Gall stone diseases hegazy

1. ‫د‬.‫حجازى‬ ‫مصطفى‬

2. Cholelithiasis involves the presence of
gallstones, which are concretions that form
in the biliary tract, usually in the
gallbladder.
Choledocholithiasis refers to the presence
of 1 or more gallstones in the common bile
duct (CBD).
Treatment of gallstones depends on the
stage of disease.

3. Gallstone disease may be thought of as
having the following 4 stages:
Lithogenic state, in which conditions favor
gallstone formation
Asymptomatic gallstones
Symptomatic gallstones, characterized by
episodes of biliary colic
Complicated cholelithiasis

4. Symptoms and complications result from
effects occurring within the gallbladder or
from stones that escape the gallbladder to
lodge in the CBD.

5. Characteristics of biliary colic include the
following:
Sporadic and unpredictable episodes
Pain that is localized to the epigastrium or
right upper quadrant, sometimes radiating
to the right scapular tip

6. Pain that begins postprandially, is often
described as intense and dull, typically
lasts 1-5 hours, increases steadily over 10-
20 minutes, and then gradually wanes
Pain that is constant; not relieved by
emesis, antacids, defecation, flatus, or
positional changes; and sometimes
accompanied by diaphoresis, nausea, and
vomiting

7. Nonspecific symptoms (eg, indigestion,
dyspepsia, belching, or bloating)
Patients with the lithogenic state or
asymptomatic gallstones have no
abnormal findings on physical
examination.

8. Distinguishing uncomplicated biliary colic
from acute cholecystitis or other
complications is important.
Key findings that may be noted include the
following:
Uncomplicated biliary colic – Pain that is
poorly localized and visceral; an
essentially benign abdominal examination
without rebound or guarding; absence of
fever

9. Acute cholecystitis – Well-localized pain in
the right upper quadrant, usually with
rebound and guarding; positive Murphy
sign (nonspecific); frequent presence of
fever; absence of peritoneal signs;
frequent presence of tachycardia and
diaphoresis; in severe cases, absent or
hypoactive bowel sounds

10. The presence of fever, persistent
tachycardia, hypotension, or jaundice
necessitates a search for complications,
which may include the following:
Cholecystitis
Cholangitis
Pancreatitis
Other systemic cause

11. Patients with uncomplicated cholelithiasis
or simple biliary colic typically have normal
laboratory test results; laboratory studies
are generally not necessary unless
complications are suspected.

12. Blood tests, when indicated, may include
the following:
Complete blood count (CBC) with
differential
Liver function panel
Amylase
Lipase

13. Imaging modalities that may be useful
include the following:
Abdominal radiography (upright and
supine) – Used primarily to exclude other
causes of abdominal pain (eg, intestinal
obstruction)

14. Ultrasonography – The procedure of
choice in suspected gallbladder or biliary
disease

15. Endoscopic ultrasonography (EUS) – An
accurate and relatively noninvasive means
of identifying stones in the distal CBD
Laparoscopic ultrasonography –Promising
as a potential method for bile duct imaging
during laparoscopic cholecystectomy

16. Computed tomography (CT) – More
expensive and less sensitive than
ultrasonography for detecting gallbladder
stones, but superior for demonstrating
stones in the distal CBD

17. Magnetic resonance imaging (MRI) with
magnetic resonance
cholangiopancreatography (MRCP) –
Usually reserved for cases in which
choledocholithiasis is suspected
Scintigraphy – Highly accurate for the
diagnosis of cystic duct obstruction

18. Endoscopic retrograde
cholangiopancreatography (ERCP)
Percutaneous transhepatic
cholangiography (PTC)

19. The treatment of gallstones depends upon
the stage of disease, as follows:
Lithogenic state – Interventions are
currently limited to a few special
circumstances
Asymptomatic gallstones – Expectant
management

20. Symptomatic gallstones – Usually,
definitive surgical intervention (eg,
cholecystectomy), though medical
dissolution may be considered in some
cases

21. Medical treatments, used individually or in
combination, include the following:
Oral bile salt therapy (ursodeoxycholic
acid)
Contact dissolution
Extracorporeal shockwave lithotripsy

22. Cholecystectomy for asymptomatic
gallstones may be indicated in the
following patients:
Those with large (>2 cm) gallstones

23. Those who have a nonfunctional or
calcified (porcelain) gallbladder on imaging
studies and who are at high risk of
gallbladder carcinoma
Those with spinal cord injuries or sensory
neuropathies affecting the abdomen
Those with sickle cell anemia in whom the
distinction between painful crisis and
cholecystitis may be difficult

24. Patients with the following risk factors for
complications of gallstones may be offered
elective cholecystectomy, even if they have
asymptomatic gallstones:
Cirrhosis
Portal hypertension
Children
Transplant candidates
Diabetes with minor symptoms

25. Surgical interventions to be considered
include the following:
Cholecystectomy (open or laparoscopic)
Cholecystostomy
Endoscopic sphincterotomy

26. Oral bile acids have been used for years to
dissolve common duct stones.
The success rates, however, are variable,
ranging from 10% to 44%.

27. • In one randomized, double-blind,
placebo-controlled study, 28 patients with
uncomplicated, non-obstructing common
duct stones were treated with
ursodeoxycholic acid (12 mg/kg/d for up
to 2 years); the bile duct stones
disappeared in 7 of 14 patients in the
treatment group and 0 of 14 in the
placebo group.

28. Four patients (14%) required operative
intervention, including one from the treated
and three from the placebo groups.
Rowachol (a terpene preparation) is known
to further promote stone dissolution.


29. Currently, optimal patient
selection,duration of treatment, and
optimal dosing has not been determined
with these medical treatments of
choledocholithiasis.

30. The area in which oral bile acid therapy
may play a role is the treatment of
asymptomatic patients with small
cholesterol duct stones discovered during
laparoscopic cholecystectomy.

31. The composition of bile ductal stones may
be inferred if cholesterol stones were
present in the gallbladder, and small duct
stones might dissolve relatively rapidly.

32. Because duct exploration during
laparoscopic cholecystectomy might be
demanding technically, especially with a
small-diameter cystic and/or common bile
duct, this dissolution therapy is a
reasonable therapeutic alternative;
however, this approach needs to be
evaluated in clinical trials.

33. Cholelithiasis is the medical term for
gallstone disease.
Gallstones are concretions that form in the
biliary tract, usually in the gallbladder.

34. Cholelithiasis
A gallbladder filled with gallstones
(examined extracorporally after
laparoscopic cholecystectomy .
Gallstones develop insidiously, and they
may remain asymptomatic for decades.

35. Migration of a a gallstone into the opening
of the cystic duct may block the outflow of
bile during gallbladder contraction.

36. The resulting increase in gallbladder wall
tension produces a characteristic type of
pain (biliary colic).
Cystic duct obstruction, if it persists for
more than a few hours, may lead to acute
gallbladder inflammation (acute
cholecystitis).

37. Choledocholithiasis refers to the presence
of one or more gallstones in the common
bile duct.
Usually, this occurs when a gallstone
passes from the gallbladder into the
common bile duct .

38. Common bile duct stone
(choledocholithiasis)
 The sensitivity of transabdominal
ultrasonography for choledocholithiasis is
approximately 75% in the presence of
dilated ducts and 50% for nondilated
ducts.

39. A gallstone in the common bile duct may
impact distally in the ampulla of Vater, the
point where the common bile duct and
pancreatic duct join before opening into
the duodenum.
Obstruction of bile flow by a stone at this
critical point may lead to abdominal pain
and jaundice.

40. Stagnant bile above an obstructing bile
duct stone often becomes infected, and
bacteria can spread rapidly back up the
ductal system into the liver to produce a
life-threatening infection called ascending
cholangitis.

41. Obstruction of the pancreatic duct by a
gallstone in the ampulla of Vater also can
trigger activation of pancreatic digestive
enzymes within the pancreas itself, leading
to acute pancreatitis.[1, 2]

42. Chronically, gallstones in the gallbladder
may cause progressive fibrosis and loss of
function of the gallbladder, a condition
known as chronic cholecystitis.
Chronic cholecystitis predisposes
to gallbladder cancer.

43. Ultrasonography is the initial diagnostic
procedure of choice in most cases of
suspected gallbladder or biliary tract
disease .

44. The treatment of gallstones depends upon
the stage of disease.
Asymptomatic gallstones may be managed
expectantly.

45. Once gallstones become symptomatic,
definitive surgical intervention with excision
of the gallbladder (cholecystectomy) is
usually indicated.

46. Cholecystectomy is among the most
frequently performed abdominal surgical
procedures .
Complications of gallstone disease may
require specialized management to relieve
obstruction and infection