
– As good as ERCP for detecting CBD stones (sensitivity of 91%
and specificity of 100%)
• PTC
– Frequently performed for both diagnostic and therapeutic
reasons in patients with primary bile duct stones
51

52. Cont.
• Treatment
– Endoscopic sphincterotomy ductal clearance +
laparascopic cholecystectomy
• Patients >70 years old should have their ductal stones
cleared endoscopically and they do not need to be
submitted for a cholecystectomy, as only about 15% will
become symptomatic from their GB stones
– CBD exploration (open or laparoscopic)
• T tube is left in place and a T-tube cholangiogram is
obtained before its removal
– Retained stones can be retrieved either endoscopically or via the
T-tube tract once it has matured (2–4 weeks)
52

53. Cont.
• Cont.
– Stones impacted in the ampulla may be difficult for
both endoscopic ductal clearance as well as CBD
exploration
• In these cases the CBD is usually quite dilated (about 2
cm in diameter)
• A choledochoduodenostomy or a Roux-en-Y
choledochojejunostomy may be the best option
53

54. Cont.
• Cholangitis
– It is one of the two main complications of
choledochal stones, the other being gallstone
pancreatitis
– It is an ascending bacterial infection in association
with partial or complete obstruction of the bile
ducts
54

55. Cont.
• Cont.
– Pathphysiology
• Bile in the bile ducts is kept sterile by continuous bile flow and by the
presence of antibacterial substances in bile, such as immunoglobulin
• Mechanical hindrance to bile flow facilitates bacterial contamination
• Biliary bacterial contamination alone does not lead to clinical
cholangitis
– The combination of both significant bacterial contamination and biliary
obstruction is required for its development
» Gallstones are the most common cause of obstruction
– Etiology
• The most common organisms cultured from bile in patients with
cholangitis include Escherichia coli, Klebsiella pneumoniae,
Streptococcus faecalis, Enterobacter, and Bacteroides fragilis
55

56. Cont.
• Cont.
– Clinical features
• The patient with gallstone- induced cholangitis is typically older
and female
• Cholangitis may present as anything from a mild, intermittent,
and self-limited disease to a fulminant, potentially life-
threatening septicemia
• The most common presentation is fever, epigastric or RUQ
pain, and jaundice (Charcot’s triad)
– Present in about two thirds of patients
• The illness may progress rapidly with septicemia and
disorientation, known as Reynolds’ pentad (e.g., fever,
jaundice, RUQ pain, septic shock, and mental status changes)
56

57. Cont.
• Cont.
– Cont.
• The presentation may be atypical, with little if any fever,
jaundice, or pain
– This occurs most commonly in the elderly, who may have
unremarkable symptoms until they collapse with septicemia
– Patients with indwelling stents rarely become jaundiced
57

58. Cont.
• Cont.
– Diagnosis
• Leukocytosis, hyperbilirubinemia, and elevation of ALP
and transaminases are common and, when present,
support the clinical diagnosis of cholangitis
• Ultrasonography is helpful, as it will document the
presence of gallbladder stones, demonstrate dilated
ducts, and possibly pinpoint the site of obstruction;
however, rarely will it elucidate the exact cause
• CT scanning and MRI will show pancreatic and peri-
ampullary masses, if present, in addition to the ductal
dilatation
58

59. Cont.
• Cont.
– Cont.
• The definitive diagnostic test is ERC
– In cases in which ERC is not available, PTC is indicated
– Both ERC and PTC:
» Will show the level and the reason for the obstruction
» Allow culture of the bile
» Possibly allow the removal of stones if present
» Allow drainage of the bile ducts with drainage catheters or
stents
59

60. Cont.
• Cont.
– Treatment
• The initial treatment of patients with cholangitis includes IV antibiotics
and fluid resuscitation
– Most patients will respond to these measures
» About 15% of patients will not respond, and an emergency biliary
decompression may be required
• The obstructed bile duct must be drained as soon as the patient has
been stabilized
– One of the following approaches (selection based on the level and the nature
of the biliary obstruction)
» Endoscopically
» Via the percutaneous transhepatic route
» Surgically (with a T tube)
• Definitive operative therapy should be deferred until the cholangitis
has been treated and the proper diagnosis established
60

61. Cont.
• Cont.
– Prognosis
• Acute cholangitis is associated with an overall mortality
rate of approximately 5%
• When associated with renal failure, cardiac impairment,
hepatic abscesses, and malignancies, the morbidity and
mortality rates are much higher
61

62. Cont.
• Biliary Pancreatitis
– Obstruction of the pancreatic duct by an impacted
stone or temporary obstruction by a stone passing
through the ampulla may lead to pancreatitis
– An ultrasonogram of the biliary tree in patients with
pancreatitis is essential
• If gallstones are present and the pancreatitis is severe, an ERC
with sphincterotomy and stone extraction may abort the
episode of pancreatitis
– Once the pancreatitis has subsided, the GB should be removed
during the same admission
• When gallstones are present and the pancreatitis is mild and
self-limited, the stone has probably passed
– For these patients, a cholecystectomy and an intraoperative
cholangiogram or a preoperative ERC is indicated
62

63. Operative interventions for
gallstone disease
63

64. Cholecystostomy
• Decompresses and drains the distended, inflamed,
hydropic, or purulent GB
• It is applicable if the patient is not fit to tolerate an
abdominal operation
• Options
– Ultrasound-guided percutaneous cholecystostomy (Drainage
with a pigtail catheter)
• It is the procedure of choice
• Through the abdominal wall, the liver, and into the GB
– By passing the catheter through the liver, the risk of bile leak around the
catheter is minimized
– Open cholecystostomy under LA
• The GB can be removed later, if indicated, usually by
laparoscopy
64

65. Cont.
• Percutaneous cholecystostomy
65

66. Cholecystectomy
• Carl Langenbuch performed the first successful
cholecystectomy in 1882
• Laparascopic Vs. Open
– Today, laparoscopic cholecystectomy is the treatment of
choice for symptomatic gallstones
– Open cholecystectomy has become an uncommon
procedure, usually performed either as a conversion from
laparoscopic cholecystectomy or as a second procedure in
patients who require laparotomy for another reason
• Absolute contraindications for the procedure are:
– Uncontrolled coagulopathy
– End-stage liver disease 66

67. Cont.
• Intraoperative Cholangiogram
– The bile ducts are visualized under fluoroscopy by
injecting contrast through a catheter placed in the
cystic duct
– Their size can then be evaluated, the presence or
absence of CBD stones assessed, and filling defects
confirmed, as the dye passes into the duodenum
67

68. Cont.
• Cont.
– Routine intraoperative cholangiography
• It will detect stones in approximately 7% of patients, as
well as outlining the anatomy and detecting injury
– Selective intraoperative cholangiography
• Jaundice
• Pancreatitis
• History of abnormal liver function tests
• A dilated duct on preoperative ultrasonography
68

69. Other procedures
• CBD exploration
• Common bile duct drainage procedures
– Choledochoduodenostomy
– Choledochojejunostomy
• By bringing up a 45-cm Roux-en-Y limb of jejunum
– Hepaticojejunostomy
• Transduodenal sphincterotomy
69

70. End!
70