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Gallstones cholelithiasis, gall bladder .ppt
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- 2. Objectives • Basic biliaryanatomy and physiology • Pathophysiology of gallstone disease • Clinical manifestations of gallstone disease • Complications of gallstone disease • Investigation and management of gallstone disease
- 3. Gallbladder Surface Anatomy •Lies in the right upper quadrant, under the costal margin at the level of the 9th costal cartilage • The level of the 9th costal cartilage can be palpated as a distinct notch
- 10. Gallstones • Common (20%population) • Cholesterol stones in West • Female proponderance (3/1) • Risk factors – Obesity – Oestrogen – Hypercholesterolaemia – Increasing age – 5 F’s
- 11. Clinical Manifestations • Asymptomatic •Cholecystitis • Biliary colic • Complications – Jaundice – Pancreatitis – Cholangitis – Gallstone ileus – Carcinoma of gallbladder
- 12. Acute Cholecystitis • Acuteinflammation of the gallbladder • Usually associated with calculi (stones) – Calculus causes obstruction at Hartmann's pouch or cystic duct • Less commonly with biliary sludge • A-calculus (no-stone) cholecystitis rare • Bacterial infection in 50% only • Recurrent attacks result in fibrosed thickened gallbladder (chronic cholecystitis)
- 13. Acute Cholecystitis ClinicalFeatures Pain • Sudden onset • Post-prandial • RUQ—around to back • Constant • Associated nausea and vomiting • May last several hours to days • Recurrent attacks common
- 14. Acute Cholecystitis Signs • Pyrexia(37.5-38.5) • Associated jaundice signifies CBD blockage – CBD stone or Mirrizi’s Syndrome • Abdominal tenderness localized to RUQ • Murphys’ sign positive
- 15. Murphys’ Sign • Inspiratoryarrest with manual pressure below the gallbladder
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- 17. Biliary Colic • Painassociated with passage of stone • Usually not colicky but constant (a misnomer) • As cholecystitis but not not associated with fever/ leucocytosis and positive Murphys’ sign • Usually resolves after minutes- few hours
- 18. Complications • Empyema/ mucocele •Obstructive jaundice • Ascending cholangitis • Pancreatitis
- 19. Charcots’ Triad- Ascendingcholangitis 1. Pain 2. Fever 3. Jaundice
- 20. Courvoisiers’ Law In thepresence of jaundice a palpable gallbladder is most likely due to malignant obstruction of the bile duct • Based on presumption that patients with gallstones have chronically inflammed, fibrosed gallbladders incapable of distension • Does not always hold true e.g. – Empyema + CBD stone
- 21. Acute Cholecystitis -Investigation • Bloods – FBC (WCC) – LFT’s (Bilirubin, GGT, Alk Phos) – Amylase • Imaging – CXR – Ultrasound – CT • Special tests
- 22. Acute Cholcystitis –Special tests • Endoscopic Retrograde Cholecystogram (ERCP) – Diagnostic and therapeutic • Magnetic Resonance Imaging (MRC) • Other forms of Cholangiography – Intra-operative – Percutaneous Transhepatic (PTC) – Oral cholangiogram
- 23. Acute Cholecystitis –Management • Restrict Oral intake (NPO) – Intravenous fluids – Ng tube aspiration (for vomiting) • Analgesia – Morphine • Intravenous antibiotics – Gram negative cover (co-amoxiclav—gentamicin—piperacillin) • Cholecystectomy after resolution
- 24. Biliary Colic -Management • Acute attack usually resolves spontaneously • Analgesia • Investigations as for cholecystitis • Prolonged attacks treated as cholecystitis • Elective cholecystectomy
- 25. Ascending Cholangitis • Charcots’Triad • Investigations – FBC, LFT's, Amylase, US • Management – Resuscitation (IV fluids) – Antibiotics (G-negative cover) – Intensive monitoring (urometry)
- 26. Ascending Cholangitis • Definitivemanagement – ERCP and stone removal +/- stent – Cholecystectomy after resolution
- 27. Gallstone Pancreatitis • Commonestcause of Pancreatitis • More severe than alcohol Pancreatitis • Due to CBD stones irritating pancreas – Obstruction at ampulla of Vater – Irritation in pancreatic portion of CBD
- 28. Gallstone Pancreatitis • Supportive –Fluid resuscitation – Antibiotics – Analgesia • Definitive – ERCP & stone retrieval – Elective cholecystectomy
- 29. Laparoscopic Cholecystectomy • Commonestelective surgical procedure • Standard treatment for gallstone disease • May be performed as daycase • Converted to open in small number
- 30. Complications • Trauma • Commonbile duct (CBD) • Intestine • Liver • Haemorrhage • Vessel injury • Liver injury • Cystic artery clips • Infection • Biliary peritonitis
- 31. Late Complications • Postcholecystectomy syndrome – Rare – Pain – Occasionally due to stones in the biliary tree • Port site hernia – Umbilical – 10mm port sites
- 32. ERCP Endoscopic Retrograde CholangioPancreato Graphy • Usually performed by gastroenterologists • Diagnostic and therapeutic • Indicated in jaundiced patients • Ampulla of Vater cannulated • Demonstrates ductal anatomy • Allows biopsy of malignant lesions • Therapeutic in relieving obstruction – Stone retrieval or Stenting
- 34. Summary • Gallstones arecommon • Usually asymptomatic • Clinical manifestations – Cholecystitis – Biliary colic • Complications – Ascending cholangitis (Charcots' Triad) • Treatment – Laparoscopic cholecystectomy – ERCP