Presented by Vd. Devendra Sancheti

GuideDr.R.R.Patil

HOD ROGNIDAN DEPARTMENT

Types of gallstone Cholesterol stones (20%) Pigment stones (5%) Mixed (75%)

Epidemiology Fat, Fair, Female, Fertile, Fourty inaccurate, but

reminder of the typical patient F:M = 2:1 10% of Indian women in their 40s have gallstones

Composition of bile: Bilirubin (by-product of haem degradation) Cholesterol (kept soluble by bile salts and lecithin) Bile salts/acids (cholic acid/chenodeoxycholic acid):

mostly reabsorbed in terminal ileum(entero-hepatic circulation).

Lecithin (increases solubility of cholesterol) Inorganic salts (sodium bicarbonate to keep bile

alkaline to neutralise gastric acid in duodenum) Water (makes up 97% of bile)

Cholesterol Imbalance between bile salts/lecithin and cholesterol

allows cholesterol to precipitate out of solution and form stones

Pigment Occur due to excess of circulating bile pigment (e.g.

Heamolytic anaemia) Mixed

Same pathophysiology as cholesterol stones

Other Factors Stasis (e.g. Pregnancy) Ileal dysfunction (prevents re-absorption of bile salts) Obesity and hypercholesterolaemia

80% Asymptomatic 20% develop complications and do so on

recurrent basis

Gallstone disease (and its related complications) Gastritis/duodenitis Peptic ulcer disease/perforated peptic ulcer Acute pancreatitis Right lower lobe pneumonia Miyocardial Infarction

If presenting with RUQ pain all patients should get

Blood tests Abdominal xray / CXR (to exclude perforation/pneumonia) ECG

Can differentiate between gallstone complications based on:

History Examination Blood tests

CBC LFT CRP Clotting Amylase

Complication History Examination Blood testsBiliary Colic - Intermittent RUQ/epigastric

pain (minutes/hours) into back or right shoulder

-Tender RUQ-Murphy’s –-HR and BP (N)

-Wbc (N) CRP (N)- LFT (N)

Acute Cholecystitis -Constant RUQ pain into back or right shoulder-Feverish

-Tender RUQ-Murphy’s +-Pyrexia, HR (↑)

-Wbc and CRP (↑)-LFT (N or mildly (↑)

Empyema -Constant RUQ pain into back or right shoulder-Feverish

-Tender RUQ -Murphy’s +-Pyrexia, HR (↑), BP (↔ or ↓)-More septic than acute cholecystitis

-Wbc and CRP (↑)-LFT (N or mildly (↑)

Obstructive Jaundice -Yellow discolouration-Pale stool, dark urine-painless or associated with mild RUQ pain

-Jaundiced-Non-tender or minimally tender RUQ-No peritonism-Murphy’s –-Apyrexial, HR and BP (N)

-Wbc and CRP (N)-LFT: obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔)-INR (↔ or ↑)

Ascending Cholangitis Becks triad-RUQ pain (constant)-Jaundice -Rigors

-Jaundiced-Tender RUQ -Peritonism RUQ-high pyrexia (38-39)-HR (↑), BP (↔ or ↓)-Can develop septic shock

-Wbc and CRP (↑)-LFT : obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔)-INR (↔ or ↑)

Gallstone Ileus - 4 cardinal features of Small Bowel Obstruction

-distended tympanic abdomen-hyperactive/tinkling bowel sounds

Blood Tests Abdominal Xray (10% gallstones are radio-opaque) Chest Xray (to exclude perforation – MUST!) ECG (to exclude MI) Ultrasound Sonography: first line investigation in gallstone disease

Confirms presence of gallstones Gall bladder wall thickness (if thickened suggests cholecystitis) Biliary tree calibre (CBD/extrahepatic/intrahepatic) – if dilated suggests stone in CBD (normal

CBD <8mm). Sometimes CBD stone can be seen.

MRCP: To visualise biliary tree accurately (much more accurate than ultrasound) Diagnostic only but non-invasive Look for biliary dilatation and any stones in biliary tree

ERCP: Diagnostic and therapeutic in biliary obstruction Diagnostic and therapeutic but invasive Look for biliary tree dilatation and stones in biliary tree Stones can be extracted to unobstruct the biliary tree and perform sphincterotomy Risk of pancreatitis, duodenal perforation

CT Abdomen: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene, or perforation and in acute pancreatitis (ultrasound not good for looking at pancreas)

Pathogenesis Stone intermittently obstructing cystic duct

(causing pain) and then dropping back into gallbladder (pain subsides)

Ultrasound confirms presence of gallstones

Pathogenesis: Due to obstruction of cystic duct by gallstone:

Cystic duct blockage by gallstone Obstruction to secretion of bile from gallbladder Bile becomes concentrated Chemical inflammation initially Secondarily infected by organisms released by liver into

bile stream

Ultrasound confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid)

Complications of acute cholecystitis Empyema of gallbaldder Gangrene of gallbladder (rare) Perforation of gallbaldder (rare)

Pathogenesis: Stone obstructing CBD with infection/pus

proximal to the blockage

Pathogenesis: Gallstone causing small bowel obstruction

(usually obstructs in terminal ileum) Gallstone enters small bowel via cholecysto-

duodenal fistula (not via CBD)

Abdominal Xray – dilated small bowel loops May see stone if radio-opaque

Diagnosis of gallstone ileus usually made at the time of surgery.

Questions?

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