Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus CHOLECYSTITIS Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus

GALLBLADDER Major Function- Concentrate, Store Bile Supplied by Cystic Artery Off Right Hepatic Artery Off Common Hepatic Artery Off Celiac Trunk Many Arterial Variations Replaced Right Hepatic Takes Off From Superior Mesenteric

DUCTS Right and Left Hepatic Ducts Join ↓ Common Hepatic Duct Cystic Duct Comes Off Common Bile Duct Ampulla, Duodenum

GALLSTONES Autopsy Prevalence 11-36% Female:Male Ratio is 3:1 First Degree Relatives Have Twice the Rate Cholecystectomy One of Commonest Operations

PREDISPOSING FACTORS Obesity Pregnancy Dietary Factors Crohn’s Disease, Ileal Resection Hemolytic Diseases Gastric Surgery

GALLSTONE CONSTITUENTS Bilirubin Bile Salts Phospholipids Cholesterol Calcium

CHOLESTEROL STONES Most Common Type Rarely Pure, >70% Cholesterol Precipitation from Supersaturated Bile Usually Multiple, Variable Sizes Hard and Facetted to Irregular and Soft Color White/Yellow to Brown/Black Only 10% are Radio-opaque

PIGMENT STONES <20% Cholesterol Dark Because of Calcium Bilirubinate Usually Tiny to Small Invariably Multiple Two Types- Black Stones Brown Stones

BLACK STONES Form ONLY in Gall Bladder Secondary to Hematologic Diseases Spherocytosis Sickle Cell Disease Thalassemia Common in Cirrhosis More Common in Asia

BROWN STONES Form in Gall Bladder AND Bile Ducts Small, Soft, Often Mushy Secondary to Bacterial Infection Caused by Bile Stasis Bacterial Cell Walls Prominent in Stones More Common in Asia

NATURAL HISTORY Most Are Asymptomatic Asymptomatic Stones Detected On Evaluation For Other Illnesses Ultrasound CT Plain Abdominal X-Ray Laparotomy 2/3 Stay Asymptomatic >20 Years

COMPLICATIONS Biliary Colic- Initial Symptom Acute Cholecystitis Choledocholithasis Cholangitis Biliary Pancreatitis Cholecysto-Duodenal Fistula Gall Bladder Carcinoma

CHOLECYSTECTOMY Indicated for Symptomatic Patients Rare Indications in Asymptomatic Ones Elderly Diabetics Before Transplantation Isolation From Medical Care Gallbladder Polyp (Controversial) Porcelain Gall Bladder Absolute Indication

CHRONIC CHOLECYSTITIS Recurrent Attacks of Pain Frequently After a Meal (Fatty?) Radiates to Back and Shoulder Nausea and Vomiting Gall Bladder- Minor Inflammation to Small, Shrunken With Fibrosis, Adhesions Mucosa Becomes Atrophied

DIAGNOSIS Stones on Ultrasound Gall Bladder May Have Sludge Cholesterolosis- Strawberry Gall Bladder Adenomyomatosis- Thick Wall Normal Ducts Cholecystectomy Cures >95%

ACUTE CHOLECYSTITIS Obstruction of Cystic Duct By Stone Gall Bladder Distention, Inflammation, Edema Mucus Secretion- Hydrops, Milk of Bile (Pearly White) 5-10% Progress to Ischemia, Necrosis Perforation Occurs in Body (Widest Part)

MANIFESTATIONS Biliary Colic → Lasting, Constant Pain Anorexia, Nausea, Vomiting, Fever Focal RUQ Tenderness, Guarding Murphys’ Sign is Suggestive Palpable Gall Bladder is Diagnostic Normal LFTs, ?Minimal Bilirubin Elevation White Blood Cell Count Often Elevated

DIAGNOSIS Ultrasound Stones Thickened Gall Bladder Wall Distended Gall Bladder Peri-Cholecystic Fluid Sonographic Murphy’s Sign If HIDA Scan Fills Gall Bladder- Precludes Diagnosis

TREATMENT Antibiotics- Gram Negative and Anaerobic Coverage Early laparoscopic Cholecystectomy Late Presentation >4-5 Days- Antibiotics Alone with Delayed Cholecystectomy Very Ill, Elderly patients- Percutaneous Cholecystostomy

LAP CHOLE Mortality 0.1%, Morbidity 0.3% Can Add Choledochotomy Conversion to Open in Acute Disease Reasons for Conversion Inability to Visualize Adhesions Duct Injury Bleeding Abnormal Anatomy

CHOLEDOCHOLITHIASIS Primary Stones Form in Ducts Associated with Biliary Dysfunction, Infection Brown Stones Secondary Stones Form in Gall Bladder Migrate to Common Bile Duct 6-12% Cholelithiasis Patients 20-25% in Patients >60

MANIFESTATIONS Symptomatic or Can Be Silent Colicky Pain, Nausea, Vomiting, ICTERUS Stones Single or Multiple, Small or Large Can Cause Common Duct Obstruction Cholangitis Biliary Pancreatitis

DIAGNOSIS Elevated Bilirubin, Alkaline Phosphatase, Transaminases Ultrasound- Dilated Ducts Magnetic Resonance Cholangiogram- Sensitivity 95%, Specificity 89% ERCP- Successful >90%, Morbidity <5% Therapeutic and Diagnostic

TREATMENT ERCP With Sphincterotomy Common Bile Duct Exploration Open or Laparoscopic T-Tube Left in Place Missed Stones Can Be Retrieved Choledochoscope

CHOLANGITIS Ascending Infection Associated With Bile Duct Obstruction Commonest Organisms E. coli Klebsiella Strep faecalis Bacteroides 5-10% Mortality

MANIFESTATIONS Charcot’s Triad Abdominal Pain Jaundice Fever Reynold’s Pentad Same Plus Septic Shock Mental Status Changes

TREATMENT Immediate Antibiotics, Resuscitation Duct Drainage (Cholangitis is Closed Space Infection) ERCP With Sphincterotomy Percutaneous Transhepatic Cholangiogram With Catheter Placement Open Common Duct Exploration