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

2. Anatomy

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

4. 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

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

6. 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

7. 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”)

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

9. 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

10. 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

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

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

13. 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

14. 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 …

15. 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

16. 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

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

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

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

21. 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

22. 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

23. Emphysematous cholecystitis

24. 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

25. 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

26. Gallstone Ileus

27. 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

28. 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

29. 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

30. 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)

31. MRCP & ERCP

32. 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

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

34. Porcelain Gallbladde
A precancerous condition
Needs cholecystectomy

35. Treatment

36. 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)

37. 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

38. Pigment stone

39. 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

40. ERCP endoscopic sphincterotomy

41. 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

43. Biliary Tract Tumours Cholangiocarcinoma Cancer of the Gall Bladder

44. 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%).

45. 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.

46. 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

47. 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

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

49. ERCP: Distal CBD Cancer

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

51. 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

52. 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

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

54. 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%

55. 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.

56. THANK
YOU