1) Gallbladder stones, or cholelithiasis, affect up to 20% of populations in developed countries. Risk factors include age, diet, rapid weight loss, certain drugs, obesity, and diseases of the liver and bile ducts. 2) Gallbladder stones are usually diagnosed using abdominal ultrasound, while MRCP or EUS may be used if ultrasound is negative but clinical suspicion remains high. Complications include cholecystitis, pancreatitis, cholangitis, and fistula formation. 3) Treatment of gallbladder stones is typically laparoscopic cholecystectomy for symptomatic stones. Medical dissolution therapy is not usually recommended. For bile duct stones, endoscopic sphincterotomy and

1. A tale Of Biliary lithiasis
DR Md kamal uddin Sohel
MD(Medicine)
MACP(USA)
MO. Gastroenterology Deptt.

2. An echo from the past
RadioGraphics 2009; 29:1191–1194

3. Epidemiology
• Gallstones are a major public health problem in Europe & other
developed countries & affect up to 20% of population.
Gut and Liver, Vol:6,(2),April 2012, p. 172-187

4. Burden
“Hindustan Times” Tuesday, Apr 12, 2022

5. Remits of today’s talk
 Dx, medical & surgical Mx & prevention of GB stones
 Dx, Endoscopic & surgical Mx of bile duct stones
 Dx & therapy of intrahepatic stones

6. Gallstone types
Basis chemical composition & macroscopic appearance:
• Cholesterol stone(majority)
• Pigment stone
• Rare stone
 Cholesterol & black pigment stones: nearly always formed in
GB
 Brown pigment stones: primarily in main BD.

7. By location

8. RISK FACTORS
• Age & gender
• Diet
• Pregnancy & parity
• Rapid weight loss
• TNP
• Biliary sludge
• Drugs: Estrogen, clofibrate ,
octreotide, ceftriaxone
• Lipid abnormalities(TG)
• Obesity(>45 kg/m2)
• DM
• Diseases of ileum
• Spinal cord injury
• Cirrhosis of liver(CTP-c &
alcoholic)

9. Pathophysiology
• Venn diagram
Image courtesy: Sleisenger 10thedition,p;1109

10. Dx of GB stones
• 80% of carriers are asymptomatic.
• Symptoms develop with a rate of 1–4%/yr, 20% becoming
symptomatic within 20 yrs of Dx .
• Complications occur with a rate of 1–3%/yr after 1st colic
episode & 0.1–0.3% in asymptomatic pts.
J Hepatol,Vol:xxx,March 2016 p:1-20

11. Cont….

12. Complications Of GB stone
• Acute or chronic Cholecystitis
• Biliary pancreatitis
• Cholangitis
• Emphysematous cholecystitis
• Cholecysto-enteric fistula
• Mirrizzi’s syndrome
• Porcelain GB
Sleisenger & Fordtran's gastrointestinal and liver disease: 10th edition

13. When & what Investigation?
 Pt with recent H/O biliary pain, abdominal USG should be
performed.
 With strong clinical suspicion of GB stones & -ve abdominal
USG, EUS / MRCP may be performed.
 No role of lab test except complcation – cholangitis,
pancreatitis, cholecystitis.
J Hepatol,Vol:xxx,March 2016 p:1-20

14. Imaging

15. Acute cholecystitis
Suspected in pt with fever, severe pain in RUQ lasting for several
hrs & RUQ tenderness on palpation (Murphy’s sign).
• Investigation
 WBC count
 CRP
 USG (distended GB, thickened (>4 mm) GB wall,
pericholecystic fluid & a sonographic Murphy’s sign)
 CT scan (GB wall emphysema, abscess formation &
perforation)
 Radioisotope cholescintigraphy (Tc-HIDA scan)

16. Cont…………..

17. Cont….

18. Medical therapy of GB stones
Bile acid dissolution therapy :
Litholysis using bile acids alone /combination with ESWL : not
recommended for GB stones.
Although meta-analysis of studies on litholysis using UDCA showed
success in stones Of
 small(<10 mm)
 non-calcified
 functioning GB
** (63% of pts free from stones after > 6 mons).
J Hepatol,Vol:xxx,March 2016 p:1-20

19. Surgical therapy Of GB stones

20. Surgical therapy of GB stones
• Symptomatic GB stones: Cholecystectomy - Preferred
option.
• Approximately 1/2 of pts with symptomatic stone have
recurring colic.
• Risk of complications such as acute cholecystitis, biliary
pancreatitis, obstructive jaundice & cholangitis is 0.5–3%/yr.
J Hepatol,Vol:xxx, March 2016 p:1-20

21. Asymptomatic GB stones
• Routine Rx is not recommended.
• Reassured that life-threatening complications are
uncommon.
• Symptom related to stone develop only minority of pts.
• Most pts in whom complications of gallstone develop have
antecedent biliary pain.

22. Cont.
• Exception (Cholecystectomy needed)
 Asymptomatic porcelain GB
 GB polyps ≥1 cm without or with
GB stones regardless of their symptoms
 Asymptomatic pts with PSC & GB polyps irrespective of size
J Hepatol,Vol:xxx,March 2016 pp:1-20

23. • Cholecysyectomy in asymptomatic GB stone:
• Large stone > 2cm
• Non-functional GB
• Porcelin GB
• Pt with spinal cord inj./sensory neuropathy
affecting abdomen
• Pt with sickle cell anaemia
• Pt with medically complicated disese
(Cirrhosis,Portal HTN,) Harrison

24. Some recommedation of surgery
 Cholecystectomy : not recommended for asymptomatic stones
during abdominal surgery.
 Early phase after heart/lung transplantation with
symptomatic GB stones, cholecystectomy should be deferred.
 Cholecystectomy in asymptomatic gallstones:
• Hereditary spherocytosis & sickle cell disease during
splenectomy.
• During abdominal surgery for other reasons in sickle cell
disease to avoid diagnostic uncertainty in case of sickle cell
crises.
J Hepatol,Vol:xxx,March 2016 p:1-20

25. GB stone in pregnancy
• Lap chole can perform in any trimester.
• Asymptomatic GB & bile duct stones who are asymptomatic
after bile duct clearance should undergo cholecystectomy post
partum.
• Better in 2nd trimester : 3rd trimester better to avoid due to
abdominal crowding.
J Hepatol,Vol:xxx,March 2016 p:1-20

26. Type of cholecystectomy

27. Type of cholecystectomy
• Laparoscopic cholecystectomy : Standard method for
symptomatic GB stones (even with CTP- A & B liver
cirrhosis).
• Open cholecystestomy
 Strong suspicion of (advanced) GB carcinoma.
 Mirizzi II (fistula betw GM & hepatic duct)
 Gallstone ileus
J Hepatol,Vol:xxx,March 2016 p:1-20

28. Future : Man- machine symbiosis

30. Timing of cholecystectomy
• As early as possible for uncomplicated biliary Colic.
• Early lap chole (preferably within 72 hrs of admission) should be
done in acute cholecystitis.
• Simultaneous GB & bile duct stones : ERCP followed by Early
lap chole (within 72 hrs).
• Elderly with high anaesthetic risk with complications (acute
cholecystitis, gallstone pancreatitis/obstructive jaundice) lap chole
done as soon as general status allows surgery.
J Hepatol,Vol:xxx,March 2016 p:1-20

31. “It's so much easier to suggest
solutions when you don't know too
much about the problem.” ― Malcolm
Forbes.

32. Post-cholecystectomy syndrome (PCS)
Extra-biliary disorder:
 Reflux oesophagitis,
 peptic ulceration,
 IBS
 Chronic pancreatitis.
Biliary aetiologies :
• Biliary strictures/leakage
• Retained calculi
• Dropped calculi
• Chronic biloma/abscess
• Long cystic duct remnant
• SOD
• Bile salt-induced
diarrhea/gastritis
*For evaluation: EUS,MRCP
Jaunoo S et al. Inter J of surgery. 2010
Jan 1;8(1):15-7.

33. GB sludge
• Mixture of particulate solids that have precipitated from bile
consists of cholesterol crystals, Ca bilirubinate pigment & other Ca
salts.
• Resolve spontaneously: 50% , Stone develops: 5-15% cases.
Shaffer EA et al.Current gastroenterology reports. 2001 Mar;3(2):166-73.

34. Cont……
Shaffer EA et al.Current gastroenterology reports. 2001 Mar;3(2):166-73.

35. Prevention of GB stone
• Primary prevention
• Lifestyle: Healthy food, regular physical activity & ideal body wt
prevent cholesterol GB stones.
• Physical activity:70% decreased risk of symptomatic GB stones in
both sexes. Effect is seen after 5yrs.
• Diet:
• High fiber & calcium diets.Fruits ,Vegetables & vegetable oils,
• Vit C, Poly- & monounsaturated fats &
• Nut consumption
• ?? Controversial: Caffeine, alcohol,Statin,Ezetimide
J Hepatol,Vol:xxx,March 2016 p:1-20

36. Primary prevention of GB stones in
high risk groups
• Rapid wt loss temporary UDCA may be recommended until body wt
has stabilized.
• Prophylactic cholecytectomy not routinely indicated during
bariatric surgery.
• Long-term somatostatin/analogues, concomitant UDCA can
consider to prevent cholesterol stone.
• No indication for pharmacological/surgical stone prevention during
HRT, TPN & Prevention of recurrent bile duct stones.
J Hepatol,Vol:xxx,March 2016 p:1-20

37. GB Polyp
Foley KG et al. Mx & F/U of gallbladder polyps: updated joint guidelines between ESGAR,
EAES, EFISDS & ESGE. European radiology. 2021 Dec 17:1-1.

38. Cont…..
Indn of Cholecystectomy:
>1 cm
6-9 mm polyp with 1 of following risk of Mg-:
 Age> 60
 PSC
 Asian
 Sessile polypoid lesion with focal GB wall thickening > 4mm.
6-9 mm /< 5 mm without risk of Mg:
 F/U USG- 6 mons, 1 yr & 2 yrly
 Discontinue F/U > 2 yrs in absence of growth.
Foley KG et al. Mx & F/U of gallbladder polyps: updated joint guidelines between ESGAR,
EAES, EFISDS & ESGE. European radiology. 2021 Dec 17:1-1.

39. Dx of bile duct stones
• Like GB, stones in BD may remain asymptomatic for yrs.
• 3-10%% of pts with GB stones also have bile duct stone.
• Conversely 95% with BD stone have GB stones.
Common presentation:
 Biliary colic
 Ascending cholangitis
 Obstructive jaundice
 Acute biliary pancreatitis
CBD stones should search for pts with jaundice, acute
cholangitis/acute pancreatitis

40. Cont.
Laboratory Dx & imaging
 Abdominal US (CBD sometimes not dilated)
 EUS (< 5mm stone can detected)
 MRCP
 Liver biochemical test
 ERCP- If concomitant endoscopic therapy is envisaged (high SEN)
** LFTs & Abdominal US – as initial steps (ESGE, Endoscopy,2019)

41. CBD stone images

42. Mx of BD stones
Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy
(ESGE) guideline. Endoscopy. 2019 May;51(05):472-91.

43. Rx of BD stones without
Complications
 Choledocholithiasis warrants Rx in nearly all cases.
 Endoscopic sphincterotomy & stone extraction : Recommended Rx
of bile duct stones.
 Balloon & basket catheters : equally effective & safe for CBDs.
 Temporary biliary plastic stent in irretrievable stones.
 Plastic stent should be removed/ exchanged within 3 – 6 mons to
avoid infectious complications.
ESGE guideline. Endoscopy. 2019 May;51(05):472-91.

44. Cont…
• Intra-operative ERCP / laparoscopic bile duct exploration
with cholecystectomy : alternatives if adequate expertise
available
• Laparoscopic cholecystectomy within 2 wks from ERCP.
• Percutaneous stone extraction with acute cholangitis : ERCP
is not feasible/ successful within recommended timeframes.
• ERCP : Safe & effective in pregnancy

45. ERCP stone extraction
Courtesy: Dr Royes Uddin ,
Gastroenterolgy dptt.SSMC Mitford Hospital

46. Cont.
 Failed standard stone extraction ESWL, electrohydraulic or
laser lithotripsy may perform.
 In altered anatomy (e.g. previous Roux-en-Y anastomosis,
bariatric surgery) percutaneous or endoscopic (balloon
endoscopy-assisted) Rx of bile duct stones can consider.

47. ESWL by lithotripsy basket

48. Cholangioscope assisted ESWL

49. Altered anatomy ERCP

50. Cont.
 Failed endoscopic therapy : cholecystectomy combined with
BD exploration /intraoperative ERCP(Rendezvous) should
perform.
 Intraoperative detection of BD stones : bile duct
exploration& transcystic stone extraction/ endoscopic
clearance represent alternative Rx options.
 In postoperative Dx of BD stones, endoscopic sphincterotomy
& stone extraction are recommended.
 Simultaneous GB & BD stones : ERCP followed by early lap
chole ( within 72 hrs).

51. Rx of acute cholangitis
 Immediate broad spectrum antibiotics
 Biliary decompression within 24 hrs.
Endoscopic Rx with sphincterotomy - preferred mode. Or
Biliary stenting with stone removal
If failed - percutaneous bile duct drainage is choice.

52. Rx of acute biliary pancreatitis
• Biliary pancreatitis with suspected coexistent acute
cholangitis antibiotics should be initiated & ERCP with
sphincterotomy and stone extraction should perform with
timing depends on the severity of cholangitis, better within
24 hr.
• Early ERCP not recommeded in absence of
Cholangitis
Obstructed bile duct

53. Cont.
 Suspected biliary pancreatitis without cholangitis,
EUS
or
MRCP may prevent potential ERCP & its risks.
 Cholecystectomy during the same hospital admission is the
preferred option in mild acute biliary pancreatitis.

54. Dx & Rx of intrahepatic BD stones
Hepatolithiasis typically occur in
 Bile duct strictures & after bile duct injury
 primary /secondary sclerosing cholangitis
 recurrent pyogenic cholangitis
Ix:
Abdominal US-1st choice
MRCP - 2nd
J Hepatol,Vol:xxx,March 2016 p:1-20

55. Cont….

56. Cont.
Rx options:
Asymptomatic intra-hepatic BD stones do not always need to treat.
 Partial hepatectomy (unilateral disease,biliary stricture &lobar
atrophy )
 Peroral cholangioscopic lithotripsy (POCSL) or
 Percutaneous transhepatic cholangioscopic
Lithotripsy (PTCSL)
# Rx decision should made individually for each pt & inter-
disciplinarily for symptomatic intrahepatic BD stones.
J Hepatol,Vol:xxx,March 2016 p:1-20