Complications of gall stone disease

Complications of gall stone disease

1. Complications of gallstone disease Shankar Zanwar Jewellery from gall stone

2. Background Reports of gall stones in history dates back Babylonian era before 2000 yrs Prevalence of gall stones in India 4.3% half of the western world percentage RK Tandon WJG 2000

3. Natural history of galls stone disease

4. Complications of gall stones Cholecystitis Cholangitis Mirrizi’s syndrome Gall stone ileus Emphysematous cholecystitis Perforation Biliary pancreatitis Carcinoma gall bladder

5. Cholecystitis Of all patients with gall stones 2% will become symptomatic every year (for first 5 years and later decrease) Of symptomatic gall stones 2% will develop complications per year Ranshoff Ann Int Med 1993 Acute cholecystitis is the most common complication of gall stone disease

6. Acute cholecystitis Pathogenesis

7. Clinical features Nearly 75% have prior attacks of biliary pain Fever – but usually <102, higher – gangrene or perforation Jaundice – 20%, in 40 % elderly patients, usually <4mg/dl if >4 suspect CBD stone Murphy’s sign – sensitivity – 97%, specificity 48% Singer Ann Int Med 1996 GB is palpable in 33% of pts. more if the attack is for first time.

8. Natural history Untreated cholecystitis – pain relives in 7-10 days Sequelae Resolution – 83% Gangrenous cholecystitis – 7% Empyema – 6% Perforation – 3% Emphysematous – 1%

9. Diagnosis Hemtological and biochemical alterations Mild amylase and lipase elevation may be seen in absence of pancreatitis USG – Sonographic tenderness – 90% PPV Non specific GB wall thickening >4mm (in absence of hypoalbu ) Pericholecystitic fluid (in absence of ascites )

10. Cholescintigraphy – HIDA/DISIDA scan Assesses patency of cystic duct Normal scan – GB seen within 30 min Non visualisation – s/o cholecystitis Sensitivity – 95%, specificity – 90 % False positive – fasting, CLD, TPN, critically ill False negative virtually absent CT can useful when complications like – perforation, emphysema abscess, or pancreatitis suspected.

11. Treatment IV fluids, Electrolyte replacement, cultures. Broad spectrum antibiotic coverage, in complicated patient extend coverage for anerobes Definitive therapy – cholecystectomy Study from KMC, Manipal Bile culture + ve in 70% Aerobes - 56.8% Anerobes – 13.6%

12. Cholangitis Most serious and lethal of all complications All causes of cholangitis 85% are due to stones embedded in the CBD Same organisms as in cholecystitis Thus urgent decompression needed

13. Clinical features and labs Charcots triad – pain, fever and jaundice – 70% of patients Pitt WB Ac. Cholangitis 1987 Fever – 95%, - usually > 102 RUQ tenderness – 90% Jaundice – 80% Leucocytosis – 80%, Bil >2mg – 80%.

14. Imaging Stones in CBD seen only in 50% cases, CBD dilatation >6mm may give indirect evidence in remaining 25% Yusuff , GE clinic of N Amer 2003 MRC for stones Sensitivity 93%, specificity -94% Recommended when low to moderate clinical probability EUS Sens – 95%, spec – 97%, NPV – 98% Recommended when low to moderate clinical probability ERCP – sens and spec – 95% Recommended when high probability and therapeutic intent

15. Treatment IV fluids, cultures, antibiotics in severe cases with shock cover anerobes Decompression ERCP Failed  PTBD Cholecystectomy.

16. Mirrizi’s syndrome. First described in 1948 by Mirrizi Stone impacted in the neck or GB or cystic duct narrowing of CHD. Occurs in 0.1 -0.7% of patients with gall stones Hazzan Surg Endo 1999 Risk of GB ca. In these group of patients is higher then the rest – 25% Redaelli Surgery 1997

17. Classifications Older – McSherry Type 1 – external compression of CHD by calculus in cystic duct/ Hartmanns’s pouch Type 2 – Cholecysto-choledochal fistula partial/ complete Newer - Csendes classification Only external compression Cysto-biliary fistula <1/3 rd of circumference of CHD Upto 2/3 rd of CHD circum Complete destruction

18. Diagnosis Symptoms and signs same as cholecystitis Lab parameters mimic cholecystitis or cholangitis USG – correct diagnosis – 8-62% Nearly 100% can be diagnosed with ERCP or EUS

19. Treatment - When preop diagnosis made – open preferred over lap chole When found intra-op during lap surgery – mandate open conversion Though reported(and sparsely) lap should be avoided unless expert is available Type 1 - cholecystectomy alone If phlegmon or fibrous reaction at Calot’s triangle – stone extraction & partial cholecystectomy – safe

20. Type 2-4 using remnant of GB to repair fistula with T-tube, Other safest alternative is Roux en Y bilio - enteric anastomosis Prognosis of type – excellent Higher types – poorer with complications like Increased postop morbidity Biliary fistulae – 10% or more Strictures Hepatic abscess

21. Cholecysto-entric fistula - Gallstone ileus Not a true ileus – rather mechanical obstruction First description – Bartholin – 1654 Seen in 0.5% of gall stone patients Occurs in nearly 1-3% of all small bowel mechanical obstructions Cooperman Ann Surg , 1986 Accounts for nearly 25% of all SB obstructions in elderly women (>65 y) Reisner RM Am J Surg 1994 Females more common - 3-16 times Mortality – 15-18 %

22. Pathogenesis Fistula formation from bile duct to the intestine due to pressure necrosis by gall stone against the biliary wall Most common entry point into the bowel – duodenum followed by hepatic flexure stomachjejunum Occur in 2-3% with cholecystitis Mirrizi’s syndrome is associated in 90% of cases of cholecysto -enteric fistulae.

23. Clinical presentation Gall stone ileus results when gallstone is large in size majority - >2.5cm Commonest site of impact 50-70% – distal ileum, since narrowest Presents as intermittent sub-acute obstruction “Tumbling obstruction” – due to stone tumbling down the bowel lumen

24. Mean symptoms period before presentation – 5days Occasional hematemesis due to hemorrhage at the entry site of the stone. Bouveret’s syndrome – Gastric outlet obstruction due to impacted gall stone in duodenum or pylorus

25. Diagnosis Clinical diagnosis made infrequently Prep-op diagnosis is made only in 20-50% of cases Chou WJG 2007 Rigler’s triad on imaging Partial or complete intestinal obs – 50% Pneumobilia – 30-60% Aberrant gall stones - <15% X-ray – detects all 3 in 17-35% cases USG + X-ray 74% Plain CT – 93%

26. Treatment Surgery after intial resuscitaion Ongoing debate – one stage vs 2 stage One stage – treating obs , cholecystectomy and fistula division withor without CBD exploration Two stage – only explorative laparotomy and enterolithotomy first in second stage rest all. Benefits of one stage operation – prevents further biliary complications, recurrent ileus and treats fistula

27. Largest review of 1000 cases by Reissner – mortality rate 16.9% in one stage vs 11.7% for enterolithotomy alone But recurrence of GS ileus is seen in only 5-9% of cases where enterolithotomy done And only 10% require reoperation for biliary symptoms Fistula may close spontaneously and unclosed fistula complicates rarely

28. A study by Tan (Singapore Med J 2004) Significantly increased operating time in one stage No significant morbidity and mortality differences in the 2 groups Many authors conclude – one stage procedure should be reserved for otherwise healthy patients and without serious fibrosis in RUQ Two stage – be considered in younger patients with risk of further biliary complications

29. Emphysematous cholecystitis Acute infection of gall bladder by gas forming organisms Surgical emergency Seen in 1% of all cases of acute cholecystitis Mortality rates between 15-25%

30. Pathogenesis Vascular compromise of the gall bladder – occlusion or stenosis of vessels, usually arteriosclerotic cystic artery More in male, DM(in up to 55%patients), elderly. Vascular compromise facilitates growth of gas forming organisms This is also reported in cases of pts. treated with sunitinib for GIST due to VEGF inhibition.

31. Common causative agents Clostridum spp – 46% E. coli – 40% Klebsiella Enterococci Symptoms and presentation is similar to acute cholecystitis except for higher degree of fever Lab findings are similar to acute cholecystitis

32. Imaging X- ray – air in side the GB – can be negative in 60% cases USG sensitivity 90-95% Stage 1 - gas in lumen Stage 2 - gas in wall Stage 3 - gas in the pericholecystic tissue Effervescent GB tiny foci floating on the nondependent wall Curvilinear gaseous artifact , ring down effect, comet-tail sign - diagnostic

33. CT confirms emphysematous cholecystitis, when USG is in doubt HPE shows full thickness necrosis of GB, gangrene seen in 75% of cases. Medical treatment same as for sever cholecystitis

34. In hemodynamically unstable patient and those who can not tolerate GA percutaneous cholecystectomy can be done to stabilize the patient. Interval cholecystectomy after 4-6week can be done Adjuvant therapy with hyperbaric oxygen- rationale – anerobes is cause in majority HBO is given within 8 hours of surgery for 5 days Kraljevic Hepatogastroenterology 1999

35. GB perforation Neimeier classification Type 1 – Acute Type 2 – Subacute Type 3 – Chronic Managed similarly as emphysematous cholecystitis In a study by Hung stable patients can be taken up for early lap cholecystectomy with equal outcomes and lesser LOS as compared elective interval cholecystectomy after PTBD.

36. Gall stone pancreatitis Of all gall stone patients only 3-7% develop pancreatitis But amongst the pancreatitis patients 40% are caused due to gall stones In thesis – 17/53(32.07%) patients had biliary cause of pancreatitis, 3 severe, 3 moderate and rest 11 mild, no mortality All underwent cholecystectomy except 2 severe ones

37. Management - Timing of cholecystectomy mild pancreatitis – Review of studies with total of 998 patients no readmissions if operated during index admission vs 18% readmission in patient with interval cholecystectomy(p<0.0001) No difference in operative complications, conversion or mortality Ann Surg 2012

38. Severe – of 187 patients 78 had early and 109 late cholecystectomy William Ann Sur 2004 Since the patients with acute severe pancreatitis often have peripancreatitic complications and SIRS operating is challenging and may invite complications should be avoided till 4-6 weeks till pancreatitis settles Early(%) Late(%) Resolution of associated fluid collection 21 40 Percutaneous drainage required 50 18 Sepsis 47 6 Complication s of cholecystectomy 44 5.5

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