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Gallstones Disease
Gallstone Disease
Dr.Amjad Maslamani
General Surgeon
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Gallstones Disease
Overview
Anatomy of galllbladder
Gallstone pathogenesis
Definitions Differential Diagnosis of RUQ pain
7 Cases
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Gallstones Disease
ANATOMY OF GALLLADDER
Gallbladder is located in a fossa on the inferior border of
the liver.
Divided into fundus, body,infundibulum,and the neck.
Supplied by the cystic artery ( branch of the right hepatic
in 90%). That runs in Calots triangle( area bounded by the
cystic duct, common hepatic duct and liver margin).
Venous return by small veins directly to the liver.
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Gallstones Disease
Anatomy of gallbladder
ANATOMY OF GALLLADDER
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Gallstones Disease
The Gallbladder and Biliary System with Pancreas
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Gallstones Disease
Gallstone Pathogenesis
Bile = bile salts, phospholipids, cholesterol
± Also bilirubin which is conjugated b4 excretion
Gallstones due to imbalance rendering
cholesterol & calcium salts insoluble
Pathogenesis involves 3 stages:
± 1. cholesterol supersaturation in bile
± 2. crystal nucleation
± 3. stone growth
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Gallstones Disease
DefinitionsSymptomatic
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,
WBC, LFT, +Murphy¶s = inspiratory arrestChronic
cholecystitis
Recurrent bouts of colic/acute chol¶y 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
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Gallstones Disease
Differential Diagnosis of RUQ pain
Biliary disease
± Acute chol¶y, chronic chol¶y, CBD stone,
cholangitis
Inflamed or perforated duodenal ulcer
Hepatitis
Also need to rule out: ± Appendicitis, renal colic, pneumonia or
pleur isy, pancreatitis
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Gallstones Disease
Case 1
46yo F w RUQ pain x4hr, after a fatty
meal, radiating to the R scapula, also w
nausea. Pt is pain-free now.
No prior episodes
Minimal RUQ tenderness, no Murphy¶s
WBC 8, LFT normal
RUQ U/S reveals cholelithiasis without GBwall thickening or pericholecystic fluid
Diagnosis: ?
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Gallstones Disease
Case 1
denotesgallstones
denotes theacoustic shadowdue to absenceof reflected
sound wavesbehind thegallstone
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Gallstones Disease
Symptomatic cholelithiasis
aka ³biliary colic´
The pain occurs due to a stone obstructing
the cystic duct, causing wall tension; pain
resolves when stone passes Pain usually lasts 1-5 hrs, rarely > 24hrs
Ultrasound reveals evidence at the crime
scene of the likely etiology: gallstones Exam, WBC, and LFT normal in this case
Treatment: Laparoscopic cholecystectomy
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Gallstones Disease
Spectrum of Gallstone Disease
Cholelithiasis
Asymptomatic
cholelithiasis
Symptomatic
cholelithiasis
Chronic
calculous
cholecystitis
Acute
calculous
cholecystitis
Symptomatic
cholelithiasis can
be a herald to:
± an attack of acutecholecystitis
± or ongoing chronic
cholecystitis
May also resolve
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Gallstones Disease
Case 2
Same case, except pt has had multiple
prior attacks of similar RUQ pain
No fever or WBC Ultrasound reveals gallstones, thickened
GB wall, no pericholecystic fluid
Diagnosis: ?
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Gallstones Disease
Chronic calculous cholecystitis
Recurrent inflammatory process due to
recurrent cystic duct obstruction, 90% of
the time due to gallstones
Overtime, leads to scarring/wall thickening
Treatment: laparoscopic cholecystectomy
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Gallstones Disease
Case 3
Same pt, now > 24hrs of RUQ painradiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever
Exam: Palpable, tender gallbladder,guarding, +Murphy¶s = inspiratory arrest
WBC 13, Mild LFT
U/S: gallstones, wall thickening (>4mm),
GB distension, pericholecystic fluid,sonographic Murphy¶s sign (very specific)
Diagnosis: ?
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Gallstones Disease
Case 3
Curved arrow ± Two small stones
at GB neck
Straight arrow
± Thickened GB wall
± pericholecystic
fluid = dark lining
outside the wall
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Gallstones Disease
Case 3
denotes the GB
wall thickening
denotes the
fluid around the
GB
GB also appears
distended
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Gallstones Disease
Acute calculous cholecystitis
Persistent cystic duct obstruction leads to
GB distension, wall inflammation & edema
Can lead to: empyema, gangrene, rupture
Pain usu. persists >24hrs & a/w N/V/Fever
Palpable/tender or even visible RUQ mass
Nuclear HIDA scan shows nonfilling of GB
± If U/S non-diagnostic, obtain HIDA
Tx: NPO, IVF, Abx (GNR & enterococcus)
Sg: Cholecystectomy usu within 48hrs
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Gallstones Disease
Case 4
87yo M critically ill, on long-term TPN w
RUQ pain, fever, WBC
Ultrasound: GB wall thickening,pericholecystic fluid, no gallstones
Diagnosis: ?
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Gallstones Disease
Acute acalculous cholecystitis
In 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
Tx: Emergent cholecystectomy usu open
If pt is too sick, perc cholecystostomy tube
and interval cholecystectomy later on
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Gallstones Disease
Complications of acute cholecystitis
Empyema of gallbladder
Pus-filled GB due to bacterial proliferation inobstructed GB. Usu. more toxic, high fever
Emphysematous
cholecystitisMore commonly in men and diabetics. Severe
RUQ pain, generalized sepsis. Imaging
shows air in GB wall or lumen
Perforated
gallbladder
Occurs in 10% of acute chol¶y, usually
becomes a contained abscess in RUQ
Less commonly, perforates into adjacentviscus = cholecystoenteric fistula & the stone
can cause SBO (gallstone ileus)
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Gallstones Disease
Choledocholithiasis
Can present similarly to cholelithiasis,except with the addition of jaundice
DDx: cholelithiasis, hepatitis, sclerosingcholangitis, less likely CA with pain
Tx: Endoscopic retrogradecholangiopancreatography (ERCP)
± Stone extraction and sphincterotomy Interval cholecystectomy after recovery
from ERCP
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Gallstones Disease
Case 6
46yo F p/w fever , RUQ pain, jaundice(Charcot¶s tr iad)
If also altered mental status and signs of
shock = Raynaud¶s pentad VS tachycardic, hypotensive
ABC¶s, Resuscitate
± 2 large bore IV, Foley, Continuous monitor
± 1-2L fluid bolus, repeat until resuscitated
Diagnosis: ?
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Gallstones Disease
Cholangitis
Infection of the bile ducts due to CBDobstruction 2ndary to stones, strictures
Charcot¶s triad seen in 70% of pts
May lead to life-threatening sepsis andseptic shock (Raynaud¶s pentad)
Tx: NPO, IVF, IV Abx
Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC)
Used to require emergency laparotomy
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Gallstones Disease
Case 7
46yo F p/w persistent epigastric & backpain
Known history of symptomatic gallstones
No EtOH abuse
Exam: Tender epigastrum
Amylase 2000, ALT 150
Ultrasound: Gallstones
Diagnosis: ?
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Gallstones Disease
Gallstone pancreatitis
35% of acute pancreatitis 2ndary 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 w stone
extraction/sphincterotomy
Cholecystectomy before hospital discharge
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Gallstones Disease
Take Home Points
As always, ABC & Resuscitate before Dx
Understanding the definitions is key
Is this acute cholecystitis? (fever, WBC, tender on
exam with positive Murphy¶s)
Or simply cholelithiasis vs ongoing chroniccholecystitis? (no fever/WBC)
Is patient sick or toxic-appearing, to suspect
empyema, gangrene or even perforation?
Elicit h/o jaundice, acholic stools, tea-colored urine
Rule out cholangitis, because this will kill the
patient unless dx & tx early