This is an overview of gallbladder stone diseases and infection of the gallbladder. I started with the surgical anatomy and physiology of gallbladder and bile secretion. furthermore, I went ahead to discuss the natural history of gallstones. then, the pathology and pathogenesis of gallstones and gallbladder infection (cholecystitis). Various investigations for Cholelithiasis and cholecystitis was discussed and the concluding part talked about various treatment modality. Finally, I went ahead to show the techniques of laparoscopic cholecystectomy.

1. Management of
Cholelithiasis and
Cholecystitis
Adewunmi O. Lukman
Senior Registrar
Division of General Surgery
UMTH
28th September, 2020

2. Outline
• Introduction
• Relevant Anatomy
• Epidemiology and Natural history
• Classification
• Clinical features
• Investigations
• Treatment
• Prognosis
• Conclusion
• References

3. Introduction
• Gallstones are the most common pathology affecting the biliary tract
• Gallbladder stone is one of the most common problems affecting the
digestive tracts
• It is estimated that gallstones are present in 10-15% of the adult
population in the USA.

4. Relevant
Anatomy/physiology

5. Relevant Anatomy/physiology
• The normal adult consuming an average diet produces within the liver
500 to 1000 mL of bile a day.
• The secretion of bile is responsive to neurogenic, humoral, and
chemical stimuli.
• Bile is mainly composed of water, electrolytes, bile salts, proteins,
lipids, and bile pigments

6. 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%. 1
• The prevalence of gallstones is related to many factors, including age,
gender and ethnic background.

7. Epidemiology
• Wichendu et al (UPTH) in Feb 2020: 2
M:F 1:5.6
age 41-50yrs
symptoms right hypochondrial/epigastric pain
type Mixed stones

8. Risk factor
Certain conditions predispose to the development of gallstones.
• Obesity
• Pregnancy
• dietary factors
• Crohn’s disease
• terminal ileal resection
• gastric surgery
• hereditary spherocytosis, sickle cell disease, and thalassemia are all
associated with an increased risk of developing gallstones. 3

9. Natural History
• Most patients will remain asymptomatic from their gallstones
throughout life
• Approximately 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. 4

10. Natural History
• Symptomatics- biliary colics (chronic cholecystitis)
• Complicated
acute cholecystitis
choledocholithiasis + Cholangitis
gallstone pancreatitis
cholecystocholedochal fistula
cholecystoduodenal fistula
gallstone ileus
gallbladder carcinoma

11. Classification
• Cholesterol 10%
• Pigment 10%
Black
Brown
• Mixed 80% 5

12. Classification
• Pure Cholesterol stones
consist of <10% of stone
contain 70-80% cholesterol by
weight
supersaturation of bile with
cholesterol
usually solitary with smooth
surface
usually radiolucent, <10% are
radio-opaque

13. Classification
• Pigment stones
contain <20% of cholesterol
contained calcium bilirubinate and
appear dark-colored
Black pigment stones
formed by supersaturation of bile
with Calcium bilirubin, carbonate and
phosphate
secondary to hemolytic anaemia or
hepatic cirrhosis
commonly formed in the gallbladder

14. Classification
• Brown pigment stone
usually less than 1cm in diameter, brownish-yellow, soft, mushy
formed in the gallbladder or CBD
formed from bacterial infection caused by bile stasis
E.coli, Klebsiella spp, etc secrete B-glucoronidase causing
deconjugated bilirubinemia
parasitic infestations e.g. Ascaris lumbricoides

15. Classification
• Mixed stones
contained variable
concentration of cholesterol and
bilirubin
most common stone in Nigeria
and Africa
made up about 80% of
gallbladder stones

16. Clinical features
Biliary colics
• Episodic pain
epigastric/Rt hypochodrial,
episodic, radiate to the upper
back/interscapular region, worsen
by fatty meal
• Atypical presentation
Bloating, belching. 6
Acute Cholecystitis
• Constant pain
• Anorexia
• Nausea and vomiting
• Fever
• Murphy’s sign- POSITIVE. 6

17. Investigations
• Abdominal Ultrasound- 95%
sensitive and specific
 thickened gallbladder wall +
peri-cholecystic fluid collection
 stones in the gallbladder
Complications
 obstructive jaundice- dilated
biliary tree, pancreatic duct, etc
 empyema- gallbladder sludge,
empyema. 7

18. Investigations
• HIDA scan (hydroxy iminodiacetic acid)
good in atypical presentation
non visualization of the gallbladder after 4hrs is diagnostic
• Complete Blood Count (CBC)
leukocytosis (12,000-15,000cells/mm3)
greater values suggest gangrene, perforation or cholangitis. 7

19. HIDA scan

20. Investigations
• Electrolyte, Urea and Creatinine (EUC)
assess renal function
• Liver function test (LFT)
ALP, ALT and AST. 7

21. Treatment
• Resuscitation
IV fluid
IV antibiotics- cephalosporins and metronidazole
Analgesics
• Definitive treatment
Cholecystectomy

22. Treatment
• Cholecystectomy
Approach
Open
Laparoscopic
Timing
Early
Delayed

23. Treatment
• Approach
Open
Laparoscopic

24. Federico Coccolini et al, meta-analysis (1248
patients, 12 RCTs)- Level 1 evidence. 8
Lap Chole Open Chole
Post-op morbidity ↓ -
Post-op wound infection ↓ -
Pneumonia ↓ -
Mortality ↓ -
Post-op hospital stay ↓ -
Bile leak ↕ ↕
Intra-op blood loss ↕ ↕
Operative time ↕ ↕

25. Adisa et al in ile-ife, retrospective studies of
cholecystectomy (173 patients)- level 5 evidence. 9
2005 2015
• Cholecystectomy: 7(2.7%) 31(9.1%)
increased was noticed when LapChole was commenced in 2008
• Open Cholecystectomy 7 2
• Post-op hospital stay 5.2days 1.8days
• Conclusion: they recommend the use of laparoscopy/minimal access
surgery across the country.

26. Treatment
• Timing
Early <3days
Late >3days

27. Wu, X-D et al(2015), meta-analysis (1625
patients, 15 RCTs)- Level 1 evidence. 10
• Early- <7days Delayed- >7days
• Early Lap Chole
lower hospital cost
shorter hospital stay
few work day lost
higher patient satisfaction
quality of life
• No difference
mortality, bile duct injury, bile leak, and conversion to open technique

28. Acute acalculous cholecystitis. 11
• Acute inflammation of the gallbladder without gallstones
• Typically developed in patients in the ICU
Burns
sepsis
multiple injuries
Parenteral feeds
Multiple organ failures

29. Acute acalculous cholecystitis
• Pathogenesis is unknown
• Conscious patient
symptoms are similar
Unconscious patient
symptoms are masked
fever, ele WBC, ALP,jaundice may be a pointer

30. Acute acalculous cholecystitis
• Abd USS
thickened gallbladder with peri-cholecystitic fluid collection,
biliary sludge,
no gallstones
• HIDA scan
• CT abdomen

31. Acute acalculous cholecystitis
• Treatment
emergency decompression of the biliary
percutaneous cholecystostomy- 90% will improve
open cholecystostomy/cholecystectomy

32. Laparoscopic cholecystectomy- overview. 12

33. Summary
• Gallstones are the commonest biliary pathology
• Asymptomatic gallstones do not require treatment
• Classified into cholesterol, pigment and mixed
• Treatment for symptomatic gallstones is laparoscopic
cholecystectomy

34. References
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SYMPTOMATIC GALL STONES IN A TERTIARY CARE HEALTH FACILITY IN SOUTHERN
NIGERIA. Journal of International Research in Medical and Pharmaceutical Sciences,
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3. Nakeeb A, Comuzzie AG, Martin L, et al. Gallstones: genetics versus environment. Ann
Surg. 2002;235:842.
4. Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: the GREPCO
experience. The GREPCO Group. Hepatology. 1995;21:655.
5. Charles F. Brunicardi: Schwartz’s principles of Surgery, 10th edition Chapters 33
6. Aliyu S and Ningi AB. The Types and Indications of Cholecystectomy in Nigeria: Our
Experience in Damaturu, North-Eastern Nigeria. A Randomized Double-Blind Placebo-
Controlled Trial. Acad J Gastroenterol & Hepatol. 2(2): 2020. AJGH.MS.ID.000535. DOI:
10.33552/AJGH.2020.02.000535

35. 7. O. James Garden and Simon Peterson-Brown: Hepatobiliary and pancreatic surgery, a companion
to specialist surgical practice, 5th edition, chapter 10.
8. Coccolini F, Catena F, Pisano M, Gheza F, Fagiuoli S, Di Saverio S, Leandro G, Montori G, Ceresoli
M, Corbella D, Sartelli M, Sugrue M, Ansaloni L. Open versus laparoscopic cholecystectomy in acute
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9. Adisa AO, Lawal OO, Adejuyigbe O. Trend over time for cholecystectomy following the
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10. Wu, X.‐D., Tian, X., Liu, M.‐M., Wu, L., Zhao, S. and Zhao, L. (2015), Meta‐analysis comparing
early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg, 102: 1302-
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