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
Stone formation is:
1. Initiated by cholesterol or bilirubinate super
saturation in bile
2. Continued to crystal nucleation (microlithiais or
sludge formation)
3. And gradually stone growth occur
Gallstone types
1. Cholesterol
2. Pigment
• Brown
• Black
What are gallstones?

Small, pebble-like
substances
Multiple or solitary
May occur anywhere
within the biliary tree
Have different
appearance - depending
on their contents
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
 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”)
 Mixed stones
Multiple
Faceted
Consist of:
– Calcium salts
– Pigment
– Cholesterol (30% - 70%)
80% - associated with chronic cholecystitis
 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
 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
 Definitions

Biliary colic

– Wax/waning postprandial epigastric/RUQ

pain due to transient cystic duct obstruction

by stone

– No fever, No leukocytosis, Normal LFT

 Definitions

Chronic cholecystitis
– Recurrent bouts of biliary colic leading to
chronic GB wall inflammation/fibrosis.
– No fever, No leukocytosis, Normal LFT
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
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
…
 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
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
 Gall bladder ultrasound
Shows
gallstones

→
the acoustic →
shadow due to
absence of
reflected sound ►
waves behind
the gallstone
Ultrasound
Curved arrow
– Two small stones
at GB neck
◄
Straight arrow
– Thickened GB wall

◄
– Pericholecystic
fluid = dark lining
outside the wall
 CT scan
→ denotes the GB
→ wall thickening
►

► denotes the
fluid around the
GB

GB also appears
distended
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

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

Emphysematous cholecystitis
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
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
Gallstone
Ileus
 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

 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

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
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)
MRCP & ERCP
 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
 Spectrum of Gallstone Disease

Symptomatic Cholelithiasis
cholelithiasis
can be a herald
to:
– an attack of
Asymptomatic Symptomatic
acute
cholelithiasis cholelithiasis
cholecystitis
– ongoing chronic
cholecystitis
May also Chronic Acute
resolve calculous calculous
cholecystitis cholecystitis
Porcelain
Gallbladde
A precancerous
condition
Needs
cholecystectomy
Treatment
 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)
 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
Pigment stone
 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
ERCP
endoscopic
sphincterotomy
 Cholangitis

Medical management (successful in 85% of cases):

– NPO
– IV Fluids
– IV AB.
Emergent decompression if medical treatment
fails
1. ERCP
2. Percutaneous transhepatic drainage (PTC)
3. Emergent laparotomy
Biliary Tract Tumours
Cholangiocarcinoma
Cancer of the Gall Bladder
 Biliary Tree Neoplasms

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

Klatskin tumour = Cholangiocarcinoma of junction of right & left hepatic

ducts
ERCP: Distal CBD Cancer
 Surgical Removal
• Node Dissection in Bile • Roux-en-Y
Duct Excision Hepaticojejunostomy
 Cholangiocarcinoma
If positive Margins or Unresectable:
Stent
Chemotherapy +/- Radiation Therapy
Survival with surgery and
chemo/radiation is 24 to 36 months
With chemotherapy / radiation alone
survival is 12 to 18 months
Gallbladder Cancer
6th decade
1:3, Male:Female
Highest prevalence in Israel,
Mexico, Chile, Japan, and Native
American women.
Risk Factors: Gallstones, porcelain
gallbladder, polyps, chronic typhoid
and some drugs
 Gallbladder Cancer

Uncommon malignancy
2.5 per 100,000 population
Represents 54% of biliary tract cancers.
 Gall Bladder Cancer
Presentation (1)
Discovered on pathology after a routine
cholecystectomy. (T-1a/b - invades
muscularis)
CT/Chest and Abdomen, 4 phase CT of liver
If negative for metastasis:
– Radical cholecystectomy with nodal dissection,
central hepatectomy, w or w/o bile duct excision
– Excise port sites
– Followed by Chemo/Radiation
5 year survival = 60%
 Gall Bladder Cancer
Presentation 2

RUQ pain, jaundice, weight loss: CT

Biopsy yields adenocarcinoma consistent
with GB primary
Biliary Decompression
Chemo/Radiation
Median survival with chemoradiotherapy is
9 months.
 THANK
YOU