Transcript GALL BLADDER STONES, INFECTION & COMPLICATIONS

By ahmed alsalmi
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Anatomy
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The biliary tree consists biliary radicles that drain the liver and forming the
right and left hepatic ducts. The left hepatic, which is mainly extrahepatic,
joins the right hepatic duct to form the common hepatic duct. This is joined
by the cystic duct to form the common bile duct, which ends at the papilla
of Vater, usually in the second part of the duodenum.
The common bile duct is approximately 8 cm long and up to 10 mm in
diameter. It lies in the free edge of the lesser omentum before passing
behind the first part of the duodenum and through the head of the pancreas.
It is usually joined by the pancreatic duct just before entering the
duodenum.
The gallbladder lies on the undersurface of the liver between its right and
left halves. It is a muscular structure with a fundus, body and neck.
Hartmann's pouch is a dilatation of the gallbladder outlet adjacent to the
origin of the cystic duct, in which gallstones frequently become impacted.
The gallbladder is supplied by the cystic artery, a branch of the right
hepatic artery.
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Physiology
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 Bile acids are synthesized by the liver from cholesterol.
The primary bile acids are conjugated and the conjugates
form sodium and potassium bile salts.
 In the intestine, bacterial action produces the secondary
bile salts.
 Bile salts + lipids  water-soluble micelles, to transport
lecithin and cholesterol from the liver.
 Facilitate digestion and absorption of fat.
 If absent: fat in the stool and malabsorption of fat soluble
vitamins.
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Physiology
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 Capacity of GB: 50mL
 Concentrates bile by 10x
 Contracts in response to CCK (cholecystokinin)
 Released from duodenum
 Secretion of bile by stimulated hormone secretin &
vagus nerve
 Liver produces 1-2L of bile.
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Physiology
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 On reaching the distal ileum, 95% of the bile salts are
reabsorbed, transported back to the liver and passed
once again into the biliary system. This enterohepatic
circulation allows a relatively small bile salt pool (2-4
g) to circulate through the intestine 6-12 times a day.
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Choledochal cysts
(CDC)
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The cystic transformation of the biliary tree.
 Most common type: saccular dilatation of the
common bile duct.
 May remain undiagnosed until adult life.
 Neonate: jaundice & perforation
 Adult: intermittent pain, jaundice, pancreatitis.
 Dx: LFT, USS, Cholangiography
 Tx: excision of cyst because may turn malignant.
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Caroli's disease
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Cystic biliary dilatation that is more marked in the
peripheral intrahepatic ducts
 Recurring infection  cirrhosis and liver failure.
 If associated with congenital hepatic fibrosis 
portal hypertension.
 Avoid endoscopic, percutaneous and surgical
manipulation.
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GALLSTONES
Cholesterol stones
Yellow-green, regular,
rough
Mixed stones – darker
and are usually multiple
Pigment stones – black or
brown, multiple, small.
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Cholesterol stones
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 When bile becomes supersaturated with cholesterol.
 Favoured by stasis or decreased gallbladder
contractility
 Risk factors: disease of ileum, high calorie diet, high
cholesterol diet, obesity, CoC, HRT, pregnancy,
cholestyramine.
 Dieting to lower cholesterol may also cause
cholesterol stones
 Middle-aged obese multiparous women.
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Pigment stones
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Calcium bilirubinate.
 More common with hemolytic blood disorders:
 ex. congenital spherocytosis, haemoglobinopathy and
malaria.
 Associated with biliary stasis and cirrhosis.
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Pathological effects of
gall stones
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 Acute cholecystitis
 Chronic cholecystitis
 Mucocoele
 Choledocholithiasis
 Gallstone ileus
 Carcinoma
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Acute cholesystitis
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 Begins with an attack of biliary colic
 Severe right hypochondrial pain radiating to the
right subscapular region, and occasionally to the
right shoulder,
 Tachycardia, pyrexia, nausea, vomiting and
leukocytosis.
 Abdominal tenderness and rigidity
 Murphy's sign
 Mass may be felt (omentum 'wrapped' around the
inflamed gallbladder)
 90% settles within 4-5 days
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Chronic cholecystitis
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 C/F:
 recurrent flatulence,
 fatty food intolerance and
 right upper quadrant pain: aggravated by food and
associated with distension and heartburn.
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Mucocele
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 C/F:
 biliary colic
 a non-tender piriform swelling in the right
hypochondrium
 no pyrexia.
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Choledocholithiasis
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Stones present in common bile duct.
 Becomes painful when it reaches sphincter of Oddi:
 + Jaundice, pale stools and dark urine.
 A totally obstructed duct system becomes filled with
clear 'white bile‘ due to prevention of clearance of
bilirubin and increased mucus secretion.
 +infection  cholangitis (triad of charcot)
 May lead to pancreatitis.
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Courvoisier's law
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Jaundice + palpable GB = Gall stones
Can detect distended GB by USS.
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Investigations
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 Blood tests:
 CBC: neutrophilia in acute cholecystitis
 RFT: high serum bilirubin, high ALP  stone in common
bile duct.
 X-Ray:
 15% of gall stones contain radiopaque calcium.
 Gas in biliary tree  fistula between biliary tract and gut
 Cholangiography: ERCP and MRCP
 Ultrasound
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Ultrasound
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 To see gallbladder, its wall and its contents, and
demonstrates dilatation of the intrahepatic and
extrahepatic biliary tree.
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SURGICAL TREATMENT OF
GALLSTONES
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Open cholecystectomy:
Right subcostal incision  identify cystic duct and
artery  intraoperative cholangiography (to display
anatomy, identify stones, and confirm route to
duodenum)  ligate cystic duct and artery  remove
GB
 A retrograde approached if the anatomy is not
clearly seen.
 GB is removed ‘fundus first’
 Drain in subhepatic space to prevent collection and
identify leakage of bile.
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SURGICAL TREATMENT OF
GALLSTONES
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Laproscopic Cholecystectomy:
Access to the peritoneal cavity is obtained through three or four cannulae
inserted through the anterior abdominal wall and following insufflation of the
peritoneal cavity with CO2. The gallbladder is retracted by grasping forceps
inserted through the most lateral cannula in order to display the structures at
the porta hepatis. the cystic duct and artery are isolated by dissection with
instruments passed through the remaining cannulae. Some surgeons have
found it difficult to undertake operative cholangiography routinely with this
approach, and have either abandoned its use or relied upon intravenous
cholangiography, MRCP or ERCP in the pre- or post-operative period to
exclude the presence of common bile duct stones.
The cystic duct and artery are divided between metal clips and the gallbladder
is dissected from the liver using diathermy. Extraction of the gallbladder
through a cannula site may require extension of the incision or the tedious
removal of individual stones from the gallbladder. Care must be taken to
secure haemostasis, and many surgeons leave a drain in the subhepatic space.
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SURGICAL TREATMENT OF
GALLSTONES
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Exploration of the common bile duct in open surgery
 If stones are present in the duct system, the common
bile duct is opened longitudinally between stay
sutures (choledochotomy) and the stones are
extracted with forceps (Desjardins forceps) or a
Fogarty balloon catheter.
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SURGICAL TREATMENT OF
GALLSTONES
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Exploration of the common bile duct in open surgery
 To allow the escape of bile in obstruction, the
opening in the common bile duct is closed around a
T-tube, the long limb of which is brought out
through a stab incision in the abdominal wall
 The T-tube can removed 7-10 days following
surgery, if free flow of dye into the duodenum and
no residual duct stones are present.
 Transduodenal sphincterotomy
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COMPLICATIONS OF
CHOLECYSTECTOMY
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 Haemorrhage
 Infective complications
 Bile leakage
 Retained stones
 Bile duct stricture
 Post-cholecystectomy syndrome
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Haemorrhage
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 From cystic artery or the gallbladder bed
 Development of pain or if the patient exhibits early
features of hypovolaemic shock.
 Blood from drain
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Infective complications
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 In patients with obstructive jaundice, cholangitis, or
complications such as acute cholecystitis or
empyema when significant bile contamination of the
peritoneal cavity has occurred.
 Collections of bile or blood readily become infected
after cholecystectomy.
 Formal drainage may be needed if this progresses to
the formation of a subhepatic or subphrenic abscess.
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Bile leakage
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 Due to:
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ligature or clip slipping off the cystic duct,
the accidental division of an unrecognized accessory duct,
damage to the common bile duct, or
retention of a duct stone after exploration
 Features: abnormal LFTs and localized or generalized
abdominal pain
 Treatment of persistent leak:
 Investigative endoscopic cholangiography
 + biliary peritonitis  surgery
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Retained stones
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T-tube cholangiogram may reveal a retained stone in the
bile duct.
 Small stones can be flushed into the duodenum with
saline
 If not, the patient is discharged with the t-tube and it is
removed 4-6 weeks later.
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Retained stones
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 In some patients, stones may be left in the bile duct after
cholecystectomy.
 Leading to jaundice, cholangitis and pancreatitis in the
months and years following cholecystectomy.
 Confirmed via ERCP
 endoscopic papillotomy is performed to recover them
via Dormia basket.
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Bile duct stricture
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 About 90% of benign duct strictures result from
damage during cholecystectomy, in which the duct is
divided, ligated or devascularized.
 Common bile duct becomes:
 Completely occluded  obstructive jaundice.
 Partially occluded  cholangitis
 The site and extent of the stricture must be defined
radiologically:
 USS then MRCP, ERCP and/or PTC.
 Treatment: bringing up a Roux loop of jejunum and
anastomosing this to the distended biliary system
above the stricture
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MANAGEMENT OF ACUTE
CHOLECYSTITIS
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 The pulse, blood pressure and temperature are
monitored, and analgesics, intravenous fluid and a
broad-spectrum antibiotic such as a cephalosporin
are prescribed.
 Patients are given nothing by mouth and a
nasogastric tube is passed if they are vomiting.
 The majority of patients settle within a few days on
this regimen.
 Failure to settle suggests the presence of an
empyema.
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MANAGEMENT OF ACUTE
CHOLECYSTITIS
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 Cholecystectomy is done electively, after
appropriate investigation, within 72 hours of the
onset of the attack, under antibiotic cover.
 If the surrounding inflammation makes
identification of the relevant anatomical structures
difficult, drainage of the gallbladder with removal of
stones (cholecystostomy) may be performed as an
interim measure.
 Elective cholecystectomy is performed approximately
2 months later.
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MANAGEMENT OF ACUTE
CHOLANGITIS
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 The patient is often extremely unwell, with evidence
of septic shock.
 Treatment involves resuscitation, the administration
of appropriate antibiotics, and decompression of the
biliary tree.
 When common bile duct stones are responsible, it
may be necessary to drain the biliary tree
temporarily by means of a stent, even if
sphincterotomy and stone extraction have
apparently been successful.
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PRIMARY SCLEROSING
CHOLANGITIS
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 In which both intrahepatic and extrahepatic bile
ducts may become indurated and irregularly
thickened.
 Over three-quarters of patients also suffer from
ulcerative colitis; other associated conditions include
retroperitoneal fibrosis, immunodeficiency
syndromes and pancreatitis.
 Bile duct carcinoma can develop, and obstruction can
give rise to bacterial cholangitis and secondary
biliary cirrhosis.
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PRIMARY SCLEROSING
CHOLANGITIS
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 Obstructive jaundice, pruritus and pain
 ERCP and liver biopsy are the mainstays of
diagnosis.
 Cured by liver transplantation
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CARCINOMA OF THE
GALLBLADDER
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 almost invariably associated with the presence of
gallstones.
 F to M 4:1
 About 90% of lesions are adenocarcinomas; the remainder
are squamous carcinomas.
 Initial symptoms are indistinguishable from those of
gallstones
 tumours presenting with jaundice cannot be cured by
resection, and palliation by endoscopic or percutaneous
insertion of a stent or surgical bypass is required.
 The 5-year survival rate is less than 5%.
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CARCINOMA OF THE
BILE DUCTS
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Cholangiocarcinoma.
 Tumours can be classified based on the level of
involvement of the biliary tree
 cholangiocarcinoma may develop in patients with
underlying primary sclerosing cholangitis or choledochal
cyst.
 C/F:
 Obstructive jaundice, often preceded by vague dyspeptic
pain
 Anorexia and weight loss
 Pruritus
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Management
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 Treated by the Whipple operation
 Resectability is best assessed by CT or MRI to
exclude the presence of hepatic metastases and nodal
involvement and to assess vascular invasion.
 Following resection, the remaining biliary tree is
anastomosed to a Roux loop of jejunum
 If not resectable palliation can be achieved by
insertion of a stent by endoscopic or percutaneous
transhepatic techniques
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