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Gall stones disease
- 1. Gall Stone disease: BY: Dr ABRAR ALI supervised by: Dr VIJAY KUMAR Consultant department of surgery
- 2. What Are Gallstones? ï” Small, pebble-like substances that May occur anywhere within the biliary tree ï” Range in size- small as a grain of sand to as large as golf ball ï” Multiple or solitary ï” Have different appearance - depending on their contents
- 3. Pigment Stones ï” Small ï” Friable ï” Irregular ï” Dark ï” Made of bilirubin and calcium salts ï” Less than 20% of cholesterol ï” Risk factors: âą Haemolysis âą Liver cirrhosis âą Biliary tract infections âą Ileal resection
- 4. Cholesterol Stones ï” Large ï” Often solitary ï” Yellow, white or green ï” Made primarily of cholesterol (>70%) ï” Risk factors: âą 4 âFâ : ï” Female ï” Forty ï” Fertile ï” Fat âą Fair (5th âFâ - more prevalent in Caucasians) âą Family history (6th âFâ)
- 5. Mixed Stones ï” Multiple ï” Faceted ï” Consist of: âą Calcium salts âą Pigment âą Cholesterol (30% - 70%) ï” 80% - associated with chronic cholecystitis
- 7. Gallstone Prevalence ï” 10% of people over 40 yrs. ï” 90% âsilent stonesâ ï” Risk factors for becoming symptomatic: âą Smoking âą Parity
- 8. Risk Factors ï” Women ï” Age > 60 years ï” American Indians & Mexican Americans ï” Overweight or obese men and women ï” People who tend to fast or lose weight quickly ï” Family history of gallstones ï” Diabetes ï” Diet high in cholesterol ï” Use of OCPs ï” Pregnancy
- 9. Gallstone Pathogenesis ï” Bile = bile salts, phospholipids, cholesterol ï” Gallstones form due to alteration in the ratio of bile salt/phospholipid /cholesterol ï” Pathogenesis involves 3 stages: Cholesterol supersaturation in bile Crystal nucleation ( mucin hypersecretion by GB mucosa creats a viscoelastic gel that foster crystal nucleation) Bile stasis ( fasting,ocps, pregnancy, vagotomy ,prolong TPN)
- 11. ANATOMY BILIIARY SYSTEM GALL BLADDER
- 13. ContâŠ
- 14. Definitions Symptomatic cholelithiasis Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT Acute cholecystitis Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, âWBC, âLFT, +Murphyâs = inspiratory arrest Chronic cholecystitis Recurrent bouts of colic/acute cholây leading to chronic GB wall inflamm/fibrosis. No fever/WBC. Acalculous cholecystitis GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Choledocho- lithiasis Gallstone in the common bile duct (primary means originated there, secondary = from GB) Cholangitis Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock Mucocele GB Overdistended GB filled with mucoid or clear fluid and watery content, Usually noninflammatory, it results from outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct.
- 15. Differential Diagnosis Of RUQ Pain ï” Biliary disease âą Acute cholecystitis, chronic cholecystitis, CBD stone, cholangitis ï” Inflamed or perforated duodenal ulcer ï” Hepatitis ï” Also need to rule out: âą Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis
- 16. Symptoms ï” Pain in the RUQ âą Most common and typical symptom âą May last for a few minutes to several hours âą Mostly felt after eating a heavy and high-fat meal ï” Pain under right shoulder when lifting up arms ï” Fever, nausea and vomiting ï” Jaundice (obstruction of the bile duct passage)
- 17. Murphyâs Sign: Inspiratory arrest with manual pressure below the gallbladder
- 18. Complications Of Gallstones ï” In the GB: âą Biliary colic âą Acute and chronic cholecystitis âą Empyema âą Mucocoele âą Carcinoma ï” In the bile ducts: âą Obstructive jaundice âą Pancreatitis âą Cholangitis ï” In the gut: âą Gallstone ileus
- 19. 0.1â0.7% of patients who have gallstones Csendes classification : âą Type 1: external compression of the common bile duct â 11% âą Type 2: cholecystobiliary fistula is present involving <1/3 rd the circumference of the bile duct â 41% âą Type 3: a fistula is present involving upto 2/3 the circumference of the bile duct â 44% âą Type 4: a fistula is present with complete destruction of the wall of the bile duct â 4% Mirizzi syndrome
- 20. Diagnosis ï” Ultrasound ï” Computerized tomography (CT) scan âą May show gallstones or complications, such as rupture of GB or bile ducts âą Only calcified GB stone are hyperattenuating to bile, making them the only type to be clearly visualized on CT scan images. Pure cholesterol stones are hypoattenuating to bile, and other gallstones are isodense to bile and these may not be clearly identified on CT. ï” Cholescintigraphy (HIDA scan) âą Used to diagnose abnormal contraction of gallbladder or obstruction of bile ducts ï” Endoscopic retrograde cholangiopancreatography (ERCP) Used to locate and remove stones in bile ducts ï” Blood tests- CBC , LFT ,CLOTTING PROFILE,S.AMYLASE/LIPASE âą Performed to look for signs of infection, obstruction, pancreatitis, or jaundice
- 21. USG CT Scan
- 22. MRCP- Used to visualize the biliary and pancreatic ducts in a non-invasive manner. This procedure can be used to determine if gallstones are lodged in any of the ducts surrounding the GB MRCP ERCP
- 23. Management
- 24. Surgical options âą Cholecystostomy âą Subtotal cholecystectomy âą Open cholecystectomy âą Laparoscopic cholecystectomy âą Mini-cholecystectomy
- 25. Cholecystostomy ï” Patients at high risk related to multisystem organ failure ï” Severe pulmonary, renal, or cardiac disease ï” Recent myocardial infarction ï” Cirrhosis with portal hypertension ï” Acalculus cholecystitis after severe trauma, burns, or surgery ï” Empyema or gangrene of the gallbladder
- 26. Subtotal Cholecystectomy ï” Severe inflammation renders identification of the anatomy impossible, eg. Gangrenous cholecystitis ï” Scarred partially intrahepatic gallbladder ï” Severe cirrhosis and portal hypertension
- 27. Cholecystectomy Laparoscopic Surgery ï” Advantages: ï” Less post-op pain ï” Shorter hospital stay ï” Quicker return to normal activities ï” Disadvantages: ï” Learning curve ï” Inexperience at performing open cholecystectomies
- 29. ContâŠâŠ
- 30. Mini-cholecystectomhy ï” MC is an effective minimally invasive surgical procedure for both acute and chronic cholecystitis, with a low morbidity rate (5.6%), an early return to oral diet, few doses of postoperative analgesic and a short postoperative hospital stay. ï” A small right subcostal incision (4-5cm ) is the appropriate choice for MC in either a normal-sized or distended gallbladder. ï” MC can be performed without the use of special instruments, thus reducing the expense. ï” Since not every case is suitable for LC and MC is cheaper, MC should be considered in every case of gallstone disease, particularly in a developing country in which the health-care budget is limited
- 31. Cholecystectomy when to perform? ï” After acute cholecystitis, cholecystectomy traditionally performed after 6 weeks ï” Arguments for 6 weeks later ï” Laparoscopic dissection more difficult when acutely inflammed ï” Surgery not optimal when patient septic/dehydrated ï” Logistical difficulties (theatre space, lack of surgeons) ï” Arguments for same admission ï” Research suggests same admission lap chole as safe as elective chole (conversion to open maybe higher) ï” Waiting increases risk of further attacks/complications which can be life threatening ï” Risk of failure of conservative management and development of dangerous complication such as empyema, gangrene and perforation can be avoided ï” National guidelines state any patient with attack of gallstone pancreatitis should have lap chole within 3 weeks of the attack
- 32. Complications of Lap Cholecystectomy ï” Trocar/Veress needle injury ï” Hemorrhage ï” Wound infection and/or abscess ï” Ileus ï” Bile leak ï” Gallstone spillage ï” Deep vein thrombosis ï” Retained common bile duct (CBD) stone ï” CBD injury & stricture ï” Pancreatitis ï” Conversion to open procedure
- 34. Cause of PCS
- 36. ï” Nonsurgical treatment: âą Only in special situations ï” When a patient has a serious medical condition preventing surgery ï” Only for cholesterol stones âą Oral dissolution therapy ï” Ursodeoxycholic acid - to dissolve cholesterol gallstones ï” Months or years of treatment may be necessary before all stones dissolve âą Contact dissolution therapy ï” Experimental procedure ï” Involves injecting a drug directly into the gallbladder to dissolve cholesterol stones
- 37. Prevention A sensible diet is the best way to prevent gall stones Avoid crash diet or very low intake of calories Eat good sources of fiber
- 38. .