Lecture on the spectrum of gallstone diseases for medical students. Encompasses basic sciences, classifications, principles of management.

1. Gallstone diseases
Chea Chan Hooi
Surgeon
Department of Surgery
Sibu Hospital

2. Content
• Introduction
• Pathophysiology
• Types of gallstone
• Spectrum of disease
– Asymptomatic
– Symptomatic (biliary colic)
– Complicated
• Q&A

3. Introduction
• 20% population
• 20% symptomatic
– 2 – 4% develop symptoms/complications
• 20% radiopaque

4. Differential diagnoses?

5. Pathophysiology
• Physical factors
– Bile stasis, impaired gallbladder motility due to
biliary tree stricture, external compression or
reduced motility form high estrogen level (Fertile,
Female, Forty)
• Chemical factors
– Disturbance in cholesterol metabolism (Fat),
haemolytic diseases (Fair) & recurrent infections

6. Types of gallstone
Cholesterol stones
• 75%
• Supersaturation of
cholesterol, decreased
lecithin or bile salts
predisposes to cholesterol
crystallisation
• Admirand’s triangle
Pigment stones
• 20%
• Crystallisation of calcium
bilirubinate
• 2 types
• Black pigment
– Hemolysis or liver cirrhosis
impairing haemoglobin
metabolism leading to excess
unconjugated bilirubin
• Brown pigment
– Infective
– Bacteria hydrolyse conjugated
to unconjugated bilirubin (β-
glucuronidase)

8. Asymptomatic gallstone
• Indications for surgery
– Gallstones >2cm
• High risk of cystic duct obstruction
– Porcelain gallbladder
• 25% malignancy rate
• Esp. patchy calcifications
– Gallstone associated with gallbladder polyp
• Continued chronic irritation on the polyp predisposes it to
malignant transformation
– Underlying sickle cell anaemia
• Distinction of acute cholecystitis from sickle crisis is difficult
– Undergoing bariatric surgery

10. Biliary colic
• RHC/Epigastric pain
• After meals, esp. oily food
• Relieves spontaneously after a few hours
• CCK
• Transient obstruction of cystic duct opening by
stone or pedunculated polyp
• USG
• OGDS TRO PUD/GERD
• Amylase, diatase

11. Complicated gallstone diseases
Acute
• Infective
– Acute cholecystitis
– Ascending cholangitis
– Gallbladder empyema
• Non-infective
– Mucocele
– Gallstone pancreatitis
Chronic
• Infective
– Liver abscess
• Non-infective
– Chronic cholecystitis
– Mirizzi syndrome
– Gallstone ileus
– Gallbladder carcinoma

12. Acute cholecystitis
• Acute inflammation of gallbladder due to cystic duct
obstruction
• Pathophysiology?
• Diagnostic criteria (2/3 to suspect)
– Local signs of inflammation
• RUQ pain/tenderness
• Murphy’s sign positive
– Systemic signs of inflammation
• Fever
• Elevated CRP or TWC
– Characteristic imaging findings
• Emphysematous cholecystitis

13. Characteristic ultrasonographic
findings
• Sludge
• Cholelithiasis
• Gallbladder wall
thickened (>4mm)
• Pericholecystic fluid
• Sonographic Murphy’s
sign

14. Management
• Resuscitation
• Empirical antibiotics
• Analgesics
• Laparoscopic cholecystectomy
– Early
• Within 72 hours of onset (4% conversion)
• Technically more demanding – thickened wall, difficult to grasp,
dissect, unclear Calot’s triangle
– Interval
• Six weeks later after inflammation has subsided
• Theoretical reduction in morbidity & conversion rate
• Increased overall hospital stay

17. Chronic cholecystitis

18. Mirizzi syndrome
• CHD obstruction caused by an extrinsic
compression from an impacted stone in the
cystic duct or Hartmann's pouch of the
gallbladder

19. Investigations
• USG
– Usually show gallstones and contracted GB
– Features suggestive of Mirrizi’s
• Dilatation of the biliary system above level of GB neck
• Stone impacted in GB neck
• An abrupt change to normal width of the common duct below the stone level
• ERCP
– To assess for
• Obstruction of CHD
• Impacted stone in GB neck or CD
• Stone size
• Bilio-biliary fistulas from proximal dilated biliary channels into gallbladder
• Duodenal, pancreatic, or ampullary pathology
• Features of malignancy
• CT scan + MRCP
– Does not significantly add to sonographic findings reg stone and biliary
obstruction
– Only helpful in ascertaining malignancy

20. Csendes classification

21. Management
Type Surgical treatment
I Partial or total cholecystectomy (open still the standard)
CBD exploration typically not required
II Cholecystectomy
+
Closure of fistula (suture repair, T tube placement thru fistula or
choledochoplasty with the remnant gallbladder)
III Cholecystectomy
+
Choledochoplasty (higher leak rate)
or
Bilioenteric anastomosis (choledochoduodenostomy, cholecystoduodenostomy,
or choledochojejunostomy), depending on size of fistula
Suture of fistula not indicated
IV Bilioenteric anastomosis, typically choledochojejunostomy
As the entire wall of CBD has been destroyed
V Bilioenteric anastomosis
Check entire GI tract & remove any escaped stones

22. Gallstone ileus
• Important but infrequent
• Elderly patients who often have significant co-
morbids
• Complicates <0.5% of gallstones, causes 5% of
mechanical I/O
• Biliary-enteric fistula
– Cholecysto-duodenal 60%
– Cholecysto-colonic
– Choledochocysto-enteric
– Cholecysto-gastric (Bouveret syndrome)
• Impacted at pylorus & causes GOO

23. • Tumbling obstruction
– Transient gallstone impaction  abdominal pain and
vomiting
– Subside as stone disimpacted, only to recur as the stone
lodges in more distally
– Vague and intermittent symptoms may be present for
some days prior to evaluation
• Common sites of impaction
– Ileum (the narrowest diameter of GIT): 50 – 70%
– Jejunum
– Stomach
– Colon (underlying constricting pathology)

24. • AXR
– Signs of intestinal obstruction
– Aerobilia
– Change in position of a previously located stone
– Two adjacent small bowel air-fluid levels in the
right upper quadrant
• Diagnosis is still frequently made on table

26. • Resuscitation
• Empirical antibiotic
• Analgesics
• Surgery
– One stage
• Enterotomy proximal to impaction site + cholecystectomy,
fistula division ± CBD exploration in single sitting
– Two stage
• Enterotomy proximal to impaction site or bowel resection
• Definitive biliary procedure later once patient recovered
– The need is now questioned  low rates of recurrent gallstone
ileus (5%) and cholecystitis (15%)

28. Gallbladder mucocele & empyema
• Pathophysiology
– Obstruction to gallbladder outflow
– Bile stagnated and collected GB
– GB wall distended
– Venous congestion leading to arterial compromise (end
artery)
– Subclinical ischaemia
– Mucosal barrier breakdown
– Bacterial translocation  superimposed infection of
stagnated bile
– Purulent material fills up the GB (empyema)
– Perforation (free or localised)

29. • Clinical features to acute cholecystitis
• BUT
– Septic
– High spiking fever
– Palpable, enlarged, tender gallbladder
• Ultrasonography
– Features of cholecystitis + echogenic content
within the gallbladder lumen

30. Management
• Resuscitation
• Empirical antibiotics
• Analgesics
• Intervention
– Surgery
• Cholecystectomy (laparoscopic or open)
• Subtotal if severe edema and adhesions
• Laparoscopic approach feasible in the hands of expert laparoscopic surgeons but
associated with higher conversion to open cholecystectomy rate
– Radiological decompression
• Transhepatic cholecystostomy
• Temporising measure for patients who are haemodynamically unstable with excessively
GA high risk
– Endoscopic decompression
• ERCP with trans-cystic biliary drainage (stent or nasobiliary tube)
• Only when neither cholecystostomy nor cholecystectomy can be performed
• Inferior option and seldom performed

34. Choledocholithiasis
• Presence of stone within main biliary outflow
tract
• Primary vs. secondary
• Clinical features
– Uncomplicated
• Obstructive jaundice
– Intermittent jaundice – due to floating stones (ball valve effect)
– Complicated
• Ascending cholangitis
• Gallstone pancreatitis

35. • Biochemistry
– LFT increase DB, GGT, ALP
– UFEME increased urobilinogen
• Ultrasonography
– Dilated biliary tree (IHDs > 4mm, CBD >7mm)
– Cholelithiasis
– Distal CBD usually obscured by bowel gas
– Complications – liver abscess, ectatic CBD
• Endoscopic ultrasonography
– Used in diagnostic dilemma (e.g. abnormal LFT with
normal CBD on USG)
– Can detect microlithiasis, distal CBD stones

36. • ERCP
– Both diagnostic and
therapeutic
– Invasive
– Radiation

38. Intervention
Elective
• Diagnosed pre-op
– 2 stage
• ERCP followed by LC
– 1 stage
• LC with lap CBD exploration
• Open cholecystectomy with
CBD exploration
• Diagnosed intra-op
– CBD exploration (lap or open)
– On table ERCP
– Post-op ERCP
• Diagnosed post-op
– ERCP
Emergency
• Ascending cholangitis
• Severe gallstone
pancreatitis
• ERCP
– Sphincterotomy & stenting
– To decompress biliary tree

40. Ascending cholangitis
• Pathphysiology
– Elevated intra-ductal pressure due to biliary obstruction
– Bacterial translocation into the bile duct and forward into
lympathic & venous systems
• Clinical features
– Charcot’s triad
• Fever, RUQ abdominal pain & jaundice
• Only 60 – 70% patients
– Reynaud’s pentad
• CT + hypotension + altered mental state (septic shock)
• Mortality rate
– Mild 0.5%
– Severe 22%

41. Etiology

42. Diagnosis
• Signs of systemic inflammation
– Fever ± chills & rigors
– Elevated CRP or TWC
• Signs of cholestasis
– Jaundice
– Abnormal LFT
• Imaging signs
– Biliary tree dilatation
– Evidence of etiology (stone, stricture, stent)
• Assign severity
– Mild
– Severe (organ dysfunction)

43. Management
• Resuscitation
• Empirical broad spectrum antibiotics
• Analgesics
• Options of biliary drainage
– Endoscopic
• ERCP
• Least invasive
• Sphincterotomy, stent or nasobiliary tube
– Percutaneous
• PTBD
• Indications
– Inaccessible papilla d/t altered GI anatomy
– No skilled endoscopist available
– Failure of conventional endoscopic drainage
– Surgical
• Obsolete if etiology is stone d/t high morbidity & mortality
• Reserved for advanced malignant cases requiring concurrent biliary-enteric bypass

46. Gallstone pancreatitis
• Initial management is as per acute pancreatitis of other
causes
• Interventions
• ERCP
– Indications
» Gallstone pancreatitis with cholangitis
» Severe pancreatitis with biliary obstruction
– Within 72 hours of diagnosis
• Laparoscopic cholecystectomy
– Index
» Within the same admission once patient recovers from pancreatitis
» The standard management nowadays
– Interval
» Postpone by 6 weeks to minimise morbidity & conversion rate
» 20 – 30% risk of recurrent gallstone pancreatitis while waiting

47. TQ!
Q&A?