Gallstones Causes and Management -Dr Kedar Patil Pune

Dr Kedar Patil
D.N.B-Gen. Surgery, F.N.B-Minimal Access Surgery,
Fellow Bariatric and Metabolic Surgery -Taiwan,
Fellow G.I Oncosurgery, Tata Memorial Hospital, Mumbai
Bariatric and Metabolic, G.I Onco surgeon and Advanced Laparoscopic Surgeon
Poona Hospital ,Bharati Hospital Pune and Sangli
8888655455,presizeclinic@gmail.com,www.lifedocsindia.com

Bile Contents
 Bile Pigments
 Bile Salts –Cholic and Chenodexoycholic acid
 Phospholipids and Cholesterol –Serves absorption of
dietary lipids and avoids toxic effect of bile on
hepatocytes
 Bilirubin –End products of globin and myoglobin
excreted with bile salts
presizeclinic@gmail.com. 8888655455,www.lifedocsindia.com

Physiology of bile
 Bile fills in Gall bladder
retrograde method due
to Sphicter Of Oddi
 CCK and Vagi influence
on Sphicter Of Oddi
presizeclinic@gmail.com.
8888655455,www.lifedocsindia.com

Enterohepatic Circulation
presizeclinic@gmail.com. 8888655455,www.lifedocsindia.com

Pathogenesis of Gallstone
formation
 Supersaturation of Secreted Bile
 Concentration of bile in GB
 Crystal nucleation
 Gallbladder dysmotility

Types Of Stones
 Pigment Stones – Black or brown
 Black-Hemoglobinopathies or cirrhosis,usually in bile
duct and GB
 Brown –Bacterial infections and motility disorders
,Found anywhere
 Pure Chlolesterol stones (10%)-Yellow

Natural history of Stones
 Asymptomatic –When free floating in GB
 Symptomatic –When obstructs a Cystic Duct or passes
in CBD
 20-30% Asymptomatic stone patient develop
symptoms

Factors affecting Gallstone
formation
Gall stone Promoting Gallstone Preventing
 Higher Cholesterol and Lipid
 Increased Hemoglobin
processing –
hemoglobinopathies
 Fasting ,Burns TPN
 Glycoproteins and Ig-
Pronucleating agents
 Gall bladder dysmotility
 Bile salts
 CCK

Clinical features
 Biliary Colic –Misnomer ,since it’s a constant pain in
right upper quadrant or epigastrium
 Due to incomplete emptying of G.B
 Pain –associated with food in epigastrium
 Fever –Systemic response to inflammation
 Jaundice – 2.5 gm/dl Scleral Icterus ,5 gm/dl- Skin
manifestation
 Pain ,Fever and jaundice –Charcots triad
 Pain ,Fever,Jaundice,Hypotension and Altered
mentation –Reynolds Pentad (Indicates sepsis)

Clinical Features
 Acute Cholecystitis –Pain >24 hours .May progress to
gangrene
 ‘Murphys sign’- Tenderness in right upper quadrant
 Jaundice –Seen in cases of choledocholithiasis or
Mirrizzis Syndrome .
 Most common presentation is ‘Dyspepsia’-belching or
bloating after food or discomfort

Investigations
 LFTs – Raised Direct S.Bilirubin and Alkaline
Phosphatase indicate an Obstructive Pattern
 S.Amylase and S.Lipase- Raised in Gallstone
pancreatitis
 Ultrasound - Sensitive than CT for gallstones .
 Gallstones,CBD Stones,CBD Diameter,Wall thickening
of G.B,Pericholecystic fluid etc can be known

Investigations-USG Showing Stone in neck
of GB

Investigations
 CT Abdomen –when malignancy is suspected or to
rule out CBD calculi
 Evaluation of CBD Injury and collections
 MRCP- Most sensitive for biliary pathologies
 HIDA Scan – Biliary excretion and level of leak or
obstruction,useful in biliary dyskinesia
 ERCP- Diagnostic-for strictures
 Therapeutic ERCP for stones / malignant obstruction

MRCP for Biliary tract

Investigations
 PTC-Percutanpercutaneous transhepatic
cholangiography (PTC) is an invasive procedure used
to evaluate the biliary tree. Useful for patients with
intrahepatic biliary disease or in whom ERCP is not
technically feasible, PTC can decompress biliary
obstruction, stent obstructions nonoperatively, and
provide anatomic information for biliary
reconstruction.

Other Modalities Of Investigation
 Endoscopic Ultrasound (EUS )-Biliary strictures and
malignancy ,Sludge
 Intraoperaative Cholangiogram –For
Choledocholithiasis ,Injury , Anatomy Unclear
 PET Scan –Malignancy suspected

Management
 Medical –Not much role except UDCA -300 mg twice
daily for 6 months ,review with USG.Only
recommended in high risk and asympromatic
individuals
 Surgical –Laparoscopic Cholecystectomy is the Gold
standard

Laparoscopic Cholecystectomy
 Who require it –Symptoms of Gallstones-Bloating
,Dyspepsia
 High risk individuals even if asymptomatic –
Hemolytic anemia/Sickle cell anemia
 Porcelian gall bladder
 Large stones >2.5 cm
 Few Bariatric Surgeries and transplant surgeries

Laparoscopic Cholecystectomy
 One of the most common surgery done worldwide
 Erich Muhe from Germany performed first
Laparoscopic Cholecystectomy in 1982
 1-3% Complication rate in acute setting
 Subtotal Cholecystectomy or Cholecystostomy
(Draining the Gall bladder ) alternatives in high risk
individuals
 In Acute Cholecystitis – Operated within first 7 days or
delayed upto 6 weeks to prevent CBD Injury

Complications of Gallstones
 Acute Cholecystitis and its sequale
Gangrene,Emphysematous
 Gallstone Pancreatitis
 Gallstone Ileus –Passing into small bowel through
duodenal fistula
 Obstructive Jaundice
 GB Malignancy –Porcelian GB and stones >3cms has
greater risk

Choledocholithiasis
 Means –Stones in the CBD
 Primary –Brown stones ; associated with infection
 Secondary –Black –retained or migrated from GB
 Can cause Pancreatitis as well
 Specific Investigations-S.Biirubin ,S.Alkaline
Phosphate ,ERCP,MRCP

Choledocholithiasis
 Treatment – ERCP /Lap
or Open CBD
Exploration with
Cholecystsectomy

Thanks for your Patient listening !
www.presizeclinic@gmail.com
8888655455

Gallstones Causes and Management -Dr Kedar Patil Pune

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