2. CHOLELITHIASIS
• Most common biliary pathology
• it is estimated that gallstones are present in 10-
15% of the adult population in the USA
• they are asymptomatic in the majority (>80%)
• in the UK the prevalence of gallstones at the
time of death is estimated to be 17% and may
be increasing
• Approximately 1-2% of asymptomatic patients
will develop symptoms requiring
cholecystectomy per year, making
cholecystectomy one of the most common
operations performed by general surgeons
3. Aetiology
• 3 main types:
• cholesterol (80% in USA)
• pigment (80% in Asia)
• mixed stones
– 51-99% pure cholesterol
– admixture of calcium salts, bile acids, bile
pigments and phospholipids
4. • Cholesterol which is insoluble in water is
secreted from the canalicular membrane
in phospholipid vesicles.
• Whether cholesterol remains in solution
depends on
– the concentration of phospholipids and bile
acids in bile and
– the type of phospholipids and the bile acid
5. • Micelles formed by the phospholipid hold
cholesterol in a stable thermodynamic
state
• when bile is supersaturated with
cholesterol or bile acid concentrations are
low, unstable unilamellar phospholipid
vesicles form from which cholesterol
crystals nucleate and stones may form.
6. Factors associated with gallstone
formation
Impaired gall bladder
function
Emptying
Absorption
Excretion
Supersaturated bile
Age
Diet- high calorie
Obesity
Genetics
Sex
Cholesterol
Glycoprotein
Infection
Mucus
Absorption/ Enterohepatic circulation of bile
acids
Cholestyramine
Deoxycholate
(increase the secretion of cholesterol and
supersaturate the bile, increasing lithogenicity of
bile)
Faecal enteric flora
Ileal resection
Bowel transit time
7. • Nucleation of cholesterol monohydrate
crystals from multilamellar vesicles is a
crucial step in gallstone formation
• abnormal emptying of the gall bladder may
promote the aggregation of nucleated
cholesterol crystals, hence removing
gallstones without removing the gall
bladder inevitably leads to gallstone
recurrence.
8. Pigment stones
• Name used for stones with <30% cholesterol
• there are two types:
• black
– black stones are largely composed of an insoluble
bilirubin pigment polymer mixed by calcium
phosphate and calcium bicarbonate
– 20-30% of stones are black
– incidence rises with age
– accompany haemolysis, usually hereditary
spherocytosis or sickle cell disease,
haemoglobinopathies
– patients with cirrhosis and biliary stasis have a higher
incidence of pigmented stones
9. • brown
– contain calcium bilirubinate
– calcium palmitate
– calcium stearate
– cholesterol
• rare in gallbladder
• form in the bile duct and related to bile
stasis and infected bile
10. • Stone formation is related to the
deconjugation of bilirubin diglucuronide by
bacterial beta- glucuronidase.
• Insoluble unconjugated bilirubinate
precipitates
• Brown pigment stones are also associated
with the presence of foreign bodies within
the bile ducts such as endoprosthesis
(stents), E coli or parasites such as
Clonorchis sinensis and Ascaris
lumbricoides
11. Clinical presentation
• Right upper quadrant pain
• Epigastric pain
• radiate to back
• colicky or dull and constant
• others:
– dyspepsia
– flatulence
– food intolerance
– particularly to fats
12. • altered bowel frequency
• Biliary colic is typically present in 10-25%
of patient
• described as a severe right upper
quadrant pain that ebbs and flows
associated with nausea and vomiting.
• Pain may radiate to the chest
• the pain is usually severe and may last for
minutes or even several hours
13. • Frequently, the pain starts during the night, waking the
patient.
• Minor episodes of the same discomfort may occur
intermittently during the day
• Dyspeptic symptoms may coexist and be worse after
such an attack.
• As the pain resolves, the patient is able to eat and drink
again, often only to suffer further episodes of this nature
over a period of a few weeks and then no more trouble
for some months
• Jaundice may result if a stone migrates from the
gallbladder and obstructs the common bile duct. Rarely,
a gallstone can lead to bowel obstructions
14. Natural History
Asymptomatic
1-2% per year 0.2% per year
Acute
cholecystitis
Biliary colic
5% per year
symptoms
Chronic
cholecystitis
Gall bladder
carcinoma
0.08%
symptomatic
patients
Bile duct
stone
Pancreatitis
Cholangitis
Jaundice
15. Complications of Gallstones
• Biliary colic
• Acute cholecystitis
• Chronic cholecystitis
• Mucocoele
• Empyema of the gall
bladder
• Perforation
• Biliary obstruction
• Acute cholangitis
• Acute pancreatitis
• Intestinal obstruction
• (gallstone ileus)
16. Complications
• Acute cholecystitis:
• due to obstruction of the neck of
gallbladder or cystic duct by a stone
resulting in a chemical inflammatory
reaction. Bacteria are cultured from the
bile in approximately 1/2 of patients with
gallstones and unrelieved obstruction in
the presence of this infected bile may
produce an empyema
• Boas' sign :hyperaesthesia below the right
scapula in cholecystitis
17. • The thickened gallbladder becomes intensely
inflamed, edematous and occasionally
gangrenous
• the fundus of the distended, inflamed gallbladder
may perforate giving rise to localised abscess
formation and occasionally to biliary peritonitis
• the commo organism implicated in inflammation
of the gallbladder are E coli, Klebsiella
aerogenes and Strep faecalis
• Staphylococci, clostridia and salmonella are
occasionally
18. Chronic cholecystitis
• Repeated bouts of biliary colic or acute
cholecystitis culminate in fibrosis,
contraction of the gallbladder nd chronic
inflammatory change my be present i the
absence of gallstones, as is the case in
the gallbladders of typhoid carriers
• the incidence of carcinoma of the
gallbladder is increased in patients with
longstanding gallstones
19. Mucocoele
• a mucocoele develops when the outlet of
the gallbladder ceomes obstructed in the
absence of infection
• the imprisoned bile is absorbed, but clear
mucus contiues to be secreted into the
distended gallbladder.
20. Choledocholithiasis
• when gallstones enter the common bile
duct, they may pass spontaneously or give
rise to obstructive jaundice, cholangitis or
acute pancreatitis
• Gallstone pancreatitis most ommonly
occurs when a small stone becomes
temporarily arrested at the ampulla of
vater
21. Gallstone ileus
• A large gallstone becomes impacted inthe
intestine
• stones large enough to block gut generally
gain access by eroding through the wall of
the gallbladder into the duodenum
22. Biliary colic
• transient obstruction of GB from an impacted
stone
• Severe gripping pain after meals an in the
evening whihc is maximal in the epigastrium and
right hypochondrium with radiation to th back
• Despite being continuous the pain may wax and
wane in intensity over several hours, vomiting
and retching are common. Resolution occurs
when the stone falls back into the gallbladder
lumen or passes onwards into the CBD
• The patient the obstruction does not resolve an
patient develops acute cholecystitis
23. Differential diagnosis of
cholecystitis
• Common
– Appendicitis
– Perforated peptic ulcer
– Acute pancreatitis
• uncommon
– Acute pyelonephritis
– Myocardial infarction
– Pneumonia- right
lower lobe
• Ultrasound scan aids
diagnosis
• Uncertain diagnosis-
do CT scan
24. Diagnosis
• A diagnosis of gallstone disease is based
on the history and physical examination
with confirmatory radiological studies such
as transabdominal U/S and radionuclide
scans
• In the acute phase, the patient may have
right upper quadrant tenderness that is
exacerbated during inspiration by the
examiner's right subcostal palpation
25. • A positive Murphy's sign may suggests acute
inflammation and may be associated with a
leucocytosis and moderately elevated liver
function tests.
• A mass may be palpable as the omentum walls
off an inflamed gallbladder. Fortunately in the
majority of cases process is limited by the stone
slipping back into the body of the gallbladder
one contents of the gallbladder escaping by way
of the cystic duct.
• This achieves adequate drainage of the gall
bladder and enables the inflammation to resolve
26. • If resolution does not occur, an empyema
of the gall bladder may result.
• The wall may become necrotic and
perforate with tthe development of
localised peritonitis
• The abscess may then perforate into the
peritoneal cavity with a septic peritonitis-
however, this is uncommon because
gallbladder is usually localised by
omentum around the perforation
27. • A palpable non tender gall bladder (courvoisier
sign) - more sinister diagnosis
• Results from a distal common duct obstruction
secondary to a peripancreatic malignancy
• Rarely a non tender palpable gall bladder results
from complete obstruction of the cystic duct with
reabsorption of the intraluminal bile salts and
secretion of uninfected mucus secreted by the
epithelium, leading to a mucocoele of the gall
bladder.
28. Investigations
• Blood tests: neutrophilia in acute
cholecystitis or its complications.
• Elevated serum bilirubin or alkaline
phosphatase may signify the presence of
common duct stones
• Prothrombin time should be measured if
there was presence of jaundice
29. • Plain Xray
• 15% contain calcium
• Gas seen in biliary tree if there is a fistula
between the biliary tract and the gut as in
gallstone ileus or following endoscopic
sphincterotomy
• Ultrasound
• permits inspection of the gallbladder, its wall and
its contents
• demonstrates dilation of the ultrasonic wave and
are throuwn into prominence by the acoustic
shadow they produce.
• Does not depend on hepatic excretion of
contrast, it can be used in both jaundicedd and
non jaundiced patients, and therefore has
supplanted oral cholecystography
30. Cholangiography
• IV cholangiography replacee by MRCP
which is increasingly to assess the biliary
tree non invasively whereas ERCP is
reserved for removing common bile duct
stones by endoscopic sphincterotomy
• Complications occur in up to 7% of
patients and may include cholangitis,
bleeding and acute pancreatitis
31. Management
• Admit patient
• Monitor
• Analgesics
• IV fluids
• Broad spectrum antibiotics eg cephalosporin
• NPO and pass NG tube only if patient is
vomiting
• Majority of patients settle within few days on this
regimen
• Failure to settle suggests presence of empyema
32. • Some surgeons delay operation for 2-3
months after the attack in the expectation
that the acute inflammatory reaction will
have resolved by then but most now prefer
to perform cholecystectomy during the
same admission and within 72hours of
onset of attack.
• Provided the operation is carried out by an
experienced surgeon and under antibiotic
cover the early cholecystectomy is not
associated with a increased incidence of
complications
33. • Duration of illness and hospitalisation is
reduced, and further attacks of acute
cholecystitis during the waiting period for
elective surery are averted
• it shouldd be noted that this a planned
procedure carrioed out after appropriate
investigation (U/S) and with all facilities,
on a scheduled list
34. • Laparoscopic cholecystectomy is more
difficult to perform in the acute setting but
is the method preferreed by most
surgeons
• If surrounding inflammation makes
identification of the relevant anatomical
structures difficult drainage of the
gallbladder with removal of stones
(cholecystectomy) may be performed as
an interim measures.Elective
cholecystectomy is usually performe
approximately 2 months later.
35. CHRONIC CHOLECYSTITIS
• Chronic cholecystitis is most common cause of
symp tomatic gallbladder disease.
• the patient gives history of recurrent flatulence,
fatty food intolerance, right upper quadrant pain
• pain worse after food, feeling of distension and
heartburn
• DDx: duodenal ulcer, hiatus hernia, MI, chronic
pancreatitis and gastrointestinal neoplasia.
• Symptoms for mucocoele are the same as those
for chronic cholecystitis but a nontender piriform
swelling may be palpable in the right
hypochondrium. there is little systemic upset and
no pyrexia
36. CHOLEDOCHOLITHIASIS
• Stones may be present in the common
bile duct of some 5-10% of patients with
gallstones
• there is little muscle in the wall of the bile
uct
• and pain is not a symptoms unless the
stone impedes flow through the sphincter
of Oddi
• the vast majority of stones in the common
bile duct originate in the gallbladder.
• Primary duct stones are really rare
37. • Impaction of a stone at the sphincter obstructs
the flow of bile producing jaundice, pale stools
and dark urine
• Obstruction commonly persists for several days
but may clear spontaneously as a result of either
passage of the stone or of its disimpaction
• Small stones may pass through the common bile
duct with no symptoms
• In longstanding obstruction the bile ducts
become markely dilated and the diameter of the
CBD may exceed its upper limit of 7mm.
• Diameter greater than 10mm is usually strongly
suggestive of stone or tumour
38. • A totally obstructed duct system becomes dilled
with clear white bile as back pressure on the
hepatocytes prevents clearance of bilirubin and
mucus secretion is increased
• Infected of an obstructed biliary tract causes
cholangitis, which is characterised by attacks of
pain, pyrexia and jaundice (Charcot) frequentl
ass/w rigors
• Long standing biliary obstruction--- secondary
biliary cirrhosis
39. Treatment
• Observe patients with asymptomatic gallstones
with cholecystectomy only performed for those
patients who develop symptoms or
complications of their gallstones
• However prophylactic cholecystectomy should
be considered in diabetic patients, those with
congenital haemolytic anemia and those due to
undergo bariatic surgery for morbid obesity as
these groups are at increased risk of
complications from gallstones
40. Treatment
• for patients with biliary colic or
cholecystitis, cholecystectomy is the
treatment of choic in the absence of
medical contraindications
• the timing of surgery in acute cholecystitis
remains controversial.
• many units favour early intervention,
whereas others suggest that a delayed
approach is preferable.
41. Conservative treatment followed by
cholecystectomy
• In more than 90% of cases, the symptoms
of acute cholecystitis subside with
conservative measures. Non operative
treatment is based on four principles.
42. 1.Nil per mouth and IV fluid administration
2.Administration of analgesics
3.Administration of antibiotics: as the cystic
duct is blocked in most instances, the
concentration of antibiotics in the serum is
more important than its concentration in
bile. Cephazolin, Cefuroxime, Gentamicin
43. • Subsequent management: when the
temperature, pulse and other physical signs
show that the inflammation is subsiding, oral
fluids are reinstated followed by regular diet.
Ultrasonography is performed to ensure that no
local complications have developed, that the bile
duct is of a normal size and that no stones are
contained in the bile duct
• Cholecystectomy may be performed on the next
available list or the patient may be allowed home
to return later when the inflammation has
completely resolved
44. When to abandon conservative
treatment?
• Conservative treatment must be abandon
if the pain and tenderness; depending on
the status of the patient, operative
intervention and cholecystectomy should
be performe
• If the patient has serious comorbid
conditions a percutaneous
cholecystectomy can be performed under
ultrasound control, which will rapidly
relieve symptoms. A subsequent
cholecystectomy is usually required
45. Routine early operation
• As noted above, some surgeons advocate
urgent operation as a routine measure in
cases of acute cholecystitis.
• Provided that the operation is undertaken
within 5-7 days of the onset of the attack,
the surgeon is experienced and excellent
operating facilities are available, good
results are achieved.
46. • Nevertheless, the conversion rate in
laparoscopic cholecystectomy is five times
higher in acute than in elective surgery
• If an early operation is not indicated, one
should wait approximately 6 weeks for the
inflammation to subside before preceding
to operate
47. Cholesterosis
• aka strawberry gallbladder
• mucosa of gallbladder infiltrated with lipid
and cholesterol
• affects middle aged and elderly patients of
both sexes
• cholesterol stones found in half
• mucosa brick red and speckled with bright
yello nodules
• Management: as for chronic cholecystitis
48. Adenomyomatosis
• Mucosal diverticulosis - Rokitansky
Aschoff sinuses
• particularly addect the fundus and
penetrate the muscular layers to the
serosa
• Muscular hypertrophy and inflammatory
cell infiltrates are present
• the diagnosis may be made on careful
imaging but is often only made following
cholecystectomy as the gallbladder
normally contains stones.
49. Acute acalculous cholecystitis
• Few patients with acute cholecystitis have acalculous
inflammation
• Major surgery
• bacteria
• trauma
• pancreatitis
• complication of parenteral nutrition
• Best diagnosedd using a nuclear imaging hepatobiliary
iminodiacetic acid scan
• the inflammatory reaction in the gallbladder wall may be
intense and severe, leding to gangrene and perforation
• in ill patients, percutaneous drainage (cholecystostomy)
under ultrasound guidance may be considered, but
urgent cholecystectomy is often advisable.
