Gallstones and it's Complications

Gallstones:
Most common biliary pathology
Asymptomatic in majority of cases (>80%)
Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year.

1. Gallstones & its complications Presented by: Anish Dhakal (Aryan)

2. GallStones Most common biliary pathology Asymptomatic in majority of cases (>80%) Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year. Inflammation of GB mucosa can lead to excessive absorption of water and bile salts leaving cholesterol in higher concentration The cholesterol, then precipitates in many small crystals, which may progress to large crystals

3. Types of Gall Stones Gallstones can be divided into three main types: Cholesterol Pigment (brown/black) Mixed stones

4. Risk Factors for Cholesterol Gallstones

5. Cholesterol Gallstone Contain 51-99% of pure cholesterol plus admixture of calcium salts, bile acids, bile pigments and phospholipids Pathological process: B ile supersaturated with cholesterol/low bile acid concentration → F ormation of unstable unilaminar phospholipid vesicles → N ucleation of cholesterol crystals → Stone formation

6. Pigment Stones Contains less than 30 % of cholesterol Arise anywhere in biliary tree They are of two types: Black pigment stone Brown pigment stone

7. Black Pigment Stone 20-30% stones are black C omposed of Insoluble bilirubin pigment polymer mixed with calcium phosphate and calcium bicarbonate A ssociated with hemolysis , hereditary spherocytosis or sickle cell disease Patients with cirrhosis have a higher instance of pigmented stones.

8. Brown Pigment Stones Calcium bilirubinate , calcium palmitate , calcium stearate and cholesterol R are in the gall bladder whereas form in the bile duct and are related to bile stasis and infected bile Pathology: due to deconjugation of bilirubin deglucuronide by bacterial ß- glucuronidase

9. Diagnosis Based on the history and physical examination with confirmatory radiological studies T ransabdominal ultrasonography R adionuclide scan Acute phase  right upper quadrant tenderness that is exacerbated during inspiration by the examiner’s right subcostal palpation ( Murphy’s sign ) Positive Murphy’s sign suggests acute inflammation and may be associated with a leukocytosis and moderately elevated liver function tests A palpable, non-tender gall bladder (Courvoisier’s sign)

10. Abdominal Ultrasonography (USG) Investigation of choice for diagnosing gallstones sensitivity > 95%; specificity 99% As 75% of gall bladder stones are radiolucent, plain film (X-ray) of the abdomen is of little use

11. ERCP (Endoscopic Retrograde Cholangiopancreatography ) Visualization of upper GI tract, ampullary region, biliary and pancreatic ducts Method for treatment of CBD stones in peri-ampullary region

12. MRCP (magnetic resonance cholangiopancreatography ) Same information gained as ERCP but non-invasive

13. Treatment of Gallstone Safe to observe asymptomatic gallstones Patients with symptoms or complications: cholecystectomy Prophylactic cholecystectomy : patients with Diabetes, congenital hemolytic anaemia , undergoing Bariatric surgery where risk of developing symptoms Cholecystectomy if no medical contraindications: patients with biliary colic or cholecystitis

14. Non-operative Treatment with conservative measures: 90% of cases symptoms subside Four principles: NPO and IV fluid untill pain resolves Administration of analgesics Administration of antibiotics: a broad spectrum antibiotic effective against gram – ve aerobes e.g. cefazolin , cefuroxime or gentamicin Subsequent management: if inflammation is subsiding, oral fluid and regular diet is reinstated. USG to confirm diagnosis. If jaundice, MRCP to exclude choledocholithiasis . CT if suspected any complication

15. Contd. If pain and tenderness increase, conservative treatment must be abandoned Cholecystostomy is performed followed by cholecystectomy once patient’s condition is stabilised If early operation is not indicated, need to wait 6wks for inflammation to subside before operating

16. Cholecystectomy 1. Open cholecystectomy : Right subcostal incision (Kocher’s incision) Upper midline or short right upper transverse incision Indications: Gall stones: symptomatic Cholecystitis : acute, chronic Acalculous cholecystitis Empyema of gall bladder Mucocele of gall bladder Figure: open cholecystectomy

17. Cholecystectomy 2. Laparoscopic cholecystectomy : Procedure of choice for patients with gall bladder disease Ports: 10mm port in umbilicus to pass telescope 10 mm port in midline epigastrium as working channel Two 5mm ports at midclavicular and anterior axillary line in subcostal region Figure: laparoscopic cholecystectomy

18. Acute cholecystitis Usually associated with an obstruction of the neck of the gallbladder or cystic duct caused by stones impacted in Hartmann's pouch I mpacted stone also cause mucosal erosion allowing bile salt to act over the submucosal tissues as bile is toxic to these tissues leading to infection and necrosis and perforation

19. Etiology 3 factors: Mechanical inflammation Increased intraluminal pressure and distention with resulting ischemia of gall bladder mucosa and wall Chemical inflammation Due to release of lysolecithin and other local tissue factors Bacterial inflammation (50-85%) Escherichia coli Klebsiella spp. Streptococcus spp. Clostridium spp. Salmonella

20. acute calculus cholecystitis Cardinal feature Pain in RUQ ( epigastrium ), right shoulder tip or interscapular region Difference between biliary colic severe and prolonged pain, fever and leucocytosis Examination Right hypochondral tenderness Murphy’s sign positive (rigidity worse on inspiration) Fever (no rigors) <10% jaundice (passage of stones into common bile duct)

21. Contd.. Complication If no resolution Gallbladder empyema Wall become necrotic and perforate  with localized peritonitis Abscess perforate into peritoneal cavity with septic peritonitis (uncommon)

22. Investigations Peripheral blood leucocytosis Minor increase in transaminase and amylase Chest x-ray USG aids in diagnosis CT uncertain diagnosis

23. Differential diagnosis of cholecystitis

24. Acute non-calculous cholecystitis Acute and chronic inflammation of the gall bladder can occur in the absence of stones and give rise to a clinical picture similar to calculous cholecystitis. Occurs in seriously ill patients Postoperative state after major, non-biliary surgery Severe trauma Burns Sepsis In these patients, the diagnosis is often missed, and the mortality rate is high

25. Treatment Asymptomatic gallstones→ not require treatment, unless the patient Has a porcelain gallbladder (which has an increased incidence of carcinoma) Has a stone > 2–3 cm Is a pediatric patient. Is immunocompromised Symptomatic patients→ cholecystectomy

26. Conservative measures More than 90 per cent of cases, the symptoms of acute cholecystitis subside with conservative measures Non-operative treatment is based on four principles Nil per oral (NPO) and intravenous fluid administration until the pain resolves. Administration of analgesics Administration of antibiotics A broad-spectrum antibiotic effective against Gram-negative aerobes is most appropriate (e.g. cefazolin , cefuroxime or gentamicin).

27. 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 confirm the diagnosis. If an early operation is not indicated, one should wait approximately 6 weeks for the inflammation to subside before operating.

28. Chronic Cholecystitis Chronic inflammation of gallbladder Symptoms: Recurrent attack of upper abdominal pain; often at night following meal Clinical feature: similar to acute calculous cholecystitis but milder Patient recover spontaneously or following analgesia and antibiotics Management: elective cholecystectomy

29. Empyema of gall bladder Results from progression of acute cholecystitis with persistent cystic duct obstruction to superinfection of stagnant bile with pus forming organisms Clinical features: High grade fever Pain and tenderness over Rt. Hypochondrium Treatment: IV antibiotics: Cefotaxime, Ceftriaxone Drainage Later cholecystectomy Complications: Septicaemia Rupture and Peritonitis (Biliary or Bacterial)

30. Mucocoele Due to obstruction of cystic duct by stone in the neck (Hartmann’s pouch) without any infection or inflammation Gallbladder distended over a period of time by mucus ( Mucocele ) or by a clear transudate (Hydrops) Patients usually remains asymptomatic but chronic RUQ pain may be there Clinical features: Visible, Easily palpable, soft, non-tender mass in right hypochondrium Dyspepsia Investigation: USG, LFT Treatment: Cholecystectomy

31. Acute cholangitis Caused by bacterial infection of bile ducts Occur in patients with preexisting biliary problems ( Choledocholithiasis , Biliary strictures or tumors) Clinical features: Charcot’s triad: Jaundice, Fever (With or without rigors) and RUQ pain Treatment: Antibiotics Relief of biliary obstruction Removal of underlying causes (if possible)

32. Gallstone Ileus Refers to mechanical intestinal obstruction resulting from passage of large gallstone into bowel lumen Enters duodenum through cholecystoenteric fistula Site of obstruction usually at ileocecal valve Usually stone of > 2.5 cm predisposes to fistula formation Clinical features: common in elderly, pain abdomen and feature of intestinal obstruction. Treatment: Laparotomy with stone extraction is choice of treatment to relieve obstruction

33. Stones in the bile duct occur many years after a cholecystectomy or be related to the development of new pathology, e.g. infection of the biliary tree or infestation by Ascaris or Clonorchis Any obstruction to the flow of bile can give rise to stasis with the formation of stones within the duct Consequences are either obstruction to bile flow or infection Stones in the bile duct-associated with infected bile (80%) than are stones in the gall bladder

34. Symptoms May be asymptomatic but usually has bouts of pain, jaundice and fever  Charcot’s triad Stone moves proximally and floats, obstruction is relieved & symptoms subside

35. Signs Tenderness - epigastrium and the right hypochondrium. In jaundiced patient; “ Courvoisier’s law ” – ‘in obstruction of the common bile duct due to a stone, distension of the gall bladder seldom occurs; the organ is usually already shriveled.’

36. Investigations USG abdomen; CBD diameter > 1 cm indicates biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP): gold standard Magnetic resonance cholangiopancreatography (MRCP). Liver function tests.

37. Treatment Full supportive measures: with rehydration, correction of clotting abnormalities and treatment with appropriate broad-spectrum antibiotics. Once the patient has been resuscitated, relief of the obstruction is essential. Endoscopic papillotomy: preferred first technique with a sphincterotomy, removal of the stones using a Dormia basket or the placement of a stent if stone removal is not possible. If this technique fails, percutaneous transhepatic cholangiography can be performed to provide drainage and subsequent percutaneous choledochoscopy . Choledochotomy , rarely used, most managed by minimally invasive

38. Indications for choledochotomy Palpable stones in the common bile duct; Jaundice, a history of jaundice or cholangitis; A dilated common bile duct; Abnormal liver function tests, in particular a raised alkaline phosphatase.

39. Reference Bailey & Love’s Short Practice of Surgery, 26 th edition SRB Manual of Surgery

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