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Gall stone disease

Gall stone disease. Dr m.Farhad General Surgeon. Anatomy. Gallstone Pathogenesis. Bile contains: Cholesterol Bile salts Phospholipids Bilirubin Gallstones are formed when cholesterol or bilirubinate are supersaturated in bile and phospholipids are decreased. Gallstone Pathogenesis.

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Gall stone disease

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  1. Gall stone disease Dr m.Farhad General Surgeon

  2. Anatomy

  3. Gallstone Pathogenesis • Bile contains: • Cholesterol • Bile salts • Phospholipids • Bilirubin • Gallstones are formed when cholesterol or bilirubinate are supersaturated in bile and phospholipids are decreased

  4. Gallstone Pathogenesis • Stone formation is: • Initiated by cholesterol or bilirubinate super saturation in bile • Continued to crystal nucleation (microlithiais or sludge formation) • And gradually stone growth occur • Gallstone types • Cholesterol • Pigment • Brown • Black

  5. What are gallstones? • Small, pebble-like substances • Multiple or solitary • May occur anywhere within the biliary tree • Havedifferent appearance - depending on their contents

  6. 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

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

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

  9. Risk Factors for Gallstones • Obesity  • Rapid weight loss    • Childbearing    • Multiparity    • Female sex    • First-degree relatives    • Drugs: ceftriaxone, postmenopausal estrogens, • Total parenteral nutrition    • Ethnicity: Native American (Pima Indian), Scandinavian    • Ileal disease, resection or bypass    • Increasing age

  10. Asymptomatic Gallstone • Incidentally found gallstone in ultrasound exam for other problems • Many individuals are concerned about the problem • Sometimes pt. has vague upper abdominal discomfort and dyspepsia which cannot be explained by a specific disease • If other work up are negative may be • Routine cholecystectomy is not indicated

  11. Definitions • Biliary colic • Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone • No fever, No leukocytosis, Normal LFT

  12. Definitions • Chronic cholecystitis • Recurrent bouts of biliary colic leading to chronic GB wall inflammation/fibrosis. • No fever, No leukocytosis, Normal LFT

  13. Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones • Overtime, leads to scarring/wall thickening • Attacks of biliary colic may occur overtime

  14. Differential diagnosis of RUQ pain • Biliary disease • Acute or chronic cholecystitis • CBD stone • cholangitis • Inflamed or perforated peptic ulcer • Pancreatitis • Hepatitis • Rule out: • Appendicitis, renal colic, pneumonia, pleurisy and …

  15. Definitions • Acute cholecystitis • Acute GB distension, wall inflammation & edema due to cystic duct obstruction. • RUQ pain (>24hrs) +/- fever, ↑WBC, Normal LFT, • Murphy’s sign = inspiratory arrest

  16. Ultrasound is the first choice for imaging • Distended gallbladder • Increased wall thickness (> 4 mm) • Pericholecystic fluid • Positive sonographic Murphy’s sign (very specific) • Nuclear HIDA scan shows no filling of GB • If U/S non-diagnostic, order HIDA

  17. Gall bladder ultrasound • Shows gallstones • the acoustic shadow due to absence of reflected sound waves behind the gallstone → → ►

  18. Ultrasound • Curved arrow • Two small stones at GB neck • Straight arrow • Thickened GB wall • ◄ • Pericholecystic fluid = dark lining outside the wall ◄

  19. CT scan • → denotes the GB wall thickening • ► denotes the fluid around the GB • GB also appears distended → ►

  20. Complications of acute cholecystitis • Empyema of gallbladder • Pus-filled GB due to bacterial proliferation in obstructed GB. Usually more toxic with high fever • Emergent operation is needed

  21. Complications of acute cholecystitis • Emphysematous cholecystitis • More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. • Imaging shows air in GB wall or lumen • Emergent cholecystectomy is needed

  22. Emphysematouscholecystitis

  23. Complications of acute cholecystitis • Perforated gallbladder • Pericholecystic abscess (up to 10% of acute cholecystitis) • Percutaneous drainage in acute phase • Biliary peritonitis due to free perforation • Emergent Laparotomy

  24. Complications of acute cholecystitis • Chronic perforation into adjacent viscus (cholecystoenteric fistula) • Air is seen in the biliary tree • The stone can cause small bowel obstruction if large enough (gallstone ileus) • Laparotomy is needed for extraction of stone, cholecystectomy and closure of fistula

  25. Gallstone Ileus

  26. Definitions • Acalculous cholecystitis • A form of acute cholecystitis • GB inflammation due to biliary stasis(5% of time) and not stones(95%). • Often seen in critically ill patients

  27. Acute acalculous cholecystitis • 5-10% of cases of acute cholecystitis • Seen in critically ill pts or prolonged TPN • More likely to progress to gangrene, empyema & perforation due to ischemia • Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin • Emergent operation is needed

  28. Cholangitis • Infection within bile ducts due to obstruction of CBD. • Infection of the bile ducts due to CBD obstruction secondary to stones, strictures • May lead to life-threatening sepsis and septic shock • It may present as two forms: • Suppurative • Non-suppurative

  29. Non suppurative: • Persistent RUQ pain + fever + jaundice, (Charcot’s triad) ↑WBC, ↑LFT, • Suppurative: • Persistent RUQ pain + fever + jaundice, ↑WBC, ↑LFT, • Hepatic encephalopathy or hypotension may ensue (Reynold’s pentad)

  30. MRCP & ERCP

  31. Gallstone pancreatitis • 35% of acute pancreatitis secondary to stones • Pathophysiology • Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone • ALT > 150 (3-fold elevation) has 95% PPV for diagnosing gallstone pancreatitis • Tx: ABC, resuscitate, NPO/IVF, pain meds • Once pancreatitis resolving, ERCP & stone extraction/sphincterotomy • Cholecystectomy before hospital discharge in mild case

  32. Spectrum of Gallstone Disease • Symptomatic cholelithiasis can be a herald to: • an attack of acute cholecystitis • ongoing chronic cholecystitis • May also resolve

  33. Porcelain Gallbladde • A precancerous condition • Needs cholecystectomy

  34. Treatment

  35. Medical Treatment • Medical treatment for • Acute biliary colic attack • Acute cholecystitis with comorbid diseases Including: • GI rest • NG tube if vomiting • IV Fluids • Analgesics (not morphine) • Antibiotics for cholecystitis (against GNR & enterococcus)

  36. Surgical Treatment • Early cholecystectomy for acute cholecystitis (usually within 48hrs) • Laparoscopic • Open • Elective cholecystectomy for biliary colic, chronic cholecystitis and some asymptomatic stones • Laparoscopic • Open • Endoluminal? • Cholecystostomy is the best choice If patient is too sick or anatomy is deranged • Percutaneous • Open

  37. Pigment stone

  38. Choledocholithiasis Treatment • Endoscopic retrograde cholangiopancreatography (ERCP) • Endoscopic sphincterotomy and stone extraction • Interval cholecystectomy after recovery from ERCP • Surgical CBD exploration if dilated (1.5-2 cm) or stone larger than 1.5 cm • Open • Laparoscopic

  39. ERCP endoscopic sphincterotomy

  40. Cholangitis • Medical management (successful in 85% of cases): • NPO • IV Fluids • IV AB. • Emergent decompression if medical treatment fails • ERCP • Percutaneous transhepatic drainage (PTC) • Emergent laparotomy

  41. Biliary Tract TumoursCholangiocarcinoma Cancer of the Gall Bladder

  42. Biliary Tree Neoplasms • Clinical symptoms: • Weight loss (77%) • Nausea (60%) • Anorexia (56%) • Abdominal pain (56%) • Fatigue (63%) • Pruritus (51%) • Symptomatic patients usually have advanced disease, with spread to hilar lymph nodes before obstructive jaundice occurs • Associated with a poor prognosis. • Fever (21%) • Malaise (19%) • Diarrheoa (19%) • Constipation (16%) • Abdominal fullness (16%).

  43. Cholangiocarcinoma • Adenocarcinoma of the bile ducts • May occur without associated risk factors • Associated with chronic cholestatic liver disease such as: • Primary Sclerosing Cholangitis • Choledochal cysts • Asbestos. • Accounts for 25% of biliary tract cancers • Presentation: • Jaundice • Vague upper or right upper quadrant abdominal pain • Anorexia, weight loss • Pruritus.

  44. Cholangiocarcinoma • Slow growing malignancy of biliary tract which tend to infiltrate locally and metastasize late. • Gall Bladder cancer = 6,900/yr • Bile duct cancer = 3,000/yr • Hepatocellular Ca = 15,000/yr

  45. CholangiocarcinomaDiagnosis and Initial Workup • Jaundice • Weight loss, anorexia, abdominal pain, fever • US – bile duct dilatation • Quadruple phase CT • MRCP/MRI • ERCP with Stent and Brush Biopsy • Percutaneous Cholangiogram with Internal Stent and Brush Biopsy

  46. MRCP: Cholangiocarcinoma at the Bifurcation Klatskin tumour = Cholangiocarcinoma of junction of right & left hepatic ducts

  47. ERCP: Distal CBD Cancer

  48. Surgical Removal • Node Dissection in Bile Duct Excision • Roux-en-Y Hepaticojejunostomy

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