KOLELITIASIS1

8/13/2019 KOLELITIASIS1

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KOLELITIASIS

Dr. SUHAEMI, SpPD, FINASIM


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G LLBL DDER DISORDERS

A. Cholelithiasis and Cholecystitis1. Definitions

a. Cholelithiasis: formation of stones (calculi) withinthe gallbladder or biliary duct system

b. Cholecystitis: inflammation of gall bladderc. Cholangitis: inflammation of the biliary ducts

2. Pathophysiologya.Gallstones form due to

1.Abnormal bile composition2.Biliary stasis3.Inflammation of gallbladder


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INTRODUCTION


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PATHOGENESISNormally, bile is sterile due to constant flush,bacteriostatic bile salts, secretory IgA, and biliary

mucous; Sphincter of Oddi forms effective barrier toduodenal reflux and ascending infection

ERCP or biliary stent insertion can disrupt the Sphincterof Oddi barrier mechanism , causing pathogeneic bacteriato enter the sterile biliary system.

Obstruction from stone or tumor increases intrabiliarypressure

High pressure diminishes host antibacterial defense- IgAproduction, bile flow- causing immune dysfunction,increasing small bowel bacterial colonization.

Bacteria gain access to biliary tree by retrograde ascent

Biliary obstruction (stone or stricture) causes bactibiliaE Coli (25-50%)Klebsiella (15-20%),Enterobacter (5-10%)

High pressure pushes infection into biliary canaliculi,hepatic vein, and perihepatic lymphatics, favoringmigration into systemic circulation- bacteremia (20-40%).

Adam.about.com

Gpnotebook.co.uk Pathology.med.edu


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CLINICAL MANIFESTATIONS

RUQ pain (65%)Fever (90%)

May be absent in elderly patients

Jaundice (60%)Hypotension (30%)

Altered mental status (10%)

CharcotsTriad:Found in50-70%of

patients

ReynoldsPentad:

Additional History

Pruitus, acholic stoolsPMH for gallstones, CBD stones,Recent ERCP, cholangiogram

Additional PhysicalTachycardiaMild hepatomegaly


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ANATOMI


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ANATOMI


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ANATOMI


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COMMON LOCATIONS OF GALLSTONES


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G LL STONES


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NORMAL GALLBLADDER


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Abdominal x-ray film,

showing a porcelaingallbladder. This is theterm used to describe agallbladder with acalcified wall.


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ABDOMINAL X-RAY DEMONSTRATING STONES IN THEGALLBLADDER


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GALLBLADDER, WITH NUMEROUS STONES PRESENT


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GALLBLADDER, WITH SLUDGE PRESENT (ARROW)


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ACUTE CHOLECYSTITIS NOTICE INCREASED GALLBLADDER WALLTHICKNESS


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DIAGNOSIS: FIRST-LINE IMAGINGUltrasonography

Advan tage :Sensitive for intrahepatic/extrahepatic/CBD dilatation

CBD diameter > 6 mm on US associated with high prevalence ofcholedocholithaisisOf cholangitis patients, dilated CBD found in 64%,

Rapid at bedsideCan image aorta, pancreas, liverIdentify complications: perforation, empyema, abscess

DisadvantageNot useful for choledocholithiasis:

Of cholangitis patients, CBD stones observed in 13% 10-20% falsely negative - normal U/S does not r/o cholangitis

acute obstruction when there is no time to dilateSmall stones in bile duct in 10-20% of cases

CTAdvan tages

CT cholangiograhy enhances CBD stones and increases detection of biliarypathology

Sensitivity for CBD stones is 95%Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscessCan visualize other pathologies- cholangitis: diverticuliits, pyelonephritis,mesenteric ischemia, ruptured appendix

DisadvantagesSensitivity to contrastPoor imaging of gallstones

Med.virgina.edu

Soto et al. J. Roenterology. 2000


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PERCUTANEOUS TRANSHEPATICCHOLANGIOGRAM (PTC)

PTC is indicated when percutaneousintervention is needed and ERCP either isinappropriate or has failed.Can be used to drain biliary obstructions.


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PTC


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PTC after injection ofdye, showing a largegallstone trapped inthe duct.


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PTC: The same ductas before, afterremoval of the stonethrough the drainagecatheter.


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ENDOSCOPIC RETROGRADECHOLANGIOPANCREATOGRAPHY (ERCP)

ERCP is the primary method of directcholangiography, and has therapeuticpotential. It also allows for examination of the

upper GI tract, the papilla of Vater, and thepancreatic duct. Biopsies of multiple sitescan be taken using this technique.ERCP causes less discomfort than PTC, butacute pancreatitis is a common complication(which is rarely seen in PTC).


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ERCP: THE ENDOSCOPE IS INTRODUCED AND IS THREADED AROUND TO THE

SPHINCTER OF ODDI. THERE, DYE CAN BE INJECTED INTO THE DUCTS.INSTRUMENTS CAN ALSO BE INSERTED THROUGH THE SCOPE TO REMOVESTONES, INSERT DRAINS, REMOVE TISSUE SAMPLES, OF PERFORM OTHERTREATMENTS.


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ERCP


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ERCP(THERAPUTIC)


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MAGNETIC RESONANCECHOLANGIOPANCREATOGRAPHY (MRCP)

MRCP is becoming a more viable imagingtechnique, as MRI technology improves. However,CT and ultrasound are faster, easier, and morereadily available, so they are used more frequentlythan MRCP.MRCP is emerging as a new tool for non-invasiveevaluation of the pancreatic and biliary ductalsystems.MRCP is gradually replacing PTC and ERCP fordiagnostic purposes.


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MRCP


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MRCP WITH STONES IN THE DUCT


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MANAGEMENT

1-Nonsurgical treatment2-Surgical treatment

PreoperativeIntraoperativepostoperative


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1-NONSURGICAL TREATMENT

Oral dissolution therapy

Aim: dissolute small radiolucent stoneDX:chenodeoxycholic acid& ursodeoxycholic

acidSide effect: diarrhea, pruritus, transient raise in

serum transaminasesDisadvantage: long term treatment (mnths)

high recurrence rate


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1-NONSURGICAL TREATMENT

Extracorporal shock wave lithiotrepsy Aim: medium sized radiolucent stone DX:+\- ODTSide effect biliary colic as fragments pass

through cystic duct


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PEMBEDAHAN

Operation ;1-gallstone inCBD:ERCP2-trumatic stricture:bypass via Roux loop of

intestinal anastomosed to the proximal dil3-cholangiocarcinoma:stenting +radiotherapy

4-CA of head of the pancreas or AOV:whipples operation:


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WHIPPLE PROCEDURE


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POSTOPERATIVE MANAGEMENT

Complication

Coagulation disorderRenal failureGIT hemorrhage (stress ulcer)Delayed wound healing

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