Gallstones: Most common biliary pathology Asymptomatic in majority of cases (>80%) Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year.

1. GALLSTONES & ITS
COMPLICATIONS
Presented by: Anish Dhakal (Aryan)

2. GALLSTONES
 Most common biliary pathology
 Asymptomatic in majority of cases (>80%)
 Approx. 1–2% of asymptomatic patients
develop symptoms requiring
cholecystectomy per year.
• Inflammation of GB mucosa can lead to
excessive absorption of water and bile salts
leaving cholesterol in higher concentration
• The cholesterol, then precipitates in many
small crystals, which may progress to large
crystals

4. TYPES OF GALL STONES
• Gallstones can be divided into three main
types:
1. Cholesterol
2. Pigment (brown/black)
3. Mixed stones

5. RISK FACTORS FOR
CHOLESTEROL GALLSTONES

6. CHOLESTEROL
GALLSTONE
• Contain 51-99% of pure cholesterol
plus admixture of calcium salts, bile
acids, bile pigments and
phospholipids
• Pathological process:
Bile supersaturated with cholesterol/low
bile acid concentration→Formation of
unstable unilaminar phospholipid
vesicles → Nucleation of cholesterol
crystals → Stone formation

7. PIGMENT STONES
• Contains less than 30 % of
cholesterol
• Arise anywhere in biliary tree
• They are of two types:
Black pigment stone
Brown pigment stone

8. BLACK PIGMENT STONE
20-30% stones are black
Composed of Insoluble bilirubin
pigment polymer mixed with calcium
phosphate and calcium bicarbonate
Associated with hemolysis,
hereditary spherocytosis or sickle cell
disease
Patients with cirrhosis have a higher
instance of pigmented stones.

9. BROWN PIGMENT
STONES
• Calcium bilirubinate, calcium palmitate, calcium stearate and
cholesterol
• Rare in the gall bladder whereas form in the bile duct and are
related to bile stasis and infected bile
• Pathology: due to deconjugation of bilirubin deglucuronide by
bacterial ß-glucuronidase

10. DIAGNOSIS
• Based on the history and physical examination with confirmatory
radiological studies
Transabdominal ultrasonography
Radionuclide scan
• Acute phase  right upper quadrant tenderness that is
exacerbated during inspiration by the examiner’s right subcostal
palpation (Murphy’s sign)
• Positive Murphy’s sign suggests acute inflammation and may be
associated with a leukocytosis and moderately elevated liver
function tests
• A palpable, non-tender gall bladder (Courvoisier’s sign)

11. ABDOMINAL ULTRASONOGRAPHY
(USG)
 Investigation of choice for diagnosing gallstones
 sensitivity > 95%; specificity 99%
 As 75% of gall bladder stones are radiolucent, plain film (X-
ray) of the abdomen is of little use

12. ERCP (ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY)
• Visualization of upper GI tract,
ampullary region, biliary and
pancreatic ducts
• Method for treatment of CBD
stones in peri-ampullary region

13. MRCP (MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY)
• Same information gained as ERCP but non-invasive

14. TREATMENT OF
GALLSTONE
• Safe to observe asymptomatic gallstones
• Patients with symptoms or complications: cholecystectomy
• Prophylactic cholecystectomy: patients with Diabetes,
congenital hemolytic anaemia, undergoing Bariatric surgery
where risk of developing symptoms
• Cholecystectomy if no medical contraindications: patients
with biliary colic or cholecystitis

15. NON-OPERATIVE TREATMENT
• with conservative measures: 90% of cases symptoms
subside
• Four principles:
NPO and IV fluid untill pain resolves
Administration of analgesics
Administration of antibiotics: a broad spectrum
antibiotic effective against gram –ve aerobes e.g.
cefazolin, cefuroxime or gentamicin
Subsequent management:
 if inflammation is subsiding, oral fluid and regular diet is reinstated.
 USG to confirm diagnosis.
 If jaundice, MRCP to exclude choledocholithiasis.
 CT if suspected any complication

16. CONTD.
• If pain and tenderness increase, conservative treatment must
be abandoned
• Cholecystostomy is performed followed by cholecystectomy
once patient’s condition is stabilised
• If early operation is not indicated, need to wait 6wks for
inflammation to subside before operating

17. CHOLECYSTECTOMY
1. Open cholecystectomy:
• Right subcostal incision (Kocher’s
incision)
• Upper midline or short right upper
transverse incision
• Indications:
Gall stones: symptomatic
Cholecystitis: acute, chronic
Acalculous cholecystitis
Empyema of gall bladder
Mucocele of gall bladder
Figure: open cholecystectomy

18. CHOLECYSTECTOMY2. Laparoscopic
cholecystectomy:
• Procedure of choice for
patients with gall bladder
disease
• Ports:
10mm port in umbilicus to pass
telescope
10 mm port in midline
epigastrium as working channel
Two 5mm ports at midclavicular
and anterior axillary line in
subcostal region
Figure:
laparoscopic cholecystectomy

20. ACUTE CHOLECYSTITIS
• Usually associated with an obstruction of the neck of the
gallbladder or cystic duct caused by stones impacted in
Hartmann's pouch
• Impacted stone also cause mucosal erosion allowing bile salt to
act over the submucosal tissues as bile is toxic to these tissues
leading to infection and necrosis and perforation

21. ETIOLOGY
• 3 factors:
1. Mechanical inflammation
Increased intraluminal pressure and distention
with resulting ischemia of gall bladder mucosa
and wall
2. Chemical inflammation
Due to release of lysolecithin and other local
tissue factors
3. Bacterial inflammation (50-85%)
a) Escherichia coli
b) Klebsiella spp.
c) Streptococcus spp.
d) Clostridium spp.
e) Salmonella

22. ACUTE CALCULUS
CHOLECYSTITIS
• Cardinal feature
– Pain in RUQ (epigastrium), right shoulder tip or interscapular region
• Difference between biliary colic
– severe and prolonged pain, fever and leucocytosis
• Examination
– Right hypochondral tenderness
– Murphy’s sign positive (rigidity worse on inspiration)
– Fever (no rigors)
– <10% jaundice (passage of stones into common bile duct)

23. CONTD..
• Complication
• If no resolution
• Gallbladder empyema
• Wall become necrotic and perforate with localized
peritonitis
• Abscess perforate into peritoneal cavity with septic
peritonitis (uncommon)

24. INVESTIGATIONS
• Peripheral blood leucocytosis
• Minor increase in transaminase and amylase
• Chest x-ray
• USG aids in diagnosis
• CT uncertain diagnosis

25. DIFFERENTIAL DIAGNOSIS OF
CHOLECYSTITIS

26. ACUTE NON-CALCULOUS
CHOLECYSTITIS
• Acute and chronic inflammation of the gall bladder can
occur in the absence of stones and give rise to a clinical
picture similar to calculous cholecystitis.
• Occurs in seriously ill patients
• Postoperative state after major, non-biliary surgery
• Severe trauma
• Burns
• Sepsis
In these patients, the diagnosis is often missed, and the mortality
rate is high

27. TREATMENT
• Asymptomatic gallstones→ not require treatment, unless the patient
• Has a porcelain gallbladder (which has an increased incidence
of carcinoma)
• Has a stone > 2–3 cm
• Is a pediatric patient.
• Is immunocompromised
• Symptomatic patients→ cholecystectomy

28. CONSERVATIVE MEASURES
• More than 90 per cent of cases, the symptoms of acute cholecystitis
subside with conservative measures
• Non-operative treatment is based on four principles
• Nil per oral (NPO) and intravenous fluid administration until the pain
resolves.
• Administration of analgesics
• Administration of antibiotics
• A broad-spectrum antibiotic effective against Gram-negative aerobes is
most appropriate (e.g. cefazolin, cefuroxime or gentamicin).

29. Subsequent management.
• When the temperature, pulse and other physical signs show that the
inflammation is subsiding, oral fluids are reinstated followed by regular
diet.
• Ultrasonography is performed to confirm the diagnosis.
• If an early operation is not indicated, one should wait approximately 6
weeks for the inflammation to subside before operating.

30. CHRONIC CHOLECYSTITIS
• Chronic inflammation of gallbladder
• Symptoms:
• Recurrent attack of upper abdominal pain; often at night
following meal
• Clinical feature: similar to acute calculous cholecystitis
but milder
• Patient recover spontaneously or following analgesia and
antibiotics
• Management:
• elective cholecystectomy

31. EMPYEMA OF GALL BLADDER
Results from progression of acute cholecystitis with persistent cystic
duct obstruction to superinfection of stagnant bile with pus forming
organisms
Clinical features:
• High grade fever
• Pain and tenderness over
Rt. Hypochondrium
Treatment:
• IV antibiotics: Cefotaxime,
Ceftriaxone
• Drainage
• Later cholecystectomy
Complications:
• Septicaemia
• Rupture and Peritonitis (Biliary or Bacterial)

32. MUCOCOELE
• Due to obstruction of cystic duct by stone in the neck (Hartmann’s
pouch) without any infection or inflammation
• Gallbladder distended over a period of time by mucus (Mucocele) or
by a clear transudate (Hydrops)
• Patients usually remains asymptomatic but chronic RUQ pain may be
there
• Clinical features:
• Visible, Easily palpable, soft,
non-tender mass in right
hypochondrium
• Dyspepsia
• Investigation: USG, LFT
• Treatment: Cholecystectomy

33. ACUTE CHOLANGITIS
• Caused by bacterial infection of bile ducts
• Occur in patients with preexisting biliary problems
(Choledocholithiasis, Biliary strictures or tumors)
• Clinical features:
• Charcot’s triad: Jaundice, Fever (With or without rigors) and
RUQ pain
• Treatment:
• Antibiotics
• Relief of biliary obstruction
• Removal of underlying causes (if possible)

35. GALLSTONE ILEUS
• Refers to mechanical intestinal obstruction
resulting from passage of large gallstone into bowel
lumen
• Enters duodenum through cholecystoenteric fistula
• Site of obstruction usually at ileocecal valve
• Usually stone of > 2.5 cm predisposes to fistula formation
• Clinical features: common in elderly, pain abdomen and feature
of intestinal obstruction.
• Treatment: Laparotomy with stone extraction is choice of
treatment to relieve obstruction

36. STONES IN THE BILE DUCT
• occur many years after a cholecystectomy or
be related to the development of new
pathology, e.g. infection of the biliary tree or
infestation by Ascaris or Clonorchis
• Any obstruction to the flow of bile can give rise
to stasis with the formation of stones within the
duct
• Consequences are either obstruction to bile
flow or infection
• Stones in the bile duct-associated with infected
bile (80%) than are stones in the gall bladder

37. SYMPTOMS
• May be asymptomatic but usually has bouts of pain, jaundice
and fever Charcot’s triad
• Stone moves proximally and floats, obstruction is relieved &
symptoms subside

38. SIGNS
• Tenderness - epigastrium and the right hypochondrium.
• In jaundiced patient;
• “Courvoisier’s law” – ‘in obstruction of the common
bile duct due to a stone, distension of the gall bladder
seldom occurs; the organ is usually already shriveled.’

39. INVESTIGATIONS
• USG abdomen; CBD diameter >
1 cm indicates biliary
obstruction.
• Endoscopic retrograde
cholangiopancreatography
(ERCP): gold standard
• Magnetic resonance
cholangiopancreatography
(MRCP).
• Liver function tests.

40. TREATMENT
• Full supportive measures:
• with rehydration, correction of clotting abnormalities and treatment
with appropriate broad-spectrum antibiotics.
• Once the patient has been resuscitated, relief of the obstruction is
essential.
• Endoscopic papillotomy: preferred first technique with a
sphincterotomy, removal of the stones using a Dormia basket
or the placement of a stent if stone removal is not possible.
• If this technique fails, percutaneous transhepatic cholangiography
can be performed to provide drainage and subsequent
percutaneous choledochoscopy.
• Choledochotomy, rarely used, most managed by minimally
invasive

41. INDICATIONS FOR
CHOLEDOCHOTOMY
• Palpable stones in the common bile duct;
• Jaundice, a history of jaundice or cholangitis;
• A dilated common bile duct;
• Abnormal liver function tests, in particular a raised alkaline
phosphatase.

42. REFERENCE
• Bailey & Love’s Short Practice of Surgery, 26th edition
• SRB Manual of Surgery