Cholelithiasis and Cholecystitis.pptx

This is an overview of gallbladder stone diseases and infection of the gallbladder. I started with the surgical anatomy and physiology of gallbladder and bile secretion. furthermore, I went ahead to discuss the natural history of gallstones. then, the pathology and pathogenesis of gallstones and gallbladder infection (cholecystitis). Various investigations for Cholelithiasis and cholecystitis was discussed and the concluding part talked about various treatment modality. Finally, I went ahead to show the techniques of laparoscopic cholecystectomy.

1. Management of Cholelithiasis and Cholecystitis Adewunmi O. Lukman Senior Registrar Division of General Surgery UMTH 28 th September, 2020

2. Outline Introduction Relevant Anatomy Epidemiology and Natural history Classification Clinical features Investigations Treatment Prognosis Conclusion References

3. Introduction Gallstones are the most common pathology affecting the biliary tract Gallbladder stone is one of the most common problems affecting the digestive tracts It is estimated that gallstones are present in 10-15% of the adult population in the USA.

4. Relevant Anatomy/physiology

5. Relevant Anatomy/physiology The normal adult consuming an average diet produces within the liver 500 to 1000 mL of bile a day. The secretion of bile is responsive to neurogenic, humoral, and chemical stimuli. Bile is mainly composed of water, electrolytes, bile salts, proteins , lipids, and bile pigments

6. Epidemiology Gallstone disease is one of the most common problems affecting the digestive tract. Autopsy reports have shown a prevalence of gallstones from 11% to 36%. 1 The prevalence of gallstones is related to many factors, including age, gender and ethnic background.

7. Epidemiology Wichendu et al (UPTH) in Feb 2020: 2 M:F 1:5.6 age 41-50yrs symptoms right hypochondrial /epigastric pain type Mixed stones

8. Risk factor Certain conditions predispose to the development of gallstones. Obesity Pregnancy dietary factors Crohn’s disease terminal ileal resection gastric surgery hereditary spherocytosis, sickle cell disease, and thalassemia are all associated with an increased risk of developing gallstones. 3

9. Natural History Most patients will remain asymptomatic from their gallstones throughout life Approximately 3% of asymptomatic individuals become symptomatic per year (i.e., develop biliary colic). Once symptomatic, patients tend to have recurring bouts of biliary colic. Complicated gallstone disease develops in 3% to 5% of symptomatic patients per year. 4

10. Natural History Symptomatics - biliary colics (chronic cholecystitis) Complicated acute cholecystitis choledocholithiasis + Cholangitis gallstone pancreatitis c holecystocholedochal fistula c holecystoduodenal fistula g allstone ileus gallbladder carcinoma

11. Classification Cholesterol 10% Pigment 10% Black Brown Mixed 80% 5

12. Classification Pure Cholesterol stones consist of <10% of stone contain 70-80% cholesterol by weight supersaturation of bile with cholesterol usually solitary with smooth surface usually radiolucent, <10% are radio-opaque

13. Classification Pigment stones contain <20% of cholesterol contained calcium bilirubinate and appear dark-colored Black pigment stones formed by supersaturation of bile with Calcium bilirubin, carbonate and phosphate secondary to hemolytic anaemia or hepatic cirrhosis commonly formed in the gallbladder

14. Classification Brown pigment stone usually less than 1cm in diameter, brownish-yellow, soft, mushy formed in the gallbladder or CBD formed from bacterial infection caused by bile stasis E.coli, Klebsiella spp , etc secrete B- glucoronidase causing deconjugated bilirubinemia parasitic infestations e.g. Ascaris lumbricoides

15. Classification Mixed stones contained variable concentration of cholesterol and bilirubin most common stone in Nigeria and Africa made up about 80% of gallbladder stones

16. Clinical features Biliary colics Episodic pain epigastric/ Rt hypochodrial , episodic, radiate to the upper back/ interscapular region, worsen by fatty meal Atypical presentation Bloating, belching. 6 Acute Cholecystitis Constant pain Anorexia Nausea and vomiting Fever Murphy’s sign- POSITIVE. 6

17. Investigations Abdominal Ultrasound - 95% sensitive and specific thickened gallbladder wall + peri- cholecystic fluid collection stones in the gallbladder Complications obstructive jaundice- dilated biliary tree, pancreatic duct, etc empyema- gallbladder sludge, empyema. 7

18. Investigations HIDA scan ( h y droxy i mino d iacetic a cid) good in atypical presentation non visualization of the gallbladder after 4hrs is diagnostic Complete Blood Count (CBC) leukocytosis (12,000-15,000cells/mm3) greater values suggest gangrene, perforation or cholangitis. 7

19. HIDA scan

20. Investigations Electrolyte, Urea and Creatinine (EUC) assess renal function Liver function test (LFT) ALP, ALT and AST. 7

21. Treatment Resuscitation IV fluid IV antibiotics- cephalosporins and metronidazole Analgesics Definitive treatment Cholecystectomy

22. Treatment Cholecystectomy Approach Open Laparoscopic Timing Early Delayed

23. Treatment Approach Open Laparoscopic

24. Federico Coccolini et al, meta-analysis (1248 patients, 12 RCTs)- Level 1 evidence. 8 Lap Chole Open Chole Post-op morbidity ↓ - Post-op wound infection ↓ - Pneumonia ↓ - Mortality ↓ - Post-op hospital stay ↓ - Bile leak ↕ ↕ Intra-op blood loss ↕ ↕ Operative time ↕ ↕

25. Adisa et al in ile-ife, retrospective studies of cholecystectomy (173 patients)- level 5 evidence. 9 2005 2015 Cholecystectomy: 7(2.7%) 31(9.1%) increased was noticed when LapChole was commenced in 2008 Open Cholecystectomy 7 2 Post-op hospital stay 5.2days 1.8days Conclusion: they recommend the use of laparoscopy/minimal access surgery across the country.

26. Treatment Timing Early <3days Late >3days

27. Wu, X-D et al(2015), meta-analysis (1625 patients, 15 RCTs)- Level 1 evidence. 10 Early- <7days Delayed- >7days Early Lap Chole lower hospital cost shorter hospital stay few work day lost higher patient satisfaction quality of life No difference mortality, bile duct injury, bile leak, and conversion to open technique

28. Acute acalculous cholecystitis. 11 Acute inflammation of the gallbladder without gallstones Typically developed in patients in the ICU Burns sepsis multiple injuries Parenteral feeds Multiple organ failures

29. Acute acalculous cholecystitis Pathogenesis is unknown Conscious patient symptoms are similar Unconscious patient symptoms are masked fever, ele WBC, ALP,jaundice may be a pointer

30. Acute acalculous cholecystitis Abd USS thickened gallbladder with peri- cholecystitic fluid collection, biliary sludge, no gallstones HIDA scan CT abdomen

31. Acute acalculous cholecystitis Treatment emergency decompression of the biliary percutaneous cholecystostomy - 90% will improve open cholecystostomy /cholecystectomy

32. Laparoscopic cholecystectomy- overview. 12

33. Summary Gallstones are the commonest biliary pathology Asymptomatic gallstones do not require treatment Classified into cholesterol, pigment and mixed Treatment for symptomatic gallstones is laparoscopic cholecystectomy

34. References Brett M, Barker DJ. The world distribution of gallstones. Int J Epidemiol . 1976;5:335 WICHENDU, P. N., DODIYI-MANUEL, A., & IKONWA, K. (2020). MANAGEMENT OF SYMPTOMATIC GALL STONES IN A TERTIARY CARE HEALTH FACILITY IN SOUTHERN NIGERIA. Journal of International Research in Medical and Pharmaceutical Sciences, 14(3), 98-103. Nakeeb A, Comuzzie AG, Martin L, et al. Gallstones: genetics versus environment. Ann Surg. 2002;235:842. Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: the GREPCO experience. The GREPCO Group. Hepatology. 1995;21:655 . Charles F. Brunicardi: Schwartz’s principles of Surgery, 10 th edition Chapters 33 Aliyu S and Ningi AB. The Types and Indications of Cholecystectomy in Nigeria: Our Experience in Damaturu , North-Eastern Nigeria. A Randomized Double-Blind Placebo-Controlled Trial. Acad J Gastroenterol & Hepatol . 2(2): 2020. AJGH.MS.ID.000535. DOI: 10.33552/AJGH.2020.02.000535

35. 7. O . James Garden and Simon Peterson-Brown: Hepatobiliary and pancreatic surgery, a companion to specialist surgical practice, 5 th edition, chapter 10. 8. Coccolini F, Catena F, Pisano M, Gheza F, Fagiuoli S, Di Saverio S, Leandro G, Montori G, Ceresoli M, Corbella D, Sartelli M, Sugrue M, Ansaloni L. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg. 2015 Jun;18:196-204. doi : 10.1016/j.ijsu.2015.04.083. Epub 2015 May 6. Erratum in: Int J Surg. 2015 Dec;24(Pt A):107. PMID: 25958296. 9. Adisa AO, Lawal OO, Adejuyigbe O. Trend over time for cholecystectomy following the introduction of laparoscopy in a Nigerian tertiary hospital. Niger J Surg 2017;23:102-5 10. Wu , X.‐D., Tian, X., Liu, M.‐M., Wu, L., Zhao, S. and Zhao, L. (2015), Meta‐analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg , 102: 1302-1313. doi:10.1002/bjs.9886 11. Norman , S. W., Christopher J.K.B., and P.Ronan O’ Connell (2008). Bailey and Love principles and practice of Surgery , 25 th edition, chapter 61, 63 and 64. 12. Michael J Zinner and Stanley W Ashley: Maingot’s abdominal operations, 12 th edition. Sections VII, VIII and IX