powerpoint: gall stone disease and related disorders

GALL STONE DISEASE GALL STONE DISEASE AND RELATED AND RELATED DISORDERSDISORDERS

STRUCTURE OF STRUCTURE OF THE BILIARY SYSTEMTHE BILIARY SYSTEM Right and left hepatic ducts- CHD Right and left hepatic ducts- CHD

at 3-4 cm. outside the liverat 3-4 cm. outside the liver Cystic duct joins CHD- CBDCystic duct joins CHD- CBD CBD- 4-5 cm. length, passes down CBD- 4-5 cm. length, passes down

behind the duodenum, near the behind the duodenum, near the head of the pancreashead of the pancreas

CBD- drains via the ampulla of CBD- drains via the ampulla of Vater- D2Vater- D2

STRUCTURE OFSTRUCTURE OFTHE BILIARY SYSTEMTHE BILIARY SYSTEM Gall bladder lies in a depression in the Gall bladder lies in a depression in the

undersurface of the right hepatic lobeundersurface of the right hepatic lobe

CBD- 6 mm. in diameterCBD- 6 mm. in diameter

Bile made by the liver, passes down Bile made by the liver, passes down the biliary tract into the GB- stored, the biliary tract into the GB- stored, concentrated- active reabsorbtion of concentrated- active reabsorbtion of waterwater

FUNCTION OF FUNCTION OF THE BILIARY SYSTEMTHE BILIARY SYSTEM Lipid-rich food- duodenum promotes Lipid-rich food- duodenum promotes

secretion of CCK- contraction of the GB secretion of CCK- contraction of the GB forcing bile into the duodenumforcing bile into the duodenum

Bile- emulsifying agent, facilitates Bile- emulsifying agent, facilitates hydrolysis of lipids by pancreatic lipases.hydrolysis of lipids by pancreatic lipases.

If bile fails to reach duodenum (biliary If bile fails to reach duodenum (biliary tract obstruction), lipids are neither tract obstruction), lipids are neither digested or absorbed resulting in the digested or absorbed resulting in the passage of loose foul-smelling fatty stools passage of loose foul-smelling fatty stools (steatorhhea) (steatorhhea)

FUNCTION OF FUNCTION OF THE BILIARY SYSTEMTHE BILIARY SYSTEM Fat-soluble vitamins (A,D,E,K) not Fat-soluble vitamins (A,D,E,K) not

absorbedabsorbed Lack of vit.K.- inadequate Lack of vit.K.- inadequate

prothrombine synthesis and prothrombine synthesis and hence defective clotting- hence defective clotting- problems if surgery is necessaryproblems if surgery is necessary

PATHOGENESIS OF PATHOGENESIS OF GALLSTONE DISEASEGALLSTONE DISEASE Most gallstones- cholesterol+bile Most gallstones- cholesterol+bile

pigment+calcium saltspigment+calcium salts Small proportion are “pure” Small proportion are “pure”

cholesterol stonescholesterol stones Asia- most gallstones-bile Asia- most gallstones-bile

pigment alonepigment alone

PATHOGENESISPATHOGENESIS

Mixed stones- combination of Mixed stones- combination of abnormalities of bile constituents, abnormalities of bile constituents, bile stasis and infectionbile stasis and infection

Pigment stones- excess bilirubin Pigment stones- excess bilirubin secretion due to hemolytic secretion due to hemolytic disorders and infectiondisorders and infection


Main factors:Main factors:– Change in concentration of bile Change in concentration of bile

constituentsconstituents– Biliary stasisBiliary stasis– InfectionInfection


Bile salts and lecithin- maintain Bile salts and lecithin- maintain cholesterol in a stable micelle cholesterol in a stable micelle formationformation

An excess of cholesterol in An excess of cholesterol in relation to bile salts and lecithin is relation to bile salts and lecithin is one of the main factorsone of the main factors

Cholesterol precipitation is Cholesterol precipitation is enhanced by biliary stasis and enhanced by biliary stasis and infection infection

EPIDEMIOLOGY OF EPIDEMIOLOGY OF GALLSTONESGALLSTONES 10% of the adult population probably 10% of the adult population probably

have gallstoneshave gallstones Women are affected 4 times as often Women are affected 4 times as often

as menas men Pregnancy, obesity, diabetis are Pregnancy, obesity, diabetis are

predisposing factorspredisposing factors The typical patient is said to be: fair, The typical patient is said to be: fair,

fat, fertile, female of fourtyfat, fertile, female of fourty Poor fiber diet may play a partPoor fiber diet may play a part

INVESTIGATIONSINVESTIGATIONS

Exclude hematological and liver Exclude hematological and liver abnormalitiesabnormalities

Establish whether gall stones are Establish whether gall stones are present in the GB or CBDpresent in the GB or CBD

Assess integrity of bile duct and Assess integrity of bile duct and pancreatic ductpancreatic duct


Hemolytic disorders: hereditary Hemolytic disorders: hereditary spherocytosis, thalassemia and spherocytosis, thalassemia and sickle cell disease- pigment stonessickle cell disease- pigment stones

Liver function tests- jaundiceLiver function tests- jaundice Blood cultures- severe angiocholitisBlood cultures- severe angiocholitis U&E for pts with frequent vomiting U&E for pts with frequent vomiting

or diarhhea or diarhhea


Ultrasound scan- can assessUltrasound scan- can assess– Presence of stones,Presence of stones,– Thickness of GB wall Thickness of GB wall

(inflammation/fibrosis), (inflammation/fibrosis), – Duct dilatation,Duct dilatation,– Obstruction: stones, tumor, Obstruction: stones, tumor,

parasitesparasites– Structure of liver, pancreas, spleenStructure of liver, pancreas, spleen

CT- ACUTE CT- ACUTE CHOLECYSTITISCHOLECYSTITIS

PLAIN ABDO X RAYPLAIN ABDO X RAY

INVESTIGATIONSINVESTIGATIONSNON-JAUNDICED NON-JAUNDICED PATIENTSPATIENTS Not necessary preop. investigations Not necessary preop. investigations

for duct stonesfor duct stones If in doubt- peroperative If in doubt- peroperative

cholangigraphy at cholecystectomycholangigraphy at cholecystectomy Cholangiography via cystic duct into Cholangiography via cystic duct into

the CBD- filling defects caused by the CBD- filling defects caused by stones or distorsion of the lower end stones or distorsion of the lower end of the CBD or obstruction of the CBD or obstruction

INVESTIGATIONSINVESTIGATIONSJAUNDICED PATIENTSJAUNDICED PATIENTS History of transient jaundice- History of transient jaundice-

ERCP or cholangio-RMN- plan the ERCP or cholangio-RMN- plan the appropriate type of operation appropriate type of operation preoperativelypreoperatively

Frank obstructive jaundice- Frank obstructive jaundice- distinguish between stone and distinguish between stone and cephalic pancreatic tumorcephalic pancreatic tumor

BIOCHEMICAL FEATURES BIOCHEMICAL FEATURES OF OBSTRUCTIVE OF OBSTRUCTIVE JAUNDICEJAUNDICE Conjugated hyperbilirubinemiaConjugated hyperbilirubinemia Elevation of alkaline phosphataseElevation of alkaline phosphatase Minimal or no elevation of the serum Minimal or no elevation of the serum

transaminasestransaminases Presence of the bilirubin in the urine as Presence of the bilirubin in the urine as

the conjugated bilirubin is water the conjugated bilirubin is water solublesoluble

Elevation in the serum of cholesterol Elevation in the serum of cholesterol and bile acid levels and bile acid levels

INVESTIGATIONSINVESTIGATIONSOBSTRUCTIVE OBSTRUCTIVE JAUNDICEJAUNDICE USS of the abdomen: dilatation of the USS of the abdomen: dilatation of the

biliary ducts, stone lodged in the duct, biliary ducts, stone lodged in the duct, cephalic pancreatic nodule, enlarged cephalic pancreatic nodule, enlarged lymph nodes in the porta hepatislymph nodes in the porta hepatis

ERCP- diagnostic and therapeutic ERCP- diagnostic and therapeutic procedure- endoscopic sphincterotomyprocedure- endoscopic sphincterotomy

releasing the stone, relieving the jaundicereleasing the stone, relieving the jaundice Percutaneous transhepatic Percutaneous transhepatic

cholangiography cholangiography

ERCPERCP

ERCP-ERCP-SPHYNCTEROTOMYSPHYNCTEROTOMYSTONE EXTRACTIONSTONE EXTRACTION

ERCPERCP

CHOLANGIO MRICHOLANGIO MRI

CHRONIC CHRONIC CHOLECYSTITISCHOLECYSTITIS Intermittent cystic duct obstructionIntermittent cystic duct obstruction Typically, patients are overweight Typically, patients are overweight

femalefemale Chronic inflammation- thickened Chronic inflammation- thickened

and shrunken GBand shrunken GB Long history of RH pain, nausea, Long history of RH pain, nausea,

vomitingvomiting Pain exacerbated by fatty mealsPain exacerbated by fatty meals

CHRONIC CHRONIC CHOLECYSTITISCHOLECYSTITIS Symptoms are ill-defined: pain, Symptoms are ill-defined: pain,

nausea, fatty food intolerancenausea, fatty food intolerance Signs: mild RH tendernessSigns: mild RH tenderness Differential dg Differential dg

– Peptic ulcer diseasePeptic ulcer disease– Urinary tract infectionUrinary tract infection– Irritable bowel diseaseIrritable bowel disease

CHRONIC CHOLECYSTITISCHRONIC CHOLECYSTITISMANAGEMENTMANAGEMENT

Cholecystectomy is the definitive Cholecystectomy is the definitive treatmenttreatment

Classic or laparoscopic Classic or laparoscopic

CHRONIC CHRONIC CHOLECYSTITISCHOLECYSTITIS

CHRONIC CHRONIC CHOLECYSTITIS-CHOLECYSTITIS-LAPAROSCOPIC VIEWLAPAROSCOPIC VIEW

LAPAROSCOPIC LAPAROSCOPIC CHOLECYSTECTOMYCHOLECYSTECTOMY

BILIARY COLICBILIARY COLIC

Sudden and complete obstruction of Sudden and complete obstruction of the cystic duct by stonethe cystic duct by stone

Severe pain, the patient twists in Severe pain, the patient twists in agony until the pain resolvesagony until the pain resolves

A bout of vomiting often precedes the A bout of vomiting often precedes the end of the attackend of the attack

History of previous similar episodesHistory of previous similar episodes Few positive physical findings- local Few positive physical findings- local

tenderness, no fevertenderness, no fever

BILIARY COLICBILIARY COLICMANAGEMENTMANAGEMENT

Pain relief, USS of the abdomenPain relief, USS of the abdomen Immediate cholecystectomy or Immediate cholecystectomy or

put the patient on the waiting listput the patient on the waiting list Avoid fatty foodsAvoid fatty foods

ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS

Surgical emergencySurgical emergency Biliary colic, fever, tachycardiaBiliary colic, fever, tachycardia RH tendernessRH tenderness Palpable RH inflammatory massPalpable RH inflammatory mass Clinical course of acute Clinical course of acute

cholecystitis is more prolonged cholecystitis is more prolonged than biliary colicthan biliary colic

ACUTE CHOLECYSTITISACUTE CHOLECYSTITISMANAGEMENTMANAGEMENT USS, CT: thickened wallUSS, CT: thickened wall Oral intake restricted to fluidsOral intake restricted to fluids IV fluids, pain killers and antibioticsIV fluids, pain killers and antibiotics Early cholecystectomyEarly cholecystectomy For inflammatory mass- For inflammatory mass-

conservative treatment- elective conservative treatment- elective cholecystectomy after 2-3 monthscholecystectomy after 2-3 months

ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS

GANGRENOUS GANGRENOUS CHOLECYSTITISCHOLECYSTITIS

Empyema ofEmpyema ofthe gall bladderthe gall bladder GB distended with pus- an abscess of GB distended with pus- an abscess of

the GBthe GB Swinging pyrexiaSwinging pyrexia Part of the GB wall becomes necrotic- Part of the GB wall becomes necrotic-

perforation- biliary peritonitisperforation- biliary peritonitis Perforation is usually walled off by Perforation is usually walled off by

omentum- localized abscess formationomentum- localized abscess formation Sometimes- subphrenic abscess or Sometimes- subphrenic abscess or

generalized peritonitisgeneralized peritonitis Surgery without delay Surgery without delay

GALLSTONE ILEUSGALLSTONE ILEUS

Uncommon complication of Uncommon complication of chronic cholecystitischronic cholecystitis

GB becomes adherent to the GB becomes adherent to the duodenum, a stone ulcerating duodenum, a stone ulcerating through the wall to form a fistulathrough the wall to form a fistula

Fistula decompresses the Fistula decompresses the obstructed GB and allows stones obstructed GB and allows stones to pass into the bowel and gas to to pass into the bowel and gas to enter the biliary treeenter the biliary tree

GALLSTONE ILEUSGALLSTONE ILEUS

Diagnosis- plain abdo Xray- gas into Diagnosis- plain abdo Xray- gas into the biliary tree or fluid levels of the the biliary tree or fluid levels of the small bowel- biliary ileussmall bowel- biliary ileus

If obstructing stone is radioopaque can If obstructing stone is radioopaque can be seen as an opacity in the RIFbe seen as an opacity in the RIF

Operation is needed to remove the Operation is needed to remove the obstructing stone from the terminal obstructing stone from the terminal ileum: enterotomy, extraction, ileum: enterotomy, extraction, enteroraphyenteroraphy

Biliary ileusBiliary ileus

Rigler’s triad Rigler’s triad of findings: of findings: small bowel obstruction; small bowel obstruction; pneumobilia; and pneumobilia; and gallstone in right iliac gallstone in right iliac fossa. fossa.

Note the gas in the biliary Note the gas in the biliary tree, and rounded opacity tree, and rounded opacity in the pelvisin the pelvis

CT of the abdomen show CT of the abdomen show air in the gall bladder air in the gall bladder (red (red arrow)arrow)

air in the CBD air in the CBD (blue arrow) (blue arrow) representing pneumobilia, representing pneumobilia,

the gallstone in the small the gallstone in the small bowel lumen bowel lumen (yellow (yellow arrow)arrow)

dilated and fluid-filled dilated and fluid-filled loops of small bowel from loops of small bowel from SBO SBO (green arrow)(green arrow)

INTRA-OPERATIVE FINDINGINTRA-OPERATIVE FINDING

TRANSVERSE ENTEROTOMYTRANSVERSE ENTEROTOMY

STONE REMOVAL AND STONE REMOVAL AND ENTERORAPHYENTERORAPHY

BILE DUCT STONESBILE DUCT STONES

Nearly always originated in the Nearly always originated in the GB and passed through the cystic GB and passed through the cystic ductduct

Most stones are small enough to Most stones are small enough to pass out of the biliary system into pass out of the biliary system into the duodenum, resulting in biliary the duodenum, resulting in biliary colic and transient jaundicecolic and transient jaundice


CBD is narrowest at its lower end CBD is narrowest at its lower end and stones too large to pass outand stones too large to pass out

They tend to lodge at this pointThey tend to lodge at this point A stone here either becomes A stone here either becomes

impacted- progressive jaundice or impacted- progressive jaundice or acts as a ball-valve- intermittent acts as a ball-valve- intermittent jaundicejaundice


Obstruction results in gradual Obstruction results in gradual dilatation of the biliary treedilatation of the biliary tree

If dilatation is long standing it does not If dilatation is long standing it does not regress even after removal of the regress even after removal of the obstruction- bile stasis- further stone obstruction- bile stasis- further stone formationformation

Note that GB does not distend when Note that GB does not distend when there is an inflammatory fibrosis there is an inflammatory fibrosis caused by gall stonescaused by gall stones

CLINICAL CLINICAL PRESENTATIONPRESENTATIONBILE DUCT STONESBILE DUCT STONES Obstructive jaundiceObstructive jaundice Asymptomatic duct stonesAsymptomatic duct stones Acute pancreatitisAcute pancreatitis Ascending cholangitisAscending cholangitis

OBSTRUCTIVE OBSTRUCTIVE JAUNDICEJAUNDICE Causes:Causes:

– Stones in the CBDStones in the CBD– Carcinoma of the head of the Carcinoma of the head of the

pancreaspancreas– Periampullary tumorsPeriampullary tumors– Benign strictures of the CBDBenign strictures of the CBD– Extrinsic bile duct obstructionExtrinsic bile duct obstruction– Intrahepatic bile duct obstructionIntrahepatic bile duct obstruction

ASYMPTOMATIC DUCT ASYMPTOMATIC DUCT STONESSTONES Any patient with gall stones may Any patient with gall stones may

have duct stoneshave duct stones Some surgeons do at Some surgeons do at

cholecystectomy, routine cholecystectomy, routine cholangiography to exclude the cholangiography to exclude the presence of CBD stonespresence of CBD stones

Some surgeons do that if there Some surgeons do that if there are positive test of cholestasis or are positive test of cholestasis or dilated CBDdilated CBD

Common bile duct stone (choledocholithiasis). The Common bile duct stone (choledocholithiasis). The sensitivity of transabdominal ultrasonography for sensitivity of transabdominal ultrasonography for choledocholithiasis is approximately 75% in the choledocholithiasis is approximately 75% in the presence of dilated ducts and 50% for nondilated presence of dilated ducts and 50% for nondilated ductsducts

Notice inside the catheter is a black and yellow striped guide wire, Notice inside the catheter is a black and yellow striped guide wire, this guide wire stays in the common bile duct as the balloon this guide wire stays in the common bile duct as the balloon catheter is manipulated. Notice the arrow pointing at a stone that catheter is manipulated. Notice the arrow pointing at a stone that was removed from the common bile duct by the balloon catheter. was removed from the common bile duct by the balloon catheter. This stone will pass through the intestines and will be expelled.This stone will pass through the intestines and will be expelled.

ACUTE PANCREATITISACUTE PANCREATITIS

Stones near the ampulla of Vater Stones near the ampulla of Vater may interfere with drainage of may interfere with drainage of pancreatic enzymes onto the pancreatic enzymes onto the duodenumduodenum

This induces bile reflux into the This induces bile reflux into the Virsung duct- acute pancreatitisVirsung duct- acute pancreatitis

ASCENDING ASCENDING CHOLANGITISCHOLANGITIS Bile stasis in the CBD due to chronic Bile stasis in the CBD due to chronic

duct obstruction- predisposis to duct obstruction- predisposis to bacterial infectionbacterial infection

The infection extends proximally to The infection extends proximally to involve the intrahepatic duct systeminvolve the intrahepatic duct system

Pain, swinging pyrexia, jaundicePain, swinging pyrexia, jaundice Life-threatening condition- acute Life-threatening condition- acute

suppurative cholangitissuppurative cholangitis Urgent bile duct drainage: surgery or Urgent bile duct drainage: surgery or

endoscopic sphincterotomyendoscopic sphincterotomy

CARCINOMA OFCARCINOMA OF THE GALL BLADDER THE GALL BLADDER Chronic iritation by stones over a long Chronic iritation by stones over a long

period is believed to predispose to period is believed to predispose to adenocarcinoma of the gall bladderadenocarcinoma of the gall bladder

Rare condition, found in the elderlyRare condition, found in the elderly Usually unexpected finding at Usually unexpected finding at

cholecystectomy, incurable at the time cholecystectomy, incurable at the time of detectionof detection

Presenting symptoms similar to Presenting symptoms similar to chronic inflammatory gall bladder chronic inflammatory gall bladder diseasedisease

Jaundice may developJaundice may develop

MANAGEMENT OF MANAGEMENT OF GALLSTONE DISEASEGALLSTONE DISEASE Non-surgical treatmentNon-surgical treatment

Surgical treatmentSurgical treatment

NON-SURGICAL NON-SURGICAL TREATMENTTREATMENT Chenodeoxycholic acid increases Chenodeoxycholic acid increases

the bile salt pool and inhibits the bile salt pool and inhibits hepatic cholesterol secretionhepatic cholesterol secretion

Long-term treatment- slow Long-term treatment- slow dissolution of cholesterol stonesdissolution of cholesterol stones

High-rate of stone recurrenceHigh-rate of stone recurrence Side-effects- diarrhea and hepatic Side-effects- diarrhea and hepatic

damagedamage

SURGICAL TREATMENTSURGICAL TREATMENT

Open or laparoscopic cholecystectomyOpen or laparoscopic cholecystectomy Exploration of CBD- peroperative Exploration of CBD- peroperative

cholangiographycholangiography Presence of CBD stone- stone Presence of CBD stone- stone

extraction- T tube drainage (Kehr)extraction- T tube drainage (Kehr) T-tube cholangiography after removal T-tube cholangiography after removal

at 14-21 days postoperativelly at 14-21 days postoperativelly

BILE DUCT DRAINAGE BILE DUCT DRAINAGE PROCEDURESPROCEDURES Choledoco-duodenostomyCholedoco-duodenostomy Choledoco-jejunostomyCholedoco-jejunostomy Transduodenal sphyncteroplastyTransduodenal sphyncteroplasty Endoscopic sphyncterotomy Endoscopic sphyncterotomy

COMPLICATIONS OF COMPLICATIONS OF BILIARY SURGERYBILIARY SURGERY Retained stone in the CBD- endoscopic Retained stone in the CBD- endoscopic

sphyncterotomysphyncterotomy Biliary peritonitis due to bile leakage- Biliary peritonitis due to bile leakage-

lavage and drainagelavage and drainage Bile duct damage- relaparotomy- Bile duct damage- relaparotomy-

reconstructionreconstruction Hemorrhage- slipping knot from the Hemorrhage- slipping knot from the

stump of the cystic artery- hemostasisstump of the cystic artery- hemostasis Ascending cholangitis- late Ascending cholangitis- late

complication of complication of choledocoduodenostomycholedocoduodenostomy

powerpoint: gall stone disease and related disorders

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