Prsenation for gall stones for medical students.ppt

It is a presentation for the gall stones, very helping for everyone

1. Pigment Stones
Small
Friable
Irregular
Dark
Made of bilirubin and
calcium salts
Less than 20% of
cholesterol
Risk factors:
•Haemolysis
•Liver cirrhosis
•Biliary tract infections
•Ileal resection

2. Pigment Stones
Small
Friable
Irregular
Dark
Made of bilirubin and
calcium salts
Less than 20% of
cholesterol
Risk factors:
•Haemolysis
•Liver cirrhosis
•Biliary tract infections
•Ileal resection

3. Cholesterol Stones
Large
Often solitary
Yellow, white or green
Made primarily of
cholesterol (>70%)
Risk factors:
•4 “F” :
Female
Forty
Fertile
Fat
•Fair (5
th
“F” - more
prevalent in Caucasians)
•Family history (6
th
“F”)

4. Mixed Stones
Multiple
Faceted
Consist of:
•Calcium salts
•Pigment
•Cholesterol (30% - 70%)
80% - associated with chronic cholecystitis

6. Gallstone Prevalence
10% of people over 40 yrs.
90% “silent stones”
Risk factors for becoming
symptomatic:
•Smoking
•Parity

7. Risk Factors
Women
Age > 60 years
American Indians & Mexican Americans
Overweight or obese men and women
People who tend to fast or lose weight quickly
Family history of gallstones
Diabetes
Diet high in cholesterol
Use of OCPs
Pregnancy

8. Gallstone Pathogenesis
Bile = bile salts, phospholipids, cholesterol
Gallstones form due to alteration in the ratio of bile
salt/phospholipid /cholesterol
Pathogenesis involves 3 stages:
Cholesterol supersaturation in bile
Crystal nucleation ( mucin hypersecretion by GB mucosa creats a
viscoelastic gel that foster crystal nucleation)
Bile stasis ( fasting,ocps, pregnancy, vagotomy ,prolong TPN)

10. ANATOMY
BILIIARY SYSTEM GALL BLADDER

11. GALL BLADDER PHYSIOLOGY

12. Cont…

13. Definitions
Symptomatic
cholelithiasis
Wax/waning postprandial epigastric/RUQ pain due to transient
cystic duct obstruction by stone, no fever/WBC, normal LFT
Acute
cholecystitis
Acute GB inflammation due to cystic duct obstruction. Persistent
RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest
Chronic
cholecystitis
Recurrent bouts of colic/acute chol’y leading to chronic GB wall
inflamm/fibrosis. No fever/WBC.
Acalculous
cholecystitis
GB inflammation due to biliary stasis(5% of time) and not
stones(95%). Seen in critically ill pts
Choledocho-
lithiasis
Gallstone in the common bile duct (primary means originated there,
secondary = from GB)
CholangitisInfection within bile ducts usu due to obstrux of CBD. Charcot triad:
RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic
shock
Mucocele GB Overdistended GB filled with mucoid or clear fluid and watery
content, Usually noninflammatory, it results from outlet
obstruction of the gallbladder and is commonly caused by an
impacted stone in the neck of the gallbladder or in the cystic
duct.
 

14. Differential Diagnosis Of RUQ
Pain
Biliary disease
•Acute cholecystitis, chronic cholecystitis, CBD
stone, cholangitis
Inflamed or perforated duodenal ulcer
Hepatitis
Also need to rule out:
•Appendicitis, renal colic, pneumonia or
pleurisy, pancreatitis

15. Symptoms
Pain in the RUQ
•Most common and typical symptom
•May last for a few minutes to several hours
•Mostly felt after eating a heavy and high-fat meal
Pain under right shoulder when lifting up arms
Fever, nausea and vomiting
Jaundice (obstruction of the bile duct passage)

16. Murphy’s Sign: Inspiratory arrest with manual
pressure below the gallbladder

17. Complications Of Gallstones
In the GB:
•Biliary colic
•Acute and chronic
cholecystitis
•Empyema
•Mucocoele
•Carcinoma
In the bile ducts:
•Obstructive jaundice
•Pancreatitis
•Cholangitis
In the gut:
•Gallstone ileus

18. 0.1–0.7% of patients who have gallstones
Csendes classification :
•Type 1: external compression of the common bile duct – 11%
•Type 2: cholecystobiliary fistula is present involving <1/3 rd the
circumference of the bile duct – 41%
•Type 3: a fistula is present involving upto 2/3 the circumference of the
bile duct – 44%
•Type 4: a fistula is present with complete destruction of the wall of the
bile duct – 4%
Mirizzi syndrome

19. Diagnosis
Ultrasound
Computerized tomography (CT) scan
•May show gallstones or complications, such as rupture of GB or
bile ducts
•Only calcified GB stone are hyperattenuating to bile, making them the
only type to be clearly visualized on CT scan images. Pure cholesterol
stones are hypoattenuating to bile, and other gallstones are isodense
to bile and these may not be clearly identified on CT.
Cholescintigraphy (HIDA scan)
•Used to diagnose abnormal contraction of gallbladder or
obstruction of bile ducts
Endoscopic retrograde cholangiopancreatography (ERCP)
Used to locate and remove stones in bile ducts
Blood tests- CBC , LFT ,CLOTTING PROFILE,S.AMYLASE/LIPASE
•Performed to look for signs of infection, obstruction, pancreatitis,
or jaundice

20. USG
CT Scan

21. MRCP- Used to visualize the biliary and pancreatic ducts in a non-invasive
manner. This procedure can be used to determine if gallstones are lodged in any of
the ducts surrounding the GB
MRCP ERCP

22. Management

23. Surgical options
•Cholecystostomy
•Subtotal cholecystectomy
•Open cholecystectomy
•Laparoscopic cholecystectomy
•Mini-cholecystectomy

24. Cholecystostomy
Patients at high risk related to multisystem organ failure
Severe pulmonary, renal, or cardiac disease
Recent myocardial infarction
Cirrhosis with portal hypertension
Acalculus cholecystitis after severe trauma, burns, or
surgery
Empyema or gangrene of the gallbladder

25. Subtotal Cholecystectomy
Severe inflammation renders identification of
the anatomy impossible, eg. Gangrenous
cholecystitis
Scarred partially intrahepatic gallbladder
Severe cirrhosis and portal hypertension

26. Cholecystectomy
Laparoscopic Surgery
Advantages:
Less post-op pain
Shorter hospital stay
Quicker return to normal activities
Disadvantages:
Learning curve
Inexperience at performing open cholecystectomies

28. Cont……

29. Mini-cholecystectomhy
MC is an effective minimally invasive surgical procedure for both acute
and chronic cholecystitis, with a low morbidity rate (5.6%), an early
return to oral diet, few doses of postoperative analgesic and a short
postoperative hospital stay.
 A small right subcostal incision (4-5cm ) is the appropriate choice for
MC in either a normal-sized or distended gallbladder.
 MC can be performed without the use of special instruments, thus
reducing the expense.
 Since not every case is suitable for LC and MC is cheaper, MC should be
considered in every case of gallstone disease, particularly in a
developing country in which the health-care budget is limited

30. Cholecystectomy when to perform?
After acute cholecystitis, cholecystectomy traditionally performed after
6 weeks
Arguments for 6 weeks later
Laparoscopic dissection more difficult when acutely inflammed
Surgery not optimal when patient septic/dehydrated
Logistical difficulties (theatre space, lack of surgeons)
Arguments for same admission
Research suggests same admission lap chole as safe as elective chole (conversion
to open maybe higher)
Waiting increases risk of further attacks/complications which can be life
threatening
Risk of failure of conservative management and development of dangerous
complication such as empyema, gangrene and perforation can be avoided
National guidelines state any patient with attack of gallstone
pancreatitis should have lap chole within 3 weeks of the attack

31. Complications of Lap
Cholecystectomy
Trocar/Veress needle injury
Hemorrhage
Wound infection and/or abscess
Ileus
Bile leak
Gallstone spillage
Deep vein thrombosis
Retained common bile duct (CBD) stone
CBD injury & stricture
Pancreatitis
Conversion to open procedure

32. Post-cholecystectomy syndrome

33. Cause of PCS

34. Management of PCS

35. Nonsurgical treatment:
•Only in special situations
When a patient has a serious medical condition preventing
surgery
Only for cholesterol stones
•Oral dissolution therapy
Ursodeoxycholic acid - to dissolve cholesterol gallstones
Months or years of treatment may be necessary before all
stones dissolve
•Contact dissolution therapy
Experimental procedure
Involves injecting a drug directly into the gallbladder to dissolve
cholesterol stones

36. Prevention
A sensible diet is the best way to prevent gall stones
Avoid crash diet or very low intake of calories
Eat good sources of fiber

37. .