Gall stones

1. GALL STONES
BY
DR. SEFEEN SAIF ATTYA
SURGERY DEPARTMENT
SOHAG TEACHING HOSPITAL

2. INTRODUCTION
Anatomy and physiology
Risk factors
Types of gallstones
IMAGING MODALITIES OF
THE GALLBLADDER
CLINICAL PRESENTATIONS OF
GALLSTONES

3. a = right hepatic duct;
b = left hepatic duct;
c = common hepatic duct;
d = portal vein;
e = hepatic artery;
f = gastroduodenal artery;
g = left gastric artery;
h = common bile duct;
i = fundus of theG.B.
j = body of gallbladder;
k = infundibulum;
l = cystic duct;
m = cystic artery;
n = superior
pancreaticoduodenal
artery.

6. Bile secretion and
flow
The liver continually secretes bile
(500- 1000 ML. daily)
Bile secreted by the liver is mostly
stored in the gall bladder where it is
concentrated and periodically
discharged into the duodenum both
during fasting and in large quantities
after meals

8. Regulation of Gallbladder
Emptying
The drainage channel for bile to
flow away from the gallbladder
into the common bile duct is
the cystic duct,
cholecystokinin stimulates
rhythmical contractions of the
gallbladder wall.

9. cholecystokinin (CCK(
It has been known for decades that
cholecystokinin (CCK) exerts
a stimulatory effect on gallbladder
emptying
The stimulus for the release of
cholecystokinin in the blood is a meal
abundant in fat. Meal without fat cannot
generate secretion with a sufficient
quantity of cholecystokinin

10. Sphincter of Oddi guards the
distal ends of the common bile
duct and the pancreatic duct
(either their common or their
separate exit into the
duodenum).

14. The effective emptying of the gallbladder
is achieved by the cooperation of two
mechanisms
first, the strong contraction of the wall of
the gallbladder
(as mediated by the neurohormonal
control)
and second, the fall of the intraluminal
pressure of the common bile duct as a
consequence of the reduction sphincter of
Oddi basal pressure.

15. The basal sphincter Pressure is 3mmHg
above the pressure in the common
bile duct and pancreatic duct, as a result
of which even the stronger contractile
activity of the gallbladder, cannot make
emptying possible ,
Relaxation of the sphincter is
a prerequisite for the emptying progress.

16. Vagal stimulation increases secretion of bile, and
stimulates contraction of the gallbladder,
Parasympathomimetic drugs contract the
gallbladder, whereas atropine leads to relaxation .
splanchnic sympathetic stimulation is inhibitory to
motor activity of the G.B.
Antral distention of the stomach causes both
gallbladder contraction and relaxation of the
sphincter of Oddi.
Somatostatin and its analogues are potent
inhibitors of gallbladder contraction.

17. Factors affecting relaxation of
sphincter of oddi
firstly,
although cholecystokinin causes
contraction of the gallbladder, it acts as
relaxant factor on the sphincteric fibers,
but this relaxation is not sufficient to allow
significant emptying of gallbladder;
second factor is the transmitted peristaltic
waves coming from gallbladder
contractions, which usually cause a
leading wave of relaxation that acts
on the sphincter of Oddi,

18. The third factor that causes relaxation of the
sphincter is
the intestinal peristaltic waves.
When these waves travel over the wall of the
duodenum itself, their relaxation phase exerts
a strong relaxing effect of the sphincter
This seems to be ,the most strong and significant
factor of all the relaxant factors on the sphincter of
Oddi.
Subsequently, bile enters the duodenum
in a squirt fashion, coinciding with the relaxation
phase of the duodenal peristaltic waves.

19. INTRODUCTION
Anatomy and physiology
Risk factors
Types of gallstones
IMAGING MODALITIES OF
THE GALLBLADDER
CLINICAL PRESENTATIONS OF
GALLSTONES

20.    
Risk Factors for GallstonesRisk Factors for Gallstones
  ObesityObesity
 Female sexFemale sex
FirstFirst--degree relativesdegree relatives      
Increasing ageIncreasing age
Childbearing Childbearing
High fat dietHigh fat diet
Multiparity Multiparity
Rapid weight loss Rapid weight loss
Oral contraception Oral contraception           
DrugsDrugs: : ceftriaxone, postmenopausal estrogens, ceftriaxone, postmenopausal estrogens,
Total parenteral nutritionTotal parenteral nutrition
Ileal disease, (resection or bypass) Loss of bile saltsIleal disease, (resection or bypass) Loss of bile salts
Biliary stasis and /or infectionBiliary stasis and /or infection
Hemolytic diseaseHemolytic disease

21. TYPES OF GALLSTONES
cholesterol stones
 composed mainly of cholesterol (> 50%
of stone composition) and comprises
multiple layers of cholesterol and
mucin glycoproteins.
Pure cholesterol stones are not common;
they comprise less than 10% of all stones.
Most other cholesterol stones contain
variable amounts of bile pigments
and calcium.

22. Biliary cholesterol is held in solution
as a result of molecular aggregation
with bile salts and phospholipids
The relative proportion of these
constituents is essential for the
maintenance of cholesterol solubility
If excessive cholesterol or
insufficient bile acids are secreted ,
bile becomes supersaturaed with
cholesterol which then preciptates
out as cholesterol crystals and
stones

23. Pigment stones
are dark due to the presence of calcium bilirubinate.
and are usually formed secondary to hemolytic
disorders such as sickle cell disease and spherocytosis,
and in those with cirrhosis.
Two types are recognized, black and brown,
Black pigment stones
are small and brittle and they almost always formed in the
gallbladder. They are the result of supersaturation of
calcium bilirubinate, carbonate and phosphate.
When the level of deconjucated bilirubin
is increased in the bile, precipitation with calcium
occurs.

24. Brown stones
may form in the gallbladder or in the
bile ducts usually after bacterial infection
caused by bile stasis.
The bacteria responsible for the infection
enzymatically catalyze the conversion of
bilirubin glucuronide to insoluble
unconjugated bilirubin.
The major constituents of these
brownish-yellow soft stones
are precipitated calcium bilirubinate and
bacterial cell bodies.

25. INTRODUCTION
- Anatomy and physiology
- Risk factors
- Types of gallstones
IMAGING MODALITIES OF THE
GALLBLADDER
CLINICAL PRESENTATIONS OF
GALLSTONES

26. Abdominal Plain X-
Ray
Plain abdominal X-ray is the simplest and oldest
imaging modality.
Gallstones can be shown, if they are calcified. It
is estimated that the percentage of gallstones that are
radiopaque reaches 20-30%.
Gallstones with mixed constituents,
namely "mercedes benz" gallstones, have a
characteristic stellate faceted appearance with gas containing
fissures.
Another finding is a porcelain gallbladder, caused by
calcification of its wall subsequent to chronic inflammatory
irritation and predisposedto malignant change.

27. Plain radiograph showing radio-opaque stones in thePlain radiograph showing radio-opaque stones in the
gall bladdergall bladder. .

28. Porcelain gall
bladder.

29. Gas in the gall bladder and gall bladder wallGas in the gall bladder and gall bladder wall
Emergency surgery is indicatedEmergency surgery is indicated..

30. Oral Cholecystography
has largely been replaced by
ultrasonography. It involves oral
administration of a radiopaque compound
that is absorbed, excreted by the liver, and
passed into the gallbladder.
Stones are noted on a film as filling
defects in a visualized, opacified
gallbladder.
Oral cholecystography is of no value in
patients with intestinal malabsorption,
vomiting, obstructed cystic duct, and
hepatic failure.

31. Oral
cholecystogram
showing
contracted gall
bladder
suggesting
chronic calcular
cholecystitis.

32. Oral
cholecys
togram.
Multiple
small
stones

33. Ultrasonography
Ultrasonography is the initial investigation of any
patient suspected of disease of the biliary tree.
It is noninvasive, painless, does not submit the
patient to radiation, It is dependent upon the skills
and the experience of the operator
Adjacent organs can be examined at the same
time.
Obese patients, patients with ascites, and patients
with distended bowel may be difficult to examine
satisfactorily with an ultrasound.
An ultrasound will show stones in the gallbladder
with sensitivity and specificity of over 90%.

34. Stones are acoustically dense and produce an
acoustic shadow
Stones also move with changes in position . Polyps
may be calcified and reflect shadows, but do not
move with change in posture .
A thickened gallbladder wall and local tenderness
indicate cholecystitis.
The patient has acute cholecystitis if a layer of
edema is seen within the wall of the gallbladder or
between the gallbladder and the liver.
When a stone obstructs the neck of the gallbladder,
the gallbladder may become very large, but thin
walled. A contracted, thick-walled gallbladder
indicates chronic cholecystitis.

35. ultrasound image ultrasound image
demonstrate the demonstrate the
normal normal
gallbladder gallbladder
The thin wall of The thin wall of
the gallbladder is the gallbladder is
seen as a white seen as a white
ring surrounding ring surrounding
bile, which bile, which
appears as a appears as a
black fluid. black fluid.
The wall The wall
thickness should thickness should
be less than 3 be less than 3
mm in adults.mm in adults.

36. Ultrasound examination. Single large gallstone Ultrasound examination. Single large gallstone
castingcasting
an ‘acoustic shadowan ‘acoustic shadow’’

38. Computerised
tomography
For benign biliary diseases, standard
computerised tomography (CT) is not that
useful investigation.
Gallstones are often not visualised, and
cholecystitis is underdiagnosed.
However, improvements in CT technology
such as multidetector helical scanners
that allow for three-dimensional
reconstruction of the biliary tree have led
to greater diagnostic accuracy and may
increase the use of this modality in the
future.

39. CT image CT image
demonstrates demonstrates
largelarge
gallstone in gallstone in
the the
gallbladdergallbladder

40. Computed tomography. Porcelain Computed tomography. Porcelain
gallbladdergallbladder..

41. Radionuclide Scanning
HIDA Scan
Biliary scintigraphy provides a noninvasive
evaluation of the liver, gallbladder and bile ducts
with both anatomic and functional information
Technetium-labeled derivatives of hydroxy
iminodiacetic acid (HIDA) are injected
intravenously, cleared by the Kupffer cells in the
liver, and excreted in the bile.
Uptake by the liver is detected within 10 minutes,
and the gallbladder, is visualized within 60 minutes
in fasting subjects.
The primary use of biliary scintigraphy is in the
diagnosis of acute cholecystitis, which appears as
a nonvisualized gallbladder, with prompt filling of
the common bile duct and duodenum .

42. complications of gallstones
 Chronic cholecystitis
 acute cholecystitis
 choledocholithiasis
 cholangitis,
 gallstone pancreatitis,
 gallstone ileus,
 perforation of the gallbladder
 gallbladder carcinoma.

43. INTRODUCTION
- Anatomy and physiology
- Risk factors
- Types of gallstones
IMAGING MODALITIES OF THE
GALLBLADDER
CLINICAL PRESENTATIONS OF
GALLSTONES

44. CLINICAL PRESENTATIONS
OF GALLSTONES
Symptomatic Gallstones
Chronic Cholecystitis
Acute Cholecystitis
Asymptomatic gallstones
Patients with suggestive
symptoms but without
gallstones (Acalculous
cholecystitis)

45. Chronic Cholecystitis
The diagnosis of symptomatic cholelithiasis is based
on the sonographic examination of the gallbladder
symptoms and signs, a steady upper abdominal pain, radiating to the
upper back, occurring at least one hour after fatty meals
and lasting at least 30 minutes, is the most sensitive clinical indicator of
cholelithiasis.
The confirmation or exclusion of gallstone disease in patients
with symptoms attributable to gallstones is achieved
by Ultrasonography which provides 95-98% sensitivity and specificity for
the diagnosis of gallstone sgreater than 2 mm in diameter.
Ultrasonography also provides additional anatomic information
on the presence of gallbladder polyps, common bile duct diameter,
or any hepatic parenchymal abnormalities.

46. The treatment of choice for patients with symptomatic
cholelithiasis is elective laparoscopic cholecystectomy
(LC).
a mortality rate of approximately 0.1% with
cardiovascular complications being the most common
cause of death
The morbidity of the procedure is less than 10%,
with iatrogenic injury to the biliary tract presenting
an infrequent but often disastrous complication
requiring long hospitalization, multiple reoperations,
repeated invasive procedures and long stenting of the
common bile duct (CBD).
The incidence of CBD injury ranges from 1/160 to 1/320
LCs,
Conversion to laparotomy is necessary in less than 5%
of patients with the
elderly, obese, male and those with periumbilical scars
from previous laparotomies being at greater risk.

47. The long-term results of laparoscopic
cholecystectomy in appropriately selected
patients with chronic cholecystitis are excellent.
Nearly 90% of patients with typical biliary pain
are rendered symptom-free after cholecystectomy.
However, persistent dyspeptic symptoms
(fatty food intolerance, flatulence), frequently occur
following cholecystectomy, especially in patients
with evidence of significant psychological distress
and a prolonged history of such
symptoms prior to surgery.

48. Acute Cholecystitis
Acute calculous cholecystitis is the distinctive
clinicopathological entity characterized by
acute inflammation of the gallbladder caused by the
obstruction of the Hartmann's pouch or cystic duct
comprising impacted gallstones or biliary sludge.
The inflammation of the gallbladder wall is chemical,
at least during the early phase.
The increase of intraluminal pressure and the
presence of supersaturated bile along with trauma to
the mucosa caused by the gallstone, trigger an acute
inflammatory response.

49. Clinical diagnosis is based on the presence of
symptoms and signs suggestive of localized
peritonitis in the right upper abdominal
quadrant.
The presence of three features, namely:
(1) constant biliary pain lasting for at least 12 hours,
(2) tenderness in the right upper quadrant (with or
without Murphy's sign and with or without a palpable
mass) and
(3) inflammatory response (fever, leucocytosis)
implicates the diagnosis and requires ultrasound
scanning to confirm or exclude acute cholecystitis.

50. Following this early phase, 20-50% of patients manifest a
proliferation of aerobic enteric bacteria, and occasionally
anaerobes, resultingin secondary bacterial infection of the
organ.
Microscopic features of the disease include necrosis
of mucosa, edema and hemorrhages in the gallbladder
wall. The gallbladder is distended, tense and vascular.
gastrohepatic omentum can be edematous
after 24-48 hours and adhesions of omentum (and probably
of duodenum) to the distended gallbladder can
be perceived as palpable mass.
The course of the inflammatory process depends on
 the degree and the duration of obstruction,
 the severity of bacterial attack,
 the age of the patient and the concurrence of
accompanyingdiseases.

51. Ultrasonography
is the initial imaging modality of choice for the evaluation
of acute pain in the right upper quadrant .
Typical sonographic findings include
Distended gallbladder with edematous wall,
pericholecystic fluid (or even abscess),
Elicitation of Murphy's sign during examination
 presence of gallstones
Ultrasonography also permits an accurate diagnosis of other
underlying causes of a patient's symptomatology,
including hepatic, renal, pancreatic, adrenal and even
pulmonary problems.
At the present time, a firm diagnosis of acute
calculous cholecystitis can be established in 90% of patients
with suggestive symptoms based on the clinical
and sonographic findings.

52. In the remaining uncertain cases,
radionuclide cholescintigraphy HIDA scan
is the best to confirm or rule out the
presence of acute cholecystitis
However, contrast-enhanced CT is the most
often preferred imaimaging modality,
complementary to US being valuable
in the assessment of acute cholecystitis
complications, in particular
emphysematous cholecystitis and
perforation of the gallbladder

53. Treatment of acute
cholecystitis
All patients with acute cholecystitis should
be referred to hospital.
Acute cholecystitis in the majority of
patients subsides spontaneously or
responds to conservative medical
treatment.
In approximately 10-20 percent of patients,
acute cholecystitis progresses to the local
complications of empyema formation
with or without gangrene, or perforation
with the formation of a pericholecystic
abcess.

54. Conservative treatment
followed by cholecystectomy
1 - Nil per mouth (NPO) and intravenous fluid administration.
2 - Administration of analgesics.
3- Administration of antibiotics. As the cystic duct is blocked in
most instances, the concentration of antibiotic in the serum is
more important than its concentration in bile . A broadspectrum
antibiotic effective against Gram-negative aerobes is
most appropriate (e.g. cefazolin, cefuroxime or gentamicin).
4 - Subsequent management. When the temperature, pulse and
other physical signs show that the inflammation is subsiding,
oral fluids are reinstated followed by regular diet.
Ultrasonography is performed to ensure that no local complications
have developed, that the bile duct is of a normal size and that
no stones are contained in the bile duct. Cholecystectomy
may be performed on the next available list, or the patient may
be allowed home to return later when the inflammation has
completely resolved.

55. Conservative treatment must be abandoned if the
pain and tenderness increase;
depending on the status of the patient,
operative intervention and cholecystectomy should
be performed
If the patient has serious comorbid conditions,
a percutaneous cholecystostomy can be performed
under ultrasound control, which will rapidly
relieve symptoms. A subsequent
cholecystectomy is usually required.

56. Routine early
operation
some surgeons advocate urgent operation as a
routine measure in cases of acute cholecystitis. Provided
that the the surgeon is experienced and excellent
operating facilities are available,
good results are achieved. Nevertheless, the
conversion rate in laparoscopic cholecystectomy is five
times higher in acute than in elective surgery.
If an early operation is not indicated, one should wait
approximately 6 weeks for the inflammation to subside
before proceeding to operate.

57. There is now firm evidence from
several prospecive randomized trials
that “early cholecystectomy ” for
acute cholecystitis
(operation within the same hospital
admission )is superior to “delayed
cholecystectomy ” (2-3 month after
resolution of the attack )provided the
patient is fit for surgery and
anaesthesia

58. The benefits of early cholecystectomy include
Reduced overall morbidity
Reduced hospital stay
Prevention of further attacks that may occur in
patients managed by the delayed
cholecystectomy policy
Unfit patients should be treated conservatively in
the first instance with the expectation that acute
cholecystitis will resolve in 80% of cases

59. If this conservative treatment
fails or in cases with empyema
of the G.B. an ulrasound
laparoscopically guided
cholecystostomy or
microcholecystostomy (under
u/s guidance ) will tide the
patient over the critical illness

60. Asymptomatic gallstones
The majority of individuals (60-
80%) with gallstones
are asymptomatic at the time
of diagnosis and most of
them will remain asymptomatic
during their lifetime

61. Treatment
 Most authors suggest that it is safe to observe
patients with asymptomatic gallstones,
with cholecystectomy only performed
for those patients who develop symptoms or
complications of their gallstones.
However, prophylactic cholecystectomy
should be considered
1- in children
2- in young women who are at increased risk of
presenting symptoms during a future pregnancy.
3-diabetic patients
4-those with congenital haemolytic anaemia
5-those who will undergo bariatric surgery
for morbid obesity,

62. Patients with asymptomatic gallstones, at
high risk of gallbladder carcinoma, would also benefit
from prophylactic cholecystectomy:
 Patients with porcelanoid gallbladder,
the estimated incidence of
carcinoma is up to 25%.
 Patients with stones greater than 3 cm in
diameter, as they present a tenfold risk of
malignancy compared with the general population
of patients with gallstones.
 Patients with gallstones and gallbladder polyps
exceeding 10 mm in diameter.
Patients with anomalous pancreatobiliary
junction.
Carriers of Salmonella typhi.

63. Acalculous
Cholecystitis
Chronic acalculous cholecystitis is a heterogeneous clinical
syndrome characterized by typical biliary attacks in
patients without cholelithiasis.
Risk factors
 prolonged ileus,
 long-term opiate administration,
 multiple blood transfusions,
 total parenteral nutrition,
presence of biliary sludge into the gallbladder,
 presence of cholesterol crystals in the bile,
gallbladder motility disorders.
This condition develops as a consequence of prolonged gallbladder
distention, bile stasis, and sludge formation,
followed by mucosal damage and vessel thrombosis.

64. Diagnosis and Radiology
Findings
Ultrasonography findings suggestive of
acalculous cholecytitis include
 gallbladder distention,
 presence of sludge within the
gallbladder,
wall thickening, and
 pericholecystic fluid.
If the diagnosis remains unclear then HIDA
scintigraphy should be performed.

65. Management
Laparoscopic cholecystectomy improves the
clinicalcourse of selected patients with gallbladder
dyskinesia
but the symptoms persist in more than 50% of the
remaining patients
Detailed selection of patients is based on
motility studies of gallbladder (cholecystokinin
cholecystoscintigraphy)
and a microscopic studyof bile collected during
ERCP.

66. Non-Operative Treatment
for Gallstones

DISSOLUTION TREATMENT

ESWL TREATMENT

67. DISSOLUTION TREATMENT
Gallstones may be dissolved with oral ursodeoxycholate and
chenodeoxycholate (bile acids).
Treatment takes many months to complete, and has been shown
to dissolve only small uncalcified stones successfully.
Pre-requisites for the dissolution treatment are:
(1)radiolucent stones,
(2) stones no greater than 20 mm in diameter
(3) a functioning gallbladder.
Among patients with symptomatic cholelithiasis, only a small
percentage (3-25%) would benefit from bile acid therapy
and up to 50% of those patients with proven dissolution,
can expect a recurrence of gallstones, during
the next five years.
At present, bile acid therapy is indicated
only for patients unfit or unwilling to undergo surgery

68. ESWL TREATMENT
After the disappointment of dissolution treatment
and the successful application of Extracorporeal Shock
Wave Lithotripsy (ESWL) in Urology, there was in the
mid 1980' an interest in the use of lithotripsy in
gallstone management.
ESWL shatters the stone into small fragments that can
either be dissolved more quickly using dissolution
treatment with ursodeoxycholate or may pass
spontaneously into the intestine.
Analysis of stone fragments in the feces of patients who
had undergone ESWL showed that 3 mm fragments can
pass to the intestine without causing symptoms

69. Dissolution and ESWL treatment for
gallstone disease are less cost-effective
than laparoscopic
cholecystectomy and should only be
recommended in
(1)elderly patients with symptomatic cholelithiasis
unfit
to receive general anesthesia and
(2) patients with symptomatic cholelithiasis actively
refusing to undergo operative treatment
if they have noncalcified, solitary
gallstones, no greater than 2 cm in diameter.

70. The ESWL procedure requires administration of propofol
anaesthesia i.v., on an outpatient
basis.
Complications are minimal (petechiae,
transient hematuria, liver hematoma) but almost half of
the patients experience one or more episodes of biliary
pain.

Furthermore, biliary pancreatitis can develop
in 1-2% of the patients.
Urgent or elective cholecystectomy
has to be performed in 3-7% of patients.

71. Operative Treatment
for Gallstones
Laparoscopic Cholecystectomy
Open Cholecystectomy
Cholecystostomy

72. KEY POINTS
1. The physiology of the gallbladder and sphincter of
Oddi are regulated by a complex interplay of
hormones and neuronal inputs designed to
coordinate bile release with food consumption.
2. complications of cholelithiasis. include
cholecystitis, choledocholithiasis, cholangitis, and
biliary pancreatitis. In addition, cholelithiasis plays
the role as the major risk factor for the
development of gallbladder cancer
3. Laparoscopic cholecystectomy has been
demonstrated to be a safe and effective alternative
to open cholecystectomy and has become the
treatment of choice for symptomatic gallstones.

73. 4. Common bile duct injuries, although uncommon,
can be devastating to patients. Proper exposure of
Calot's triangle and careful identification of the
anatomic structures are keys to avoiding these
injuries.
5. Carcinoma of the gallbladder and bile duct
generally have a poor prognosis because patients
usually present late in the disease process
and have poor response to chemo and radiation
therapies.
Surgery offers the best chance for survival and
has good long-term survival in patients with early-
stage disease.

74. Laparoscopic Laparoscopic
CholecystectomyCholecystectomy

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