cholelithiasis final year mbbs lecture

GALLSTONES

by; Mr. ADEEL ABBAS

• 20% are Cholesterol Stones.• 5% are Pigment Stones.• 75% are Mixed… … …

• In Asia 80% Pigment Stones.

• In Europe 80% Cholesterol Stones.

Risk Factors

• BIG 4..?1. Female.2. Forty.3. Fertile.4. Fatty.

Risk Factors

• Pregnancy.• OCP.• Hemolytic Anemia.• Cirrhosis.• Infection.• IBD/Terminal Ileal Resection.• TPN.• Hyperlipidemia.

Pathogenesis

• Excess secretion of Cholesterol in Bile.• Excess Mucous Production.• Non-Functioning Gallbladder.• Stasis in Gallbladder.

Pathological Effects

1. Silent Gallstones.2. Obstruction of the Cystic Duct.3. Movement of Stone into CBD.4. Ulceration of Stone through Gallbladder

Wall.

Clinical Presentation

1. Biliary Colic.2. Acute Cholecystitis.3. Chronic Cholecystitis.4. Gallstone Pancreatitis.5. Obstructive Jaundice.6. Acute Cholangitis.7. Gallstone Ileus.8. Mucocele / Empyema of the Gallbladder.

1. Biliary Colic

• Episodic Pain in RHC / Epigastrium.• Pain Radiates to Lower Pole of Right Scapula.• Sweaty, Nauseous, Vomiting Patient.• Intermittent Jaundice with Pale Stool & Dark Urine.

• Differential Diagnosis:– Renal Colic.– Intestinal Obstruction.– Angina.

• Pain Episode may Resolve when Stone is Passed into CBD / Falls Back into the Gallbladder.

2. Acute Cholecystitis

• Sever, Constant & Localized RHC Pain.• Fever / Toxaemia / Rigors / Leucocytosis.• Tenderness in RHC / Murphy’s Sign.• Palpable Gallbladder.• Complications;– Empyema.– Perforation.– Obstructive Jaundice.– Acalculous Cholecystitis.

Murphy’s Sign

Chronic Cholecystitis

• Repeated Inflammation resulting in Fibrosis & Thickening of Gallbladder.

• Longstanding Dyspepsia with Episodic Cholecystitis.

• Differential Diagnosis:– Peptic Ulcer.– Hiatus Hernia.– Angina.

Gallstone Pancreatitis

• Due to Transient Blocking of Ampulla of Vater by Stone.

• Especially when Stones are Small & Numerous.

Obstructive Jaundice

• Acute Onset.• History of Pain.• Non-Palpable Gallbladder.

• Courvoisier’s Law..?????

Acute Cholangitis

CAUSE … ?

• Infection of Bile In the Biliary Tree…

• Charcot’s Triad … ?

1. Pain.2. Fever.3. Jaundice.

• Predisposing Factors;– Stone in CBD.– Biliary Stricture.– Post – ERCP.– Post – Biliary Reconstructive Procedure.

• Antibiotics & Resuscitation followed by Decompression of Biliary Tree.

Gallstone Ileus

• Gallstones may Erode into Duodenum / Colon.• Gallstone lodge at Level of Meckel’s Diverticulum /

Ileocaecal Valve.

• Present as Acute Abdomen.

• Treat by;– Drip & Suck.– Urgent Laparatomy.

Cholecysto-Enteric Fistula LEFT UNTIL ACUTE EPISODE IS OVER.

Investigations (for Gallstones)

• Ultrasound.• LFTs.• ERCP / MRCP.• AXR.• CT Scan

Ultrasound Pictures

ERCP

MRCP

CT SCAN

Treatment

• Conservative Management for Acute Cholecystectomy.

• Laparoscopic Cholecystectomy.• Open Cholecystectomy.• Cholecystostomy.• Medical Treatment;– Chenodeoxycholic Acid.

Acute Cholecystitis

• Principles of Management:– Admission to Hospital.– Pain Relief.– NPO.– IV Fluids.– Broad Spectrum Antibiotics.– Elective / Emergency Cholecystectomy.

Laparoscopic Cholecystectomy

• Preoperatively;– U/S + LFT + Clotting Screen.– Exclude Peptic Ulcer & Hiatal Hernia.– Encourage Weight Loss & Smoking Cessation.– Consent.

• Ports;– 3 or 4 Ports.

• Closure.• Postoperatively;– Orally Allowed when fully recovered.– Home in 24hrs when Pain-Free.

• Complications;

THANK YOU . . . !