etiology ,classifications of gall stones & causes,risk factors,presentations, clinical examinations ,investigations including radiological (role of ERCP and MRCP ) and serological ,treatment including surgical and non surgical ,post cholecystectomy syndrome and its management ,Iindicatrions for cholecystectomy and cholecystotomy & when to perform ,complications of gall stones ,preventions of gall stone disease
1. Gall Stone disease:
BY: Dr ABRAR ALI supervised by: Dr VIJAY KUMAR
Consultant department of surgery
2. What Are Gallstones?
Small, pebble-like substances
that May occur anywhere
within the biliary tree
Range in size- small as a grain
of sand to as large as golf ball
Multiple or solitary
Have different appearance -
depending on their contents
3. Pigment Stones
Small
Friable
Irregular
Dark
Made of bilirubin and
calcium salts
Less than 20% of
cholesterol
Risk factors:
• Haemolysis
• Liver cirrhosis
• Biliary tract infections
• Ileal resection
4. Cholesterol Stones
Large
Often solitary
Yellow, white or green
Made primarily of
cholesterol (>70%)
Risk factors:
• 4 “F” :
Female
Forty
Fertile
Fat
• Fair (5th “F” - more
prevalent in Caucasians)
• Family history (6th “F”)
7. Gallstone Prevalence
10% of people over 40 yrs.
90% “silent stones”
Risk factors for becoming
symptomatic:
• Smoking
• Parity
8. Risk Factors
Women
Age > 60 years
American Indians & Mexican Americans
Overweight or obese men and women
People who tend to fast or lose weight quickly
Family history of gallstones
Diabetes
Diet high in cholesterol
Use of OCPs
Pregnancy
9. Gallstone Pathogenesis
Bile = bile salts, phospholipids, cholesterol
Gallstones form due to alteration in the ratio of bile
salt/phospholipid /cholesterol
Pathogenesis involves 3 stages:
Cholesterol supersaturation in bile
Crystal nucleation ( mucin hypersecretion by GB mucosa creats a
viscoelastic gel that foster crystal nucleation)
Bile stasis ( fasting,ocps, pregnancy, vagotomy ,prolong TPN)
14. Definitions
Symptomatic
cholelithiasis
Wax/waning postprandial epigastric/RUQ pain due to transient
cystic duct obstruction by stone, no fever/WBC, normal LFT
Acute
cholecystitis
Acute GB inflammation due to cystic duct obstruction. Persistent
RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest
Chronic
cholecystitis
Recurrent bouts of colic/acute chol’y leading to chronic GB wall
inflamm/fibrosis. No fever/WBC.
Acalculous
cholecystitis
GB inflammation due to biliary stasis(5% of time) and not
stones(95%). Seen in critically ill pts
Choledocho-
lithiasis
Gallstone in the common bile duct (primary means originated there,
secondary = from GB)
Cholangitis Infection within bile ducts usu due to obstrux of CBD. Charcot triad:
RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic
shock
Mucocele GB Overdistended GB filled with mucoid or clear fluid and watery
content, Usually noninflammatory, it results from outlet
obstruction of the gallbladder and is commonly caused by an
impacted stone in the neck of the gallbladder or in the cystic
duct.
15. Differential Diagnosis Of RUQ
Pain
Biliary disease
• Acute cholecystitis, chronic cholecystitis, CBD
stone, cholangitis
Inflamed or perforated duodenal ulcer
Hepatitis
Also need to rule out:
• Appendicitis, renal colic, pneumonia or
pleurisy, pancreatitis
16. Symptoms
Pain in the RUQ
• Most common and typical symptom
• May last for a few minutes to several hours
• Mostly felt after eating a heavy and high-fat meal
Pain under right shoulder when lifting up arms
Fever, nausea and vomiting
Jaundice (obstruction of the bile duct passage)
18. Complications Of Gallstones
In the GB:
• Biliary colic
• Acute and chronic
cholecystitis
• Empyema
• Mucocoele
• Carcinoma
In the bile ducts:
• Obstructive jaundice
• Pancreatitis
• Cholangitis
In the gut:
• Gallstone ileus
19. 0.1–0.7% of patients who have gallstones
Csendes classification :
• Type 1: external compression of the common bile duct – 11%
• Type 2: cholecystobiliary fistula is present involving <1/3 rd the
circumference of the bile duct – 41%
• Type 3: a fistula is present involving upto 2/3 the circumference of
the bile duct – 44%
• Type 4: a fistula is present with complete destruction of the wall of
the bile duct – 4%
Mirizzi syndrome
20. Diagnosis
Ultrasound
Computerized tomography (CT) scan
• May show gallstones or complications, such as rupture of GB or
bile ducts
• Only calcified GB stone are hyperattenuating to bile, making them the
only type to be clearly visualized on CT scan images. Pure cholesterol
stones are hypoattenuating to bile, and other gallstones are isodense
to bile and these may not be clearly identified on CT.
Cholescintigraphy (HIDA scan)
• Used to diagnose abnormal contraction of gallbladder or
obstruction of bile ducts
Endoscopic retrograde cholangiopancreatography (ERCP)
Used to locate and remove stones in bile ducts
Blood tests- CBC , LFT ,CLOTTING PROFILE,S.AMYLASE/LIPASE
• Performed to look for signs of infection, obstruction, pancreatitis,
or jaundice
22. MRCP- Used to visualize the biliary and pancreatic ducts in a non-invasive
manner. This procedure can be used to determine if gallstones are lodged in any of
the ducts surrounding the GB
MRCP ERCP
25. Cholecystostomy
Patients at high risk related to multisystem organ failure
Severe pulmonary, renal, or cardiac disease
Recent myocardial infarction
Cirrhosis with portal hypertension
Acalculus cholecystitis after severe trauma, burns, or
surgery
Empyema or gangrene of the gallbladder
26. Subtotal Cholecystectomy
Severe inflammation renders identification of
the anatomy impossible, eg. Gangrenous
cholecystitis
Scarred partially intrahepatic gallbladder
Severe cirrhosis and portal hypertension
27. Cholecystectomy
Laparoscopic Surgery
Advantages:
Less post-op pain
Shorter hospital stay
Quicker return to normal activities
Disadvantages:
Learning curve
Inexperience at performing open cholecystectomies
30. Mini-cholecystectomhy
MC is an effective minimally invasive surgical procedure for both acute
and chronic cholecystitis, with a low morbidity rate (5.6%), an early
return to oral diet, few doses of postoperative analgesic and a short
postoperative hospital stay.
A small right subcostal incision (4-5cm ) is the appropriate choice for
MC in either a normal-sized or distended gallbladder.
MC can be performed without the use of special instruments, thus
reducing the expense.
Since not every case is suitable for LC and MC is cheaper, MC should be
considered in every case of gallstone disease, particularly in a
developing country in which the health-care budget is limited
31. Cholecystectomy when to perform?
After acute cholecystitis, cholecystectomy traditionally performed after
6 weeks
Arguments for 6 weeks later
Laparoscopic dissection more difficult when acutely inflammed
Surgery not optimal when patient septic/dehydrated
Logistical difficulties (theatre space, lack of surgeons)
Arguments for same admission
Research suggests same admission lap chole as safe as elective chole (conversion
to open maybe higher)
Waiting increases risk of further attacks/complications which can be life
threatening
Risk of failure of conservative management and development of dangerous
complication such as empyema, gangrene and perforation can be avoided
National guidelines state any patient with attack of gallstone
pancreatitis should have lap chole within 3 weeks of the attack
32. Complications of Lap
Cholecystectomy
Trocar/Veress needle injury
Hemorrhage
Wound infection and/or abscess
Ileus
Bile leak
Gallstone spillage
Deep vein thrombosis
Retained common bile duct (CBD) stone
CBD injury & stricture
Pancreatitis
Conversion to open procedure
36. Nonsurgical treatment:
• Only in special situations
When a patient has a serious medical condition preventing
surgery
Only for cholesterol stones
• Oral dissolution therapy
Ursodeoxycholic acid - to dissolve cholesterol gallstones
Months or years of treatment may be necessary before all stones
dissolve
• Contact dissolution therapy
Experimental procedure
Involves injecting a drug directly into the gallbladder to dissolve
cholesterol stones
37. Prevention
A sensible diet is the best way to prevent gall stones
Avoid crash diet or very low intake of calories
Eat good sources of fiber