Transcript Cholelithiasis and it’s Complication

A.WEISS M.D
D.E.S ,Chirurgie Générale,Viscérale et Laparoscopique
A.F.S/A.F.S.A/DU- France
References :
R. S.SNELL/ Clinical Anatomy/By SNELL/7e.Vol2.
S.I. SCHWARTZ/ Principles of Surgery Companion Handbook/McGraw-Hill/1998.
F. C BRUNICARDI and others/Schwartz’s Principles of Surgery/McGraw-Hill/8e/2004.
J.SPENCER and others/The Washington Manual of Surgery/Lippincott Williams & Wilkins/5e/2008.
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The extra hepatic biliary system begins
with the hepatic ducts and ends at the
stoma of the common bile duct in the
duodenum.
The right hepatic and the left hepatic
ducts join to form a common hepatic
duct that is 3–4 cm in length.
It is then joined at an acute angle by the
cystic duct to form the common bile duct.
The common bile duct is approximately
8–11.5 cm in length and 6–10 mm in
diameter.
The lower third of the common bile duct
curves more to the right behind the head
of the pancreas, which it grooves, and
enters the duodenum at the
hepatopancreatic ampulla (of Vater),
where it is frequently joined by the
pancreatic duct.
The sphincter of Oddi surrounds the
common bile duct at the ampulla of
Vater.
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The gallbladder is located in the bed of the
liver in line with that organ's anatomic
division into right and left lobes.
It has an average capacity of 50 mL and is
divided into four anatomic portions: the
fundus, the corpus or body, the
infundibulum, and the neck.
The fundus is the rounded, blind end that
normally extends beyond the liver's margin. It
contains most of the smooth muscle of the
organ, in contrast to the corpus or body,
which is the major .
The body tapers into the neck, which is funnel
shaped and connects with the cystic duct.
The neck usually may be distended into a
dilatation known as the infundibulum, or
Hartmann's pouch.
The lumen is lined with a high columnar
epithelium that contains cholesterol and fat
globules.
The mucus secreted into the gallbladder
originates in the tubular alveolar glands in the
globular cells of the mucosa lining the
infundibulum and neck.
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Blood supply to the gallbladder is by
the cystic artery, which normally
originates from the right hepatic artery
behind the cystic duct.
It is approximately 2 mm in diameter
and courses above the cystic duct for a
variable distance until it passes down
the peritoneal surface of the
gallbladder and branches.
Venous return is carried through small
veins, which enter directly into the
liver, and a large cystic vein, which
carries blood back to the right portal
vein.
Lymph flows directly from the
gallbladder to the liver and drains into
several nodes along the surface of the
portal vein.
The nerves of the gallbladder arise
from the celiac plexus.
The gallbladder is connected with the
common duct system via the cystic
duct.
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The main constituents of bile are:
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Bile acids, produced endogenously or
taken orally, reduce cholesterol synthesis
and increase cholesterol absorption from
the intestine.
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The principal bile acids are cholic and
deoxycholic acids, and they are
synthesized from cholesterol within the
liver; they are conjugated there with
taurine and glycine and act within the
bile as anions that are balanced by
sodium.
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The color of the bile secreted by the liver
is related to the presence of the pigment
bilirubin diglucuronide, which is the
metabolic product of the breakdown of
hemoglobin and is present in bile in
concentrations 100 times greater than in
plasma.
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After this pigment has been acted on by
bacteria within the intestine and
converted into urobilinogen, a small
fraction of the urobilinogen is absorbed
and secreted into the bile.
Water.
Electrolytes (Sodium, potassium, calcium,
and chloride have the same concentration in
bile as in extracellular fluid or plasma).
Bile salts.
Proteins.
Lipids.
Bile pigments.
The pH of hepatic bile is usually neutral
or slightly alkaline and varies with diet.
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Composition :
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The major elements involved in the formation of gallstones are :
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Cholesterol (85% of stones, radiolucent) .
Bile pigment ((15% of stones, radiopaque) .
Calcium.
In Western cultures, most stones are made up of the three major elements and
have a particularly high content of cholesterol.
“Pure” pigment stones are usually associated with hemolytic jaundice.
Formation :
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Gallstones form as a result of solids settling out of solution.
Gallstones are classified by their cholesterol content as either cholesterol stones or
pigment stones.
Pigment stones can be further classified as either black or brown.
In Western countries, about 80% of gallstones are cholesterol stones and about 15
to 20% are black pigment stones.
Brown pigment stones account for only a small percentage.
Both types of pigment stones are more common in Asia.
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Prevalence and incidence :
Gallstone disease is one of the most common problems affecting the
digestive tract.
 Autopsy reports have shown a prevalence of gallstones from 11 to 36%.
 The prevalence of gallstones is related to many factors, including age,
gender, and ethnic background.
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Risk factors:
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Obesity.
Pregnancy.
Dietary factors.
Crohn's disease.
Terminal ileal resection.
Gastric surgery.
Hereditary spherocytosis.
Sickle cell disease.
Thalassemia
Asymptomatic Gallstones
Symptomatic Gallstones
( BILIARY COLIC )
Gallstones with Complications
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The liberal use of ultrasonography has resulted in the diagnosis of
calculi in patients without symptoms referable to the biliary tract.
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Diagnosis :
Asymptomatic gallstones are usually discovered on routine imaging
studies or incidentally at laparotomy for unrelated problems.
 Common abdominal symptoms such as dyspepsia, bloating,
eructation, or flatulence without associated pain are probably not
caused by gallstones.
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Management :
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There is no role for prophylactic cholecystectomy in most patients
with asymptomatic gallstones, with a few exceptions.
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Patients with a porcelain gallbladder .
Children with gallstones have a relative indication for cholecystectomy .
Patients with diabetes mellitus, spinal cord trauma, and sickle cell
anemia, prophylactic cholecystectomy is generally not indicated for
asymptomatic or uncomplicated gallstone disease.
Management of gallstones discovered at laparotomy remains
controversial .
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Diagnosis largely depends on correlating symptoms with the
presence of stones on imaging.
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Symptoms :
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Biliary colic is the main symptom and is initiated by impaction of a gallstone in
the outlet of the gallbladder, as characterized by the following :
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Periodicity : The pain comes in distinct attacks lasting 30 minutes to several
hours.
Location : In the epigastrium or right upper quadrant.
Severity : The pain is steady and intense and may cause the patient to
restrict breathing. Frequently, it is so severe that immediate care is sought
and narcotics are necessary for control.
Timing :The pain occurs within hours of eating a meal, often awakening the
patient from sleep.
Other symptoms include :
 back pain, left-upper-quadrant pain, nausea, and vomiting. These usually
occur in addition to, rather than in place of, the pain as described.
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Physical signs :
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mild right-upper-quadrant tenderness .
Diagnostic imaging :
By Ultrasound.
There is usually little or no associated gallbladder wall thickening or other
evidence of cholecystitis.
 Bile ducts must be assessed for evidence of dilation or choledocholithiasis
(gallstones in the common bile duct).
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Differential diagnosis:
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Acute cholecystitis.
Liver diseases.
Peptic ulcer disease.
Renal colic.
Gastroesophageal reflux.
Irritable bowel syndrome.
Diseases based in the chest( iInferior wall myocardial ischemia/infarct or rightlower-lobe pneumonia ).
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Management :
 Laparoscopic cholecystectomy
(LC) is the appropriate
treatment for the vast majority
of patients with symptomatic
gallstones .
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Acute calculous cholecystitis .
Choledocholithiasis .
Biliary pancreatitis .
Cholangitis is often caused by choledocholithiasis .
Gallstone ileus (bowel obstruction caused by a gallstone) .
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Acute calculous cholecystitis is initiated by obstruction of the cystic duct by
an impacted gallstone.
Persistence of stone impaction leads to inflammation of the gallbladder.
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Diagnosis :
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Symptoms :
( Similar to but more severe and persistent than those of biliary colic).
Tenderness in the right upper quadrant .
Anorexia.
Nausea.
Vomiting .
Murphy's sign .
Mild jaundice may be present .
Laboratory abnormalities :
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leukocytosis (typically 12,000 to 15,000 cells/µL).
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Liver function tests (LFTs), including serum bilirubin, alkaline phosphatase,
alanine transaminase (ALT), aspartate transaminase (AST), and serum amylase,
also may be abnormal.
Diagnostic imaging :
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Ultrasonography :is the most commonly used test for diagnosing acute
cholecystitis and any associated cholelithiasis.
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Findings indicative of acute cholecystitis include :
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Gallbladder wall thickening.
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Pericholecystic fluid.
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Sonographic Murphy sign
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Radionuclide cholescintigraphy.
Computed tomographic (CT) scanning.
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Management :
Depends on available expertise and clinical situation.
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Initial management :
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Hospitalization.
NPO
Intravenous fluid .
Parenteral antibiotics .
Patients with acute cholecystitis should have cholecystectomy as
definitive treatment :
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Early cholecystectomy :
The operation is best performed within 48 hours after the onset of symptoms,
when there is less gallbladder inflammation.
Delayed cholecystectomy :
6 weeks after the onset of symptoms .
Tube cholecystostomy :
Should be performed in patients who have acute cholecystitis and who are
failing systemic therapy but are not candidates for cholecystectomy because of
severity of illness or concomitant medical problems.
Drainage of the gallbladder almost uniformly resolves the episode of acute
cholecystitis .
After resolution of the acute episode, the patient can eventually undergo either
cholecystectomy or percutaneous stone extraction and removal of the
cholecystostomy tube.
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Gallstones that originate in the gallbladder and pass
through the cystic duct into the common duct.
In Western countries, stones rarely originate in the hepatic
or common ducts, although these “primary” stones, usually
brown pigment stones, are more prevalent in Asia.
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Diagnosis :
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Jaundice :
 With bilirubin typically between 3 and 10 mg/dL.
Biliary colic .
On examination :
 Icterus .
Ultrasonography :
 Demonstrates gallbladder stones and bile duct dilation .
The diagnosis may be confirmed by :
 Endoscopic retrograde cholangiopancreatography (ERCP) .
 Percutaneous transhepatic cholangiography (PTC) .
Occasionally, the diagnosis of choledocholithiasis is confirmed by
intraoperative cholangiography (IOC) at the time of cholecystectomy.
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Management :
Depends on available expertise
and clinical situation.
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In patients with
choledocholithiasis who also
have cholelithiasis, standard
management consists of LC
and IOC, possibly followed by
laparoscopic CBD exploration
if stones are seen .
In some cases,
choledocholithiasis should be
handled by ERCP or PTC.
ERCP with sphincterotomy and
stone removal is used in
patients who are not surgical
candidates or have had prior
cholecystectomy.
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Blockage of pancreatic secretions by passage of a gallstone into the
common biliary-pancreatic channel.
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The greatest risk is carried by small (~2 mm) stones.
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Once the acute episode of pancreatitis has resolved, the
gallbladder should be removed as expeditiously as possible to
avoid recurrent pancreatitis.
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A longer delay may be justified in patients who have had severe
pancreatitis and in whom local inflammation or systemic illness
contraindicates surgery.
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An IOC should always be done at the time of the cholecystectomy
to confirm that the bile duct is free of stones.
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In patients in whom cholecystectomy is contraindicated,
endoscopic sphincterotomy (ES) may be protective against further
attacks of pancreatitis.
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Acute cholangitis is a potentially life-threatening bacterial infection of the
biliary tree typically associated with partial or complete obstruction of the
ductal system.
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Acute cholangitis is often associated with cholelithiasis and
choledocholithiasis, other causes of biliary tract obstruction and infection,
including benign and malignant strictures of the bile ducts or at biliaryenteric anastomoses, parasites, and indwelling tubes or stents, also have a
causative relationship.
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Diagnosis :
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Greater than 90% of patients present Charcot's triad (fever, jaundice, and right-upperquadrant pain) .
The advanced symptoms of Reynold's pentad (Charcot's triad with hemodynamic
instability and mental status changes) are seen on presentation in up to 10% of
patients .
Laboratory data supportive of acute cholangitis include elevations of the white blood
cell count and LFTs.
Ultrasonography or CT scan may reveal gallstones and biliary dilatation .
Definitive diagnosis is made by ERCP or PTC, and these studies are both diagnostic
and therapeutic because they demonstrate the level of obstruction and allow culture
of bile, removal of stones or indwelling foreign bodies, and placement of drainage
catheters if necessary.
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Management :
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Initial management :
 Hospitalization.
 NPO
 Intravenous fluid .
 Parenteral antibiotics (the most commonly cultured organisms: Escherichia
coli, Klebsiella pneumoniae, enterococci, and Bacteroides fragilis ) .
 In patients with acute toxic cholangitis or in patients who fail to respond to
antibiotic therapy, emergent decompression of the biliary tree via ERCP or
PTC is required
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If decompression by these means is not available or intervention to decompress
the biliary tree is indicated, though it should usually be limited to extraction of
obvious stones and insertion of a T tube in the CBD.
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Cholangitis in patients with indwelling tubes or stents generally requires stent
removal and replacement.
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Definitive operative therapy for benign or malignant biliary tract strictures
should be deferred until a later date.
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Uncommon complication that results from a gallstone eroding
through the wall of the gallbladder into the adjacent bowel
(usually duodenum).
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Usually the stone migrates until it lodges in the narrowest portion
of the small bowel, just proximal to the ileocecal valve.
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Patients present with symptoms of bowel obstruction and air in
the biliary tree (from the cholecystoenteric fistula).
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Treatment is exploratory laparotomy and removal of the
obstructing gallstone by milking it back to an enterotomy made in
healthy intestine.
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The entire bowel should be searched diligently for other stones,
and cholecystectomy should be performed if the patient is stable
and the inflammation is not too severe.