Cholelithiasis and cholecystitis

Cholelithiasis and cholecystitis

1. CHOLELITHIASIS AND CHOLECYSTITIS Dr.Sundarprakash Sivalingam Associate Professor in Surgery

2. SURGICAL ANATOMY Gallbladder It is a pear-shaped (size is 5-12 cm) reservoir, located in a fossa on the inferior surface of the liver. Parts Fundus Body Infundibulum Neck . HARTMANN‘S POUCH - pathological -located in the infundibular region created by gallstones . • Gallbladder drains Cystic duct Common hepatic duct Common bile duct. • S upplied by cystic artery, a branch of right hepatic artery .

3. SURGICAL ANATOMY CALLOT’S TRIANGLE - Cystic artery - Lymph node of Lund VALVES OF HEISTER - Mucosal folds - GB neck & Cystic duct

4. SURGICAL ANATOMY EXTRA-HEPATIC BILIARY TREE Segments of Liver Segments of Liver I, II, III & IV V, VI, VII & VIII Left Hepatic duct Right Hepatic duct Common Hepatic Duct Cystic Duct Common Bile Duct

5. SURGICAL ANATOMY EXTRA-HEPATIC BILIARY TREE Common bile duct 10-12 cm in length 6-8 mm in diameter Joins the major pancreatic duct in the wall of the 2nd part of duodenum to form the A mpulla of Vater Intra-duodenal part of CBD is surrounded by smooth muscle fibers called as S phincter of Oddi .

6. PHYSIOLOGY OF GALL BLADDER Bile Daily up to 1000 ml of bile is secreted from the liver C ontains water (98%), bile salts, bile pigments, fatty acids, lecithin, cholesterol, and electrolytes (sodium , potassium, chloride, bicarbonate, calcium, magnesium) pH more than 7.0 Main function of gallbladder is to concentrate and store the bile Capacity of gallbladder is 40-50 ml Bile salts form micelle which makes cholesterol soluble .

7. PHYSIOLOGY OF GALL BLADDER

8. INVESTIGATIONS DONE FOR GALL BLADDER Ultrasonogram of the abdomen First line of management gallstones are seen with posterior acoustic shadowing Can show biliary stones Stones in CBD Biliary strictures Malignancy

9. INVESTIGATIONS DONE FOR GALL BLADDER ORAL CHOLECYSTOGRAM (OCG; GRAHAM-COLE TEST ) To study function of the gallbladder. 6 tablets of iopanoic acid ( Telepaque ), is given orally. Contraindications 1. Patients with serum bilirubin > 3 mg% 2. Acute cholecystitis 3. Vomiting

10. INVESTIGATIONS DONE FOR GALL BLADDER IV CHOLANGIOGRAM It is to visualize bile ducts and biliary tree IV Meglumine ioglycamate ( Biligram ) Disadvantages Poor visualization Drug reaction Not very useful if serum bilirubin is >3 mg %.

11. INVESTIGATIONS DONE FOR GALL BLADDER ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP ) Side viewing gastro duodenoscope Sphincter of Oddi is cannulated, and dye is injected. Biliary and pancreatic trees are visualized . Patient is placed in prone When cannula goes upwards beside vertebra - bile duct I f cannula goes across the vertebra - pancreatic duct.

12. ERCP Indications • Malignancy—irregular filling defect. • Chronic pancreatitis —‘chain-of-lakes’ appearance. • Congenital anomalies. • Stones. • Stricture of biliary tree. • Choledochal cyst. • For sampling of biliary and pancreatic juices for analysis and cytology. • Brush biopsy from tumour site. Therapeutic uses 1. Extraction of stone from biliary duct 2. Stenting of CBD 3. Dilatation of the biliary stricture 4 . Endoscopic papillotomy

13. ERCP Complications • Pancreatitis. • Duodenal injury. • Cholangitis. • Bleeding. Relative Contraindications 1. Acute pancreatitis. 2. Previous gastrectomy.

14. INVESTIGATIONS DONE FOR GALL BLADDER PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) Chiba or Okuda needle is passed into the liver through right 8th intercostal space in mid-axillary line. B ile is aspirated (sent for culture , cytology, analysis) and then water soluble iodine dye is injected Fluoroscopy (C-ARM ) Uses T o visualise the dilated biliary radicles, also the site and extent of the obstruction, i.e. tumour , stricture . T herapeutic stenting U sed whenever ERCP fails in Klatskin tumour, in catheter drainage (external ) in high blocks, in stenting high tumours .

15. INVESTIGATIONS DONE FOR GALL BLADDER MAGNETIC RESONANCE CHOLANGIO PANCREATOGRAPHY (MRCP ) Non-invasive Excellent diagnostic tool

16. INVESTIGATIONS DONE FOR GALL BLADDER RADIOISOTOPE SCAN STUDY HIDA ( Hippuran Immuno Diacetic Acid) Scan very useful in diagnosing acute cholecystitis and other biliary disorders, like biliary atresia.

17. CHOLELITHIASIS

18. Types Cholesterol stones - ( Cholesterol solitaire – radiating crystalline appearance) - 6 % - often solitary . 2. Mixed stones - 90% - It contains cholesterol, calcium salts of phosphate , carbonate, palmitate, proteins , and are multiple, faceted . 3. Pigment stones - small , black or greenish black, - multiple - Often they can be sludge like.

19. FAT FLATULENT FEMALE FERTILE FORTY

20. CAUSES Altered GB function :- Stasis Poor emptying Poor absorption Infection Supersaturated bile :- Female Fertile Fat Forty High Calorie Altered EHC :- Ileal resection Ileal disease Altered bowel transit time Cholestyramine Deoxycholate Cholesterol nucleation factor Hemolytic diseases

21. PATHOGENESIS Excess secretion of Cholesterol in Bile. Excess Mucous Production. Non-Functioning Gallbladder. Stasis in Gallbladder.

22. Pathological Effects Silent Gallstones . Pancreatitis Obstruction of the Cystic Duct. Movement of Stone into CBD. Ulceration of Stone through Gallbladder Wall . Gallstone ileus Carcinoma Mirizzi syndrome

23. Clinical Presentation Silent gallstone Flatulent dyspepsia Biliary Colic Mirizzi syndrome (Rare) Acute Cholecystitis Chronic Cholecystitis Gallstone Pancreatitis Obstructive Jaundice Ascending Cholangitis Gallstone Ileus Mucocele / Empyema of the Gallbladder

24. Silent gallstone • Asymptomatic stone in the gall bladder • Usually it is cholesterol stone, often single • It is accidentally discovered by Ultrasound. Indications for cholecystectomy in silent stones Patient is diabetic/immunosuppressed. High chances of developing gallbladder carcinoma. Stone more than 2.5 cm in size. Multiple stones. If gallbladder wall is thickened.

25. Flatulent dyspepsia Discomfort in the abdomen Belching Heartburn Fat intolerance Sensation of fullness in the abdomen

26. Biliary colic Sudden , severe colicky abdominal pain in right upper quadrant. R adiates to back and shoulder. The pain is due to sudden spasm of gallbladder wall when gall stone moves towards the neck of the gallbladder or cystic duct and gets impacted. Tachycardia and restlessness are common. Right hypochondrium is tender. Precipitated by supine position while sleeping at night. It lasts for few hours and is episodic. It may precipitate acute cholecystitis or empyema gallbladder. There is reflex pylorospasm causing vomiting.

27. MANAGEMENT OF GALLSTONES Investigations Ultrasonogram of the abdomen LFT P lain X-ray abdomen Total WBC count. Surgical management Laparoscopic cholecystectomy. Open cholecystectomy through right subcostal Kocher’s incision.

28. Mirizzi syndrome Gallstone impacts in the gallbladder wall and compresses it causing pressure necrosis which further gets adherent to CBD wall. Leads into cholecystocholedochal fistula. Occurs either from Hartmann’s pouch into CBD ( common) or from fundus of gallbladder into the CBD. Suspected on CT scan, but usually identified on table. It needs cholecystectomy; on table cholangiogram; and exploration of CBD. It often needs choledochojejunostomy . Types Type I: Compression of CBD without lumen narrowing Type II: Compression causing CBD lumen narrowing Type III: Compression causing CBD wall necrosis. Type IV: Cholecysto-choledochal fistula

29. Classification 1. Acute calculous cholecystitis. 2. Acute acalculous cholecystitis. Mode of Infection • Haematogenous through hepatic artery – cystic artery . • Portal vein. • Through bile after filtering in the liver via portal circulation . ACUTE CHOLECYSTITIS

30. ACUTE CALCULOUS CHOLECYSTITIS • Commonly it occurs in a patient with pre-existing chronic cholecystitis but often also can occur as a first presentation . • Usual cause is impacted gallstone in the Hartmann’s pouch , obstructing cystic duct. Causative bacteria E. coli - commonest Klebsiella Pseudomonas proteus Strep. faecalis Salmonella Clostridium welchii .

31. Pathogenesis of Acute Calculous Cholecystitis Gallstone obstruction at Hartmann’s pouch or in cystic duct Stasis oedema of the wall bacterial infection acute cholecystitis

32. Complications of Acute Calculous Cholecystitis 1. Perforation - usually occurs in the fundus or in the neck (Hartmann’s ). - can cause cholecystoduodenal , cholecysto -intestinal or cholecysto -biliary fistula . 2. Peritonitis 3. Pericholecystitic abscess 4. Empyema GB. 5 . Ascending Cholangitis 6. Septicaemia . 5. Emphysema gallbladder, gangrenous gall bladder.

33. Clinical Features Sudden onset of pain in the right hypochondrium , with tenderness, guarding, and rigidity. Positive Murphy’s sign , where in sitting position during deep inspiration, while palpating in right hypochondrium , patient winces with pain at the summit of the inspiration. Same sign elicited in lying down position is called as Moynihan’s sign . Palpable , tender, smooth, soft gallbladder. Area of hyperaesthesia between 9th and 11th ribs posteriorly on the right side ( Boas’s sign ) . Jaundice may be present . Fever , nausea (25%). Tachycardia and toxic features.

34. Investigations • Ultrasound abdomen —very useful, reveals presence or absence of gallstones; and thickening of gallbladder wall. • Plain X-ray abdomen —10% of gallstones are radioopaque ; also rules out other causes of acute pain abdomen . Gas is seen in emphysematous GB. • Total count shows neutrophilia. • HIDA/PIPIDA radioisotope study —very useful. Non-visualisation of gallbladder is diagnostic . • LFT is important. Increased serum bilirubin often signifies cholangitis or stone in the CBD .

35. Differential diagnosis • Duodenal ulcer perforation • Acute pancreatitis • Acute appendicitis • Acute pyelonephritis • Lobar pneumonia, myocardial infarction • Ruptured ectopic pregnancy

36. Treatment • Advised hospitalisation. • Initially (non-operative) conservative treatment (95%) : – Nasogastric aspiration. – IV fluids. – Analgesics and antispasmodics. – Broad spectrum antibiotics ( cefoperazone , ceftazidime, ceftriaxone, cefotaxime + amikacin, tobramycin + metronidazole {antimicrobial}). – Observation. – Follow-up U/S scan. • Later after 3-6 weeks, elective cholecystectomy , either by open method through right subcostal (Kocher’s) incision or through laparoscopy is done.

37. Cholecystostomy - Gallbladder is opened and all stones and pus are removed. Either a Foley’s or Malecot’s catheter is placed in the gallbladder and is exteriorised . After 3 weeks, elective cholecystectomy is done. Indications for cholecystostomy or emergency cholecystectomy (5 %) • Empyema GB • Persisting symptoms/failure of medication • Emphysematous cholecystitis • Perforation/peritonitis • Elderly

38. ACUTE ACALCULOUS CHOLECYSTITIS (5%) N ot an uncommon entity Common in patients who have undergone major surgeries , trauma, burns, or any other stress or in cases of cholecystoses . Common in ICU patients. Exact cause is not known. Pathology is oedema and necrosis of the gall bladder wall with features of acute inflammation. Presentation is usually acute. Investigations : Isotope study (HIDA), U/S abdomen. Treatment : Cholecystectomy

39. EMPYEMA GALLBLADDER a type of acute cholecystitis The gallbladder is filled with pus. In 30% cases pus may be sterile. can occur in a pre-existing mucocele of the gallbladder where it gets infected . commonly observed in impacted stone, diabetic individual , immunosuppressed people like HIV, long time steroid therapy. can perforate; can form abscess or can cause peritonitis – biliary and bacterial. high mortality. Clinical Features Fever , toxicity. Pain and tenderness in right hypochondrium . Tender , smooth, globular, palpable gallbladder.

40. EMPYEMA GALLBLADDER Complications Septicaemia . Rupture and peritonitis. Investigations U/S abdomen. Total count is raised. Radio isotope scan. Treatment Antibiotics : Cefotaxime, quinolones, ceftriaxone. Cholecystectomy - an emergency procedure. Often initially cholecystostomy is done Later after 3-6 weeks, cholecystectomy is done.

41. • Seen in elderly male patients • Common in diabetic and immunosuppressed individuals • Clostridium welchii is the causative organism • Gas is seen in the gallbladder • Results in life-threatening septicaemia • It causes severe fulminant cholecystitis • Gangrene, perforation and peritonitis are common • Emergency cholecystectomy is needed Emphysematous cholecystitis

42. MUCOCELE OF THE GALLBLADDER D ue to obstruction of the cystic duct by a stone in the neck (Hartmann’s pouch) of the gallbladder, without any infection or inflammation in the gallbladder. This causes absorption of all bile and secretion of mucus into the gallbladder allowing gallbladder to distend causing mucocele of the gallbladder. Rarely cholangiocarcinoma occluding cystic duct may cause mucocele of gallbladder. Content is usually sterile.

43. MUCOCELE OF THE GALLBLADDER Clinical Features • Painless swelling in the right hypochondrium . • Nontender , smooth, soft, globular, palpable gallbladder. • Features of dyspepsia . Complications • If infected, can cause empyema gallbladder. • Rupture can cause pseudomyxoma peritonei ( but rare). Investigations • U/S abdomen. • Liver function tests. Treatment Cholecystectomy .

44. CHRONIC CHOLECYSTITIS It is chronically inflamed, thickened gallbladder. nonfunctioning and nondistending . Causes • Gallstones. • Cholecystoses . • Chronic acalculous cholecystitis. Organisms • Klebsiella . • Streptococci. • Salmonella.

45. Clinical Features • Pain in right hypochondrium , may be colicky, or persistent . • Flatulent dyspepsia. • Intolerance to fatty meals. • Biliary dyspepsia. Complications • CBD stone. • Cholangitis. • Pancreatitis. • Mirizzi’s syndrome. Differential Diagnosis • Peptic ulcer. • Pancreatitis. • Hiatus hernia.

46. Investigations • U/S abdomen • Isotope study may help to confirm the infection. • LFT. • Total count may be raised Treatment Cholecystectomy