Cholelithiasis

Definitions

The presence of gallstones in the gallbladder is called cholelithiasis.

BILIARY ANATOMY

Anatomy: vascular supply

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:

1. Initiated by cholesterol or bilirubinate super saturation in bile

2. Continued to crystal nucleation (microlithiais or sludge formation)

3. And gradually stone growth occur

Gallstone types

1. Cholesterol

2. Pigment

Brown

Black

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

Signs and Symptoms.

Complaints of indigestion after eating high fat foods.

Localized pain in the right-upper quadrant epigastric region.

Anorexia, nausea, vomiting and flatulence.

Increased heart and respiratory rate – causing patient to become diaphoretic which in turn makes them think they are having a heart attack.

Signs and Symptoms.

Low grade fever.

Elevated leukocyte count.

Mild jaundice.

Stools that contain fat – steatorrhea.

Clay colored stools caused by a lack of bile in the intestinal tract.

Urine may be dark amber- to tea-colored.

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

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 …

Medical Management.

Lithotripsy for patients with

only a FEW stones.

If the attack of cholelithiasis is mild –

bed rest is prescribed.

patient is placed on NPO to allow GI tract and gallbladder to rest.

an NG tube is placed on low suction.

fluids are given IV in order to replace lost fluids from NG tube suction.

Medical Management.

Cholecystectomy

or

Laparoscopic Cholecystectomy

– removal of the gallbladder.

This is the treatment of choice.

The gallbladder along with the cystic duct, vein and artery are ligated.

Medical Management.

If stones are present in the common bile duct, an endoscopic sphincterotomy must be performed to remove them BEFORE a cholecystectomy is done.

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Cholecystitis

ACUTE CHOLECYSTITIS

Acute cholecystitis is inflammation of gall-bladder.

BILIARY ANATOMY

ETIOLOGY AND PATHOGENESIS

• infection• discoordination passage of bile • metabolic disturbance

The pathological sequences during a bout of uncomplicated cholecystitis

Sequence of pathological processes with local inflammation around a gallbladder

Sequence of pathological processes. Formation of an empyema or mucocele of the gallbladder

Sequence of pathological processes leading to perforation of the gallbladder

Sequence of pathological processes localising a perforation of the gallbladder

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

Symptoms and clinical signs

Pain syndrome. Characteristic for it is great acute pain in right hypochondrium and epigastric area with an irradiation in right supraclavicular area and right shoulder. If pain syndrome has the strongly expressed character, it is named hepatic colic.

Dyspepsic syndrome. Frequent symptoms which disturb a patient, are nausea, frequent vomitting, at first by gastric maintenance, and later — with bile. Afterwards feelings of swelling of stomach, delay of emptying and gases.

Symptoms and clinical signsMurphy's symptoms is a delay of breathing during

palpation of gall-bladder on inhalation.

Kehr's symptom is strengthening of pain at pressure on the area of gall-bladder, especially on deep inhalation.

Ortner's symptom — painfulness at the easy pushing on right costal arc by the edge of palm.

Mussy's symptom — painfulness at palpation between the legs (above a collar-bone) of right nodding muscle.

Blumberg's signs are the increases of painfulness at the rapid taking away of fingers by which a front abdominal wall is pressed on. This symptom is not pathognomic for cholecystitis but matters very much in diagnostics of peritonitis.

DiagnosisA. Local sign inflammation

1. Murphy sign

2. RUQ mass/pain/ tenderness

B. Systemic sign of inflammation

1.fever

2. elevated CRP

3. Elevated WBC count

C. Imaging Finding

Imaging finding criteria of acute cholecystitis

Suspected : one item A + one item BDefinite : one item A + one item B + one item C

Severity

Grade III (severe) acute cholecystitis Associated with dysfunction of any one of the following organs/systems: Cardiovascular dysfunction Hypotension requiring treatment with dopamine C5 lg/kg per min, or any dose of norepinephrine Neurological dysfunction Decreased level of consciousness Respiratory dysfunction PaO2/FiO2 ratio \300 Renal dysfunction Oliguria, creatinine [2.0 mg/dl ]Hepatic dysfunction PT-INR[1.5 x elevated]Hematological dysfunction Platelet count \100,000/mm3

Severity

Grade II (moderate) acute cholecystitis Associated with any one of the following conditions:

1.Elevated white blood cell count ([18,000/mm3 )

2.Palpable tender mass in the right upper abdominal quadrant

3.Duration of complaints [72 h ]

4.Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis

Severity

Grade I (mild) acute cholecystitis Does not meet the criteria of ‘‘Grade III’’ or ‘‘Grade II’’ acute cholecystitis. Grade I can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure

Management1. When acute cholecystitis is suspected, diagnostic assessment is

made using TG13 diagnostic criteria every 6–12 h

2. Abdominal US is carried out, followed by HIDA scan and CT scan if needed to make the diagnosis

3. Severity is repeatedly assessed using severity assessment criteria; at diagnosis, within 24 h after diagnosis, and during the time zone of 24–48 h

4. Take that cholecystectomy is performed into consideration, as soon as a diagnosis has been made, the initial treatment takes place involving the replacement of sufficient fluid after fasting, electrolyte compensation, intravenous injection of analgesics and full dose antimicrobial agents

5. For patients with Grade I (mild), cholecystectomy at an early stage within 72 h of onset of symptoms is recommended

6. If conservative treatment patients with Grade I (mild) is selected and no response to the initial treatment is observed within 24 h, reconsider early cholecystectomy if still within 72 h of onset of symptoms or biliary tract drainage

Management7. For patients with Grade II (moderate), perform immediate biliary

drainage or drainage if no early improvement (or cholecystectomy in experienced centers) along with the initial treatment

8. For patients with Grade II (moderate) and III (severe) at high surgical risk, biliary drainage is immediately carried out

9. Blood culture and/or bile culture is performed for Grade II (moderate) and III (severe) patients

10. Among patients with Grade II (moderate), for those with serious local complications including biliary peritonitis, pericholecystic abscess, liver abscess or for those with gallbladder torsion, emphysematous cholecystitis, gangrenous cholecystitis, and purulent cholecystitis, emergency surgery is conducted (open or laparoscopic depending on experience) along with the general supportive care of the patient. If surgery cannot be performed due to the lack of facilities or skilled personnel, transfer of the patient is considered

11. For patients with Grade III (severe) with jaundice and those in poor general conditions, emergency gallbladder drainage is considered with initial therapy with antibiotics and general support measures. For patients who are found to have gallbladder stones during biliary drainage, cholecystectomy is performed at after 3 month interval after the patient’s general conditions are improved

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