surgical management of gall bladder disease and extrahepatic biliary obstruction

7/31/2019 Surgical Management of Gall Bladder Disease and Extrahepatic Biliary Obstruction

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SURGICAL MANAGEMENT OF GALL BLADDER DISEASE AND EXTRAHEPATIC BILIARY

OBSTRUCTION

Gary W. Ellison, DVM, MS, Diplomate ACVS

University of Florida, College of Veterinary Medicine, Gainesville, FL

Incidence/Clinical SignsGall bladder mucoceles often form in the gall bladder as a mucous filled bile concretions of the

gall bladder secondary to dysfunction of mucous secreting glands. They are rarely reported in cats. The

obstruction can extend into the cystic and common bile duct causing extrahepatic obstruction but this is less

common. These structures cause either emergent or periodic clinical signs which include anorexia,

vomiting, abdominal pain, and icterus. They are becoming increasingly common and are the most common

reason to perform cholecystectomy in our clinical practice. Histologically they are characterized byhyperplasia of the mucous secreting glands of the gallbladder mucosa. Cholecystitis ar necrotizing

cholecystitis are suspected as predisposing diseases but inflammatory or infectious changes are not

typically seen histologically. Bile peritonitis may also result if the mucolcele erodes the gallbladder wall

requiring early surgical intervention.

In our experience the most common cause of clinical icterus occurs secondary to pancreatitis.

Biliary obstruction may also be caused by biliary concretions, stenosis of the common bile duct, neoplasia,

cholelithiasis, or choledocholithiasis. Cholelithiasis occurs uncommonly in the dog and even less frequently

in the cat. In the southeast US biliary obstruction secondary to liver flukes are common in cats due to theingestion of anole lizards indigenous to the area. Proposed etiologies for cholelithiasis are bile stasis,

infection, changes in bile composition, injury to the bile duct mucosa, and reflux of pancreatic juices.Cholelithiasis does not usually cause overt clinical signs in dogs or cats unless complete obstruction occurs.

Occasionally, choleliths formed in the gallbladder or bile ducts will pass into the common bile duct and

cause permanent or temporary obstruction. Clinical signs associated with biliary obstruction include

anorexia, vomiting, abdominal pain, and icterus.

Diagnosis

Evidence of extrahepatic biliary obstruction is suspected with grossly elevated serum bilirubin

levels of which 60-90 percent is in the conjugated form. Elevation of urine bilirubin to a 2-3+ level, andabsence or reduction of urine urobilinogen levels further substantiates the obstruction. Clinical steatorrhea

may also be seen.

Radiographic diagnosis of biliary obstruction is sometimes difficult because only 20-30 percent ofthe choleliths are radiodense, and oral or intravenous cholecystography is not always successful in

identifying gallbladder pathology. The technique of percutaneous cholecystography has been recently

described and will distinguish hepatic from posthepatic jaundice. The disadvantage of this technique is that

it must be performed under fluoroscopy.

Diagnosis of gall bladder disease and extrahepatic biliary obstruction is best achieved withultrasonography. This imaging modality can help identify a dilated common bile duct, tortuous dilated

cystic duct, a thickened gall bladder wall , the presence of cholethiasis, gall bladder sludge and of course

the pathognomonic stellate kiwifruitappearance of a gall bladder mucocele. Additonally ultrasound can

identify defects in the gall bladder wall free peritoneal fluid and adherence of omentum to the gall bladder.

All these signs are consistent with gall bladder rupture.

Fluid distention of the abdomen with the recovery of Ictotest positive coffee-colored fluid

indicates that bile peritonitis is present and leakage from the hepatobiliary tree has occurred. Exploratory

celiotomy is warranted.

Surgical Management of Gall Bladder Disease and Biliary Obstruction

Biliary obstruction should initially be managed by cholecystotomy and exploration of the

extrahepatic biliary tree with a probe or catheter. Obstructing calcium bilirubinate stones or inspissated bile

may be removed from the gallbladder or dislodged from the bile ducts with saline under pressure.

Choleliths lodged in the common bile duct are best dislodged via a duodenotomy passage of a catheter up

the duodenal papilla and retrograde flushing of the stone to a dilated portion of the bile duct or cystic duct

were it can be more easily removed. If severe cholangitis or erosion of the gallbladder wall is present, a

cholecystectomy should be performed. A cholecystoenterostomy procedure is performed if the calculus can


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I always place an enterostomy tube prior to abdominal closure. The enterostomy tube allows you to feed

the dog or cat directly into the jejunum thereby bypassing the pancreas and pyloric antrum. There is less

excretion of the hormone cholecystokinin and therefore less contraction of the biliary tract in the early

postoperative period.

Prognosis

Dogs tend to survive ruptured gall bladders when the bile is sterile however rupture secondary toinfectious cholecystitis is often fatal. Ascending cholecystitis has been reported as a common sequela to a

cholecystoenterostomy. The pathogenesis is thought to be due to a reflux of duodenal contents into the

gallbladder. Clinical signs include fever, abdominal pain, vomiting, neutrophilia, and elevation of SGPT

and SGOT. Patients usually respond to oral antibiotic therapy, but recurrent episodes are common. Creation

of a stoma at least 2.5 cm in length may decrease gallbladder retention of ingesta and minimize the

occurrence of postoperative cholecystitis.

REFERENCES

1. Besso JG,Wrigley RH,Gliatto, JM. Ultrasoundappearence and clinical findings in 14 dogs with

gallbladder mucocele. Vet Rad Ultrasound41:261 2004.

2. Pike FS, Berg J,KingNV. Gallbladder mucocele in diogs: 30 cases 2000-2002.J Am Vet Med Assoc

224:1615. 2004.

3. Worley DR, Hottinger HA, Lawrence HJ. Surgical management of gallbladder mucocele in dogs22 cases. ( 1999-2003.J Am Vet Med Assoc 225: 1418,2004.

4. Mahour GH, Wahin KG, Saule EH, Ferris DO. Effect of cholecystectomy on the biliary ducts inthe dog.Arch Surg1968;97:570.

6. Tangner CH, Turrill JM, Hobson HP. Complications associated with proximal duodenal resection

and cholecystoduodenostomy in two cats. Vet Surg1982;11(2):60.

7. Bellah JR. Guest ed in surgical stapling. Vet Clin N Am 1994;24(2):375-393.

surgical management of gall bladder disease and extrahepatic biliary obstruction

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