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- 1. Stones and Sludge Johnathan Righetti
- 5. Main Pathologies ● Cholelithiasis ● Biliary Colic ● Acute Cholecystitis ● Choledocolithiasis ● Gallstone Pancreatitis ● Cholangitis ● Malignancy ○ Cholangio, IPMN, ■ adeno
- 6. Overview of the Problem ● One of Most Common, Most Costly Digestive Diseases in America ● ~6 billion health care dollars, annually ● 1 million new cases annually ● 700,000 cholecystectomies performed Asymptomatic Stones ● Annual risk of 1% for biliary colic ● 0.3% acute cholecystitis, 0.2% for symptomatic choledocholithiasis, and 0.4%-1.5% for gallstone pancreatitis.
- 7. Stone Formation ● Cholesterol ○ Bile Supersaturation with Cholesterol ○ Nucleation of cholesterol monohydrate with subsequent crystal retention and stone growth ○ Abnormal gallbladder motor function with delayed emptying and stasis ● Pigment Stones ○ Caused by presence of unconjugated, insoluble bilirubin in bile ○ More common in chronic hemolytic states, Liver Cirrhosis, Gilbert’s syndrome, Cystic Fibrosis, Ileal Resection or ileal bypass
- 8. Risk Factors For Stones ● Non-Modifiable ○ Increasing Age ○ Female Gender ○ Ethnicity (Central Americans, particularly those of Chilean ancestry) ● Modifiable ○ Pregnancy or Parity ○ Obesity or Rapid Weight Loss >1.5 kg/week ○ Fasting ○ OCPs
- 9. Board Fodder ● Murphy’s Sign ○ Inspiratory arrest with deep palpation ● Charcot’s Triad ○ RUQ Pain, Fever, Jaundice ● Reynold’s Pentad ○ Charcot’s Triad + Hypotension and AMS ● Mirizzi’s Syndrome ○ Rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the CBD, resulting in CDB obstruction and jaundice
- 10. Board Questions A 57 year old man undergoes Lap Chole for Symptomatic Gallstone Disease. The surgery is uneventful, but 2 days after the procedure, the patient develops intense abdominal pain without fever. Bilirubin level of 4.2. Lipase 40. AST 225. Diagnosis? A. Bile Leak B. Pancreatitis C. Post-op Ileus D. Retained Stone E. Infection
- 11. Next Step? A. Percutaneous Transhepatic Biliary Drain? B. Surgical Exploration of CBD with Stone Removal C. Endoscopic Retrograde Cholangeopancreatography D. Endoscopic Ultrasound of the biliary tree E. Magnetic Resonance Cholangeopancreatography
- 12. Board Questions A 60 year old man undergoes CT scan to evaluate his abdominal aorta. The images show a normal aorta, but his gallbladder contains several stones and intramural calcification of the gallbladder is noted. No other abnormal findings are seen. The patient is asymptomatic and CMR and CBC are WNL. What is the most appropriate therapy for this patient? A. Cholecystectomy B. Cholecystojejunostomy C. ERCP D. Endoscopic ultrasound of the gallbladder and biliary tree E. Observation and re-imaging in 1 year
- 13. Discussion ● Interval Cholecystectomy vs. Same Hospitalization? ○ Cochrane Review: Early Vs. Delayed Lap Chole for Patients with Acute Cholecystitis ○ 2013 ○ 7 RCTs included. 244 randomized to early vs. 244 randomized to interval lap chole ○ No significant difference in bile duct injury, serious complication, or requirement of conversion to open cholecystectomy. ○ Hospital stay was shorter in early group by 4 days ● Surgery vs. Medicine Management