Dr m.Farhad General Surgeon Gall stone disease Dr m.Farhad General Surgeon

Anatomy

Gallstone Pathogenesis Bile contains: Cholesterol Bile salts Phospholipids Bilirubin Gallstones are formed when cholesterol or bilirubinate are supersaturated in bile and phospholipids are decreased

Gallstone Pathogenesis Stone formation is: Initiated by cholesterol or bilirubinate super saturation in bile Continued to crystal nucleation (microlithiais or sludge formation) And gradually stone growth occur Gallstone types Cholesterol Pigment Brown Black

What are gallstones? Small, pebble-like substances Multiple or solitary May occur anywhere within the biliary tree Have different appearance - depending on their contents

Pigment stones Small Friable Irregular Dark Made of bilirubin and calcium salts Less than 20% of cholesterol Risk factors: Haemolysis Liver cirrhosis Biliary tract infections Ileal resection

Cholesterol stones Large Often solitary Yellow, white or green Made primarily of cholesterol (>70%) Risk factors: 4 “F” : Female Forty Fertile Fat Fair (5th “F” - more prevalent in Caucasians) Family history (6th “F”)

Mixed stones Multiple Faceted Consist of: Calcium salts Pigment Cholesterol (30% - 70%) 80% - associated with chronic cholecystitis

Risk Factors for Gallstones Obesity  Rapid weight loss    Childbearing    Multiparity    Female sex    First-degree relatives    Drugs: ceftriaxone, postmenopausal estrogens, Total parenteral nutrition    Ethnicity: Native American (Pima Indian), Scandinavian    Ileal disease, resection or bypass    Increasing age

Asymptomatic Gallstone Incidentally found gallstone in ultrasound exam for other problems Many individuals are concerned about the problem Sometimes pt. has vague upper abdominal discomfort and dyspepsia which cannot be explained by a specific disease If other work up are negative may be Routine cholecystectomy is not indicated

Definitions Biliary colic Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone No fever, No leukocytosis, Normal LFT

Definitions Chronic cholecystitis Recurrent bouts of biliary colic leading to chronic GB wall inflammation/fibrosis. No fever, No leukocytosis, Normal LFT

Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones Overtime, leads to scarring/wall thickening Attacks of biliary colic may occur overtime

Differential diagnosis of RUQ pain Biliary disease Acute or chronic cholecystitis CBD stone cholangitis Inflamed or perforated peptic ulcer Pancreatitis Hepatitis Rule out: Appendicitis, renal colic, pneumonia, pleurisy and …

Definitions Acute cholecystitis Acute GB distension, wall inflammation & edema due to cystic duct obstruction. RUQ pain (>24hrs) +/- fever, ↑WBC, Normal LFT, Murphy’s sign = inspiratory arrest

Ultrasound is the first choice for imaging Distended gallbladder Increased wall thickness (> 4 mm) Pericholecystic fluid Positive sonographic Murphy’s sign (very specific) Nuclear HIDA scan shows no filling of GB If U/S non-diagnostic, order HIDA

Gall bladder ultrasound Shows gallstones the acoustic shadow due to absence of reflected sound waves behind the gallstone → → ►

Ultrasound Curved arrow Straight arrow ◄ Two small stones at GB neck Thickened GB wall ◄ Pericholecystic fluid = dark lining outside the wall ◄

CT scan → → denotes the GB wall thickening ► denotes the fluid around the GB GB also appears distended → ►

Complications of acute cholecystitis Empyema of gallbladder Pus-filled GB due to bacterial proliferation in obstructed GB. Usually more toxic with high fever Emergent operation is needed

Complications of acute cholecystitis Emphysematous cholecystitis More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen Emergent cholecystectomy is needed

Emphysematous cholecystitis

Complications of acute cholecystitis Perforated gallbladder Pericholecystic abscess (up to 10% of acute cholecystitis) Percutaneous drainage in acute phase Biliary peritonitis due to free perforation Emergent Laparotomy

Complications of acute cholecystitis Chronic perforation into adjacent viscus (cholecystoenteric fistula) Air is seen in the biliary tree The stone can cause small bowel obstruction if large enough (gallstone ileus) Laparotomy is needed for extraction of stone, cholecystectomy and closure of fistula

Gallstone Ileus

Definitions Acalculous cholecystitis A form of acute cholecystitis GB inflammation due to biliary stasis(5% of time) and not stones(95%). Often seen in critically ill patients

Acute acalculous cholecystitis 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 Emergent operation is needed

Cholangitis Infection within bile ducts due to obstruction of CBD. Infection of the bile ducts due to CBD obstruction secondary to stones, strictures May lead to life-threatening sepsis and septic shock It may present as two forms: Suppurative Non-suppurative

Non suppurative: Suppurative: Persistent RUQ pain + fever + jaundice, (Charcot’s triad) ↑WBC, ↑LFT, Suppurative: Persistent RUQ pain + fever + jaundice, ↑WBC, ↑LFT, Hepatic encephalopathy or hypotension may ensue (Reynold’s pentad)

MRCP & ERCP

Gallstone pancreatitis 35% of acute pancreatitis secondary 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 & stone extraction/sphincterotomy Cholecystectomy before hospital discharge in mild case

Spectrum of Gallstone Disease Symptomatic cholelithiasis can be a herald to: an attack of acute cholecystitis ongoing chronic cholecystitis May also resolve

Porcelain Gallbladde A precancerous condition Needs cholecystectomy

Treatment

Medical Treatment Medical treatment for Including: Acute biliary colic attack Acute cholecystitis with comorbid diseases Including: GI rest NG tube if vomiting IV Fluids Analgesics (not morphine) Antibiotics for cholecystitis (against GNR & enterococcus)

Surgical Treatment Early cholecystectomy for acute cholecystitis (usually within 48hrs) Laparoscopic Open Elective cholecystectomy for biliary colic, chronic cholecystitis and some asymptomatic stones Endoluminal? Cholecystostomy is the best choice If patient is too sick or anatomy is deranged Percutaneous

Pigment stone

Choledocholithiasis Treatment Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic sphincterotomy and stone extraction Interval cholecystectomy after recovery from ERCP Surgical CBD exploration if dilated (1.5-2 cm) or stone larger than 1.5 cm Open Laparoscopic

ERCP endoscopic sphincterotomy

Cholangitis Medical management (successful in 85% of cases): NPO IV Fluids IV AB. Emergent decompression if medical treatment fails ERCP Percutaneous transhepatic drainage (PTC) Emergent laparotomy

Biliary Tract Tumours Cholangiocarcinoma Cancer of the Gall Bladder

Biliary Tree Neoplasms Clinical symptoms: Weight loss (77%) Nausea (60%) Anorexia (56%) Abdominal pain (56%) Fatigue (63%) Pruritus (51%) Symptomatic patients usually have advanced disease, with spread to hilar lymph nodes before obstructive jaundice occurs Associated with a poor prognosis. Fever (21%) Malaise (19%) Diarrheoa (19%) Constipation (16%) Abdominal fullness (16%).

Cholangiocarcinoma Adenocarcinoma of the bile ducts May occur without associated risk factors Associated with chronic cholestatic liver disease such as: Primary Sclerosing Cholangitis Choledochal cysts Asbestos. Accounts for 25% of biliary tract cancers Presentation: Jaundice Vague upper or right upper quadrant abdominal pain Anorexia, weight loss Pruritus.

Cholangiocarcinoma Slow growing malignancy of biliary tract which tend to infiltrate locally and metastasize late. Gall Bladder cancer = 6,900/yr Bile duct cancer = 3,000/yr Hepatocellular Ca = 15,000/yr

Cholangiocarcinoma Diagnosis and Initial Workup Jaundice Weight loss, anorexia, abdominal pain, fever US – bile duct dilatation Quadruple phase CT MRCP/MRI ERCP with Stent and Brush Biopsy Percutaneous Cholangiogram with Internal Stent and Brush Biopsy

MRCP: Cholangiocarcinoma at the Bifurcation Klatskin tumour = Cholangiocarcinoma of junction of right & left hepatic ducts

ERCP: Distal CBD Cancer

Surgical Removal Node Dissection in Bile Duct Excision Roux-en-Y Hepaticojejunostomy

Cholangiocarcinoma If positive Margins or Unresectable: Stent Chemotherapy +/- Radiation Therapy Survival with surgery and chemo/radiation is 24 to 36 months With chemotherapy / radiation alone survival is 12 to 18 months

Gallbladder Cancer 6th decade 1:3, Male:Female Highest prevalence in Israel, Mexico, Chile, Japan, and Native American women. Risk Factors: Gallstones, porcelain gallbladder, polyps, chronic typhoid and some drugs

Gallbladder Cancer Uncommon malignancy 2.5 per 100,000 population Represents 54% of biliary tract cancers.

Gall Bladder Cancer Presentation (1) Discovered on pathology after a routine cholecystectomy. (T-1a/b - invades muscularis) CT/Chest and Abdomen, 4 phase CT of liver If negative for metastasis: Radical cholecystectomy with nodal dissection, central hepatectomy, w or w/o bile duct excision Excise port sites Followed by Chemo/Radiation 5 year survival = 60%

Gall Bladder Cancer Presentation 2 RUQ pain, jaundice, weight loss: CT Biopsy yields adenocarcinoma consistent with GB primary Biliary Decompression Chemo/Radiation Median survival with chemoradiotherapy is 9 months.

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