This is an overview of gallbladder stone diseases and infection of the gallbladder. I started with the surgical anatomy and physiology of gallbladder and bile secretion. furthermore, I went ahead to discuss the natural history of gallstones. then, the pathology and pathogenesis of gallstones and gallbladder infection (cholecystitis). Various investigations for Cholelithiasis and cholecystitis was discussed and the concluding part talked about various treatment modality. Finally, I went ahead to show the techniques of laparoscopic cholecystectomy.
2. Outline
• Introduction
• Relevant Anatomy
• Epidemiology and Natural history
• Classification
• Clinical features
• Investigations
• Treatment
• Prognosis
• Conclusion
• References
3. Introduction
• Gallstones are the most common pathology affecting the biliary tract
• Gallbladder stone is one of the most common problems affecting the
digestive tracts
• It is estimated that gallstones are present in 10-15% of the adult
population in the USA.
5. Relevant Anatomy/physiology
• The normal adult consuming an average diet produces within the liver
500 to 1000 mL of bile a day.
• The secretion of bile is responsive to neurogenic, humoral, and
chemical stimuli.
• Bile is mainly composed of water, electrolytes, bile salts, proteins,
lipids, and bile pigments
6. Epidemiology
• Gallstone disease is one of the most common problems affecting the
digestive tract. Autopsy reports have shown a prevalence of
gallstones from 11% to 36%. 1
• The prevalence of gallstones is related to many factors, including age,
gender and ethnic background.
7. Epidemiology
• Wichendu et al (UPTH) in Feb 2020: 2
M:F 1:5.6
age 41-50yrs
symptoms right hypochondrial/epigastric pain
type Mixed stones
8. Risk factor
Certain conditions predispose to the development of gallstones.
• Obesity
• Pregnancy
• dietary factors
• Crohn’s disease
• terminal ileal resection
• gastric surgery
• hereditary spherocytosis, sickle cell disease, and thalassemia are all
associated with an increased risk of developing gallstones. 3
9. Natural History
• Most patients will remain asymptomatic from their gallstones
throughout life
• Approximately 3% of asymptomatic individuals become symptomatic
per year (i.e., develop biliary colic). Once symptomatic, patients tend
to have recurring bouts of biliary colic.
• Complicated gallstone disease develops in 3% to 5% of symptomatic
patients per year. 4
12. Classification
• Pure Cholesterol stones
consist of <10% of stone
contain 70-80% cholesterol by
weight
supersaturation of bile with
cholesterol
usually solitary with smooth
surface
usually radiolucent, <10% are
radio-opaque
13. Classification
• Pigment stones
contain <20% of cholesterol
contained calcium bilirubinate and
appear dark-colored
Black pigment stones
formed by supersaturation of bile
with Calcium bilirubin, carbonate and
phosphate
secondary to hemolytic anaemia or
hepatic cirrhosis
commonly formed in the gallbladder
14. Classification
• Brown pigment stone
usually less than 1cm in diameter, brownish-yellow, soft, mushy
formed in the gallbladder or CBD
formed from bacterial infection caused by bile stasis
E.coli, Klebsiella spp, etc secrete B-glucoronidase causing
deconjugated bilirubinemia
parasitic infestations e.g. Ascaris lumbricoides
15. Classification
• Mixed stones
contained variable
concentration of cholesterol and
bilirubin
most common stone in Nigeria
and Africa
made up about 80% of
gallbladder stones
16. Clinical features
Biliary colics
• Episodic pain
epigastric/Rt hypochodrial,
episodic, radiate to the upper
back/interscapular region, worsen
by fatty meal
• Atypical presentation
Bloating, belching. 6
Acute Cholecystitis
• Constant pain
• Anorexia
• Nausea and vomiting
• Fever
• Murphy’s sign- POSITIVE. 6
17. Investigations
• Abdominal Ultrasound- 95%
sensitive and specific
thickened gallbladder wall +
peri-cholecystic fluid collection
stones in the gallbladder
Complications
obstructive jaundice- dilated
biliary tree, pancreatic duct, etc
empyema- gallbladder sludge,
empyema. 7
18. Investigations
• HIDA scan (hydroxy iminodiacetic acid)
good in atypical presentation
non visualization of the gallbladder after 4hrs is diagnostic
• Complete Blood Count (CBC)
leukocytosis (12,000-15,000cells/mm3)
greater values suggest gangrene, perforation or cholangitis. 7
24. Federico Coccolini et al, meta-analysis (1248
patients, 12 RCTs)- Level 1 evidence. 8
Lap Chole Open Chole
Post-op morbidity ↓ -
Post-op wound infection ↓ -
Pneumonia ↓ -
Mortality ↓ -
Post-op hospital stay ↓ -
Bile leak ↕ ↕
Intra-op blood loss ↕ ↕
Operative time ↕ ↕
25. Adisa et al in ile-ife, retrospective studies of
cholecystectomy (173 patients)- level 5 evidence. 9
2005 2015
• Cholecystectomy: 7(2.7%) 31(9.1%)
increased was noticed when LapChole was commenced in 2008
• Open Cholecystectomy 7 2
• Post-op hospital stay 5.2days 1.8days
• Conclusion: they recommend the use of laparoscopy/minimal access
surgery across the country.
27. Wu, X-D et al(2015), meta-analysis (1625
patients, 15 RCTs)- Level 1 evidence. 10
• Early- <7days Delayed- >7days
• Early Lap Chole
lower hospital cost
shorter hospital stay
few work day lost
higher patient satisfaction
quality of life
• No difference
mortality, bile duct injury, bile leak, and conversion to open technique
28. Acute acalculous cholecystitis. 11
• Acute inflammation of the gallbladder without gallstones
• Typically developed in patients in the ICU
Burns
sepsis
multiple injuries
Parenteral feeds
Multiple organ failures
29. Acute acalculous cholecystitis
• Pathogenesis is unknown
• Conscious patient
symptoms are similar
Unconscious patient
symptoms are masked
fever, ele WBC, ALP,jaundice may be a pointer
30. Acute acalculous cholecystitis
• Abd USS
thickened gallbladder with peri-cholecystitic fluid collection,
biliary sludge,
no gallstones
• HIDA scan
• CT abdomen
31. Acute acalculous cholecystitis
• Treatment
emergency decompression of the biliary
percutaneous cholecystostomy- 90% will improve
open cholecystostomy/cholecystectomy
33. Summary
• Gallstones are the commonest biliary pathology
• Asymptomatic gallstones do not require treatment
• Classified into cholesterol, pigment and mixed
• Treatment for symptomatic gallstones is laparoscopic
cholecystectomy
34. References
1. Brett M, Barker DJ. The world distribution of gallstones. Int J Epidemiol. 1976;5:335
2. WICHENDU, P. N., DODIYI-MANUEL, A., & IKONWA, K. (2020). MANAGEMENT OF
SYMPTOMATIC GALL STONES IN A TERTIARY CARE HEALTH FACILITY IN SOUTHERN
NIGERIA. Journal of International Research in Medical and Pharmaceutical Sciences,
14(3), 98-103.
3. Nakeeb A, Comuzzie AG, Martin L, et al. Gallstones: genetics versus environment. Ann
Surg. 2002;235:842.
4. Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: the GREPCO
experience. The GREPCO Group. Hepatology. 1995;21:655.
5. Charles F. Brunicardi: Schwartz’s principles of Surgery, 10th edition Chapters 33
6. Aliyu S and Ningi AB. The Types and Indications of Cholecystectomy in Nigeria: Our
Experience in Damaturu, North-Eastern Nigeria. A Randomized Double-Blind Placebo-
Controlled Trial. Acad J Gastroenterol & Hepatol. 2(2): 2020. AJGH.MS.ID.000535. DOI:
10.33552/AJGH.2020.02.000535
35. 7. O. James Garden and Simon Peterson-Brown: Hepatobiliary and pancreatic surgery, a companion
to specialist surgical practice, 5th edition, chapter 10.
8. Coccolini F, Catena F, Pisano M, Gheza F, Fagiuoli S, Di Saverio S, Leandro G, Montori G, Ceresoli
M, Corbella D, Sartelli M, Sugrue M, Ansaloni L. Open versus laparoscopic cholecystectomy in acute
cholecystitis. Systematic review and meta-analysis. Int J Surg. 2015 Jun;18:196-204. doi:
10.1016/j.ijsu.2015.04.083. Epub 2015 May 6. Erratum in: Int J Surg. 2015 Dec;24(Pt A):107. PMID:
25958296.
9. Adisa AO, Lawal OO, Adejuyigbe O. Trend over time for cholecystectomy following the
introduction of laparoscopy in a Nigerian tertiary hospital. Niger J Surg 2017;23:102-5
10. Wu, X.‐D., Tian, X., Liu, M.‐M., Wu, L., Zhao, S. and Zhao, L. (2015), Meta‐analysis comparing
early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg, 102: 1302-
1313. doi:10.1002/bjs.9886
11. Norman, S. W., Christopher J.K.B., and P.Ronan O’ Connell (2008). Bailey and Love principles and
practice of Surgery, 25th edition, chapter 61, 63 and 64.
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