Transcript The gallbladder, gallstones, and beyond*.

Leslie Kobayashi, MD
January 31, 2012
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Liver
Bile ducts
Pancreas
Duodenum
Transverse colon
Fundus
Body
 Infundibulum/Neck
 Cystic duct
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 Spiral Valves of
Heister
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Triangle of calot
 Borders: CHD, cystic duct, liver edge
 Contents: Cystic artery, node of Calot
Right and Left Hepatic ducts
Common Hepatic duct
 Cystic duct
 Common bile duct
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Vascular
 Normally (>90%)
cystic a. arises from
RHA
 Replaced right
hepatic a.
 Replaced left
hepatic a.

500-1500mL produced daily
 Composition: water, electrolytes, bile salts,
proteins, lipids
 Ductal epithelium products
▪ Alkaline phosphatase
▪ HCO3
 Hepatocyte products
▪ Bile in conjugated soluble form synthesized from
cholesterol
▪ Primarily cholate and chenodeoxycholate
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95% of bile re-absorbed into the liver via
portal vein (enterohepatic circulation)
 85-90% in terminal ileum via active transport
 10-15% deconjugated in colon, absorbed passively
 5% excreted in stool
 Cycles 6-10x daily
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80% of bile stored in GB in
fasting state
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Function store and concentrate bile
 Absorption: NaCL, H2O occurs rapidly
 Secretion: mucus, H+
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GB average capacity 30-50mL
 Can increase to 300mL with obstruction
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Normal ejection 50-70% in 30-40min
 Do gallbladder problems create a
significant healthcare
burden?
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Health burden
 6.2 Billion$ in US
 1.8 million ambulatory care visits
 Increased 20% since 1980’s
 Cholecystectomy most common elective
abdominal procedure in the US
▪ 750,000 annually
 Stones
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Cholesterol stones (75%)
 Female fat fertile
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Black stones (20%)
 Hemolytic diseases (Sickle cell disease)
 Cirrhosis
*primarily form in the
 Brown stones (5%)
ducts
 Infection
 PSC
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Low calcium, radiolucent
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Created when fractional cholesterol
content of bile increased, and with
incomplete emptying of GB
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Associated with obesity, rapid weight
loss, Native American/Hispanic heritage,
↑TG’s, ↓HDL, Spinal cord injury
 Hormonal influence
 Estrogen increases lithogenicity of bile
▪ Increased risk for females
▪ Increased risk in obesity
 Progesterone increases SM relaxation and
bile stasis, decrease bile salt secretion
▪ Increased risk in pregnancy
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Increase risk of stone formation
 TPN
 Octreotide
 Ceftriaxone
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Decrease risk of stone formation
 Statins
 ?ursodiol
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Often radiopaque due to calcium
bilirubinate, calcium fatty acid soaps
and inorganic calcium salts
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Two types
 Black
 Brown
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Black
 Form in GB
 Bile sterile
 Associated with age, hemolytic DO’s, alcoholism,
cirrhosis, Gilbert’s syndrome, Cystic fibrosis,
pancreatitis and TPN
 Cholecystectomy curative
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Brown
 Form in ducts as well as GB
 Always infected 1O with enteric organisms, often
associated with cholangitis
 Associated with parasitic infection (liver fluke)
 Associated with IBD, duodenal diverticulae
 Will often recur after LC/OC
And what
do they do?
Stones
Asymptomatic
Symptomatic
Biliary
Uncomplicated
colic
Complicated
No obstruction
+ Obstruction
+
Cholecystitis
Infection/inflammation
GSP
CBD
Choledocho
- Infection
Ampulla
Cholangitis
+infection
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Incidence: 10-30% of the population
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Asymptomatic (80%)
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Symptomatic (1-3% per year)
 No inflammation: Biliary colic
 +inflammation: acute cholecystitis
 +obstruction : choledocholithiasis, GSP
 +obstruction+inflammation: cholangitis
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History
 Transient abdominal pain
 Occurs after fatty meals
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Exam
 Benign
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Labs
 Normal
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Ultrasound
 GS
Hyperechoic masses,
dependent in
location
Acoustic shadowing
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History
Labs
 Prolonged pain
 Leukocytosis
 Fevers
 Mild ↑ LFT’s
 Nausea/emesis
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Exam
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Imaging
 Fever, tachycardia
 Ultrasound
 RUQ TTP, Murphy’s
 HIDA
sign
 Gallstones
 Obstruction of gallbladder
 Obstruction causes inflammation
 Inflamed wall is thickened
 Edema or emphysema of GBW
 Inflammation may or may not be
associated with infection
 50-70% of bile cultures are positive
 E. coli, Klebsiella, Streptococcus,
Enterobacter
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95% sensitivity/specificity
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Signs of cholecystitis
 Gallstones
 GBW >3mm
 Pericholecystic fluid
 GBW striations or air within GBW
 Sonographic Murphy’s sign
GS with GBW
thickening
Normal GBW <3mm
Pericholecystic
fluid
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Cholescintigraphy: Injection of Tc99
labeled hydroxyl iminodiacetic acid
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HIDA→hepatocytes→secreted into bile
 Normal visualization of GB, CBD and SB
within 30-60 min
 +scan if no visualization of GB within 1hr
and +uptake in CBD or SB
Normal HIDA
Positive HIDA
Rim sign
*Sphincter, ↙CBD
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False positives common in fasting
patients
 Up to 40-60% in critically ill
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Can decrease false+ rate with morphine
 ↑sphincter of Oddi pressure causing
preferential filling of the GB
 ↑Tension in GBW =↓perfusion
→Necrosis of GBW
 Gangrenous/emphysematous cholecystitis
▪ 1% of cases, 3:1 M>F
▪ Conversion rate 30-50%
 GB Perforation
▪ Assoc with ↑mortality (~20%)
▪ Gallstone ileus
 Cystic duct obstruction→ Hydrops
 Bile is absorbed but GB mucosa
continues to secrete mucus
 GB tense, filled with mucinous fluid
 Mirrizi’s syndrome
 Impacted stone in infundibulum or CD
→External compression of the CBD
 0.7-1.4% of patients
 Assc with ↑risk of
CBD
injury, GB cancer
Stone in CBD
No obstruction
Symptomatic
Asymptomatic
+ obstruction
No infection
+Infection
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History: jaundice, icterus, pruritis, dark urine,
steatorrhea, acholic stools, bleeding
Exam: jaundice, icterus, RUQ pain, Murphy’s
sign
Labs
 Elevated LFT’s, INR
 Elevated bilirubin highest PPV 25-50%
 May be normal in up to 30% of patients
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Imaging
 Dilated CBD on UTZ
▪ CBD <5mm risk of stone ~1%
▪ CBD >5mm risk of stone 58%
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MRCP
 Sensitivity 95%
 Specificity 89%
CBD dilation
Stones within the bile
duct
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History/Exam: similar to choledocholithiasis
with sepsis, septic shock
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Labs/Imaging: similar to choledocholithiasis
with leukocytosis, bactermia, ±MSOF
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Charcot’s triad RUQ pain, fevers, jaundice
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Reynolds pentad Triad + ΔMS, shock
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History: epigastric pain, nausea/emesis
Exam: RUQ/epigastric TTP, SIRS
Labs: amylase/lipase ↑3x nl, ±↑LFT’s,
leukocytosis
Imaging: ±CBD dilation, pancreatic edema,
necrosis, fluid collection
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First 24hours:
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48 hours
 Glucose >200
 Ca <8
 Age >55
 Hct↓>10
 LDH>350
 PaO2 <60
 AST>250
 BUN↑>5
 WBC>16k
 Base Deficit >4
 Sequestration >6L
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First 24hours:
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48 hours
 Glucose >220
 Ca <8
 Age >70
 Hct↓>10
 LDH>400
 PaO2 <60
 AST>440
 BUN↑>2
 WBC>18k
 Base Deficit >5
 Sequestration >6L
Each category 0 or 1
Add up total points
 Mortality
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 0-2 <5%
 3-4 15%
 5-6 40%
 7-8 ~100%
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Medical
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 sphincterotomy,
Surgical
 Lap
 Open
 CBDE
ERCP
 stent
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Percutaneous
 Cholecystostomy
tube
Preparation
Eat a diet high in alkaline-forming foods and low in fats for at least 3-5
days before the cleanse.
Help to gently prepare the liver by having a glass of fresh apple juice
every day for 1 week prior to the cleanse. Apple juice helps to dissolve the
stones
Ingredients
•Epsom salts (Magnesium Sulfate): 4 tablespoons
•Olive oil: 1/2 cup or 125 ml
•Fresh pink grapefruit: squeeze 1/2 cup (125 ml) juice
•Or use 7-8 fresh lemons/limes: squeezed into 1/2 cup
•1 liter jar with lid
juice
 Or you could try:
 IVF hydration
 Antibiotics
 Bowel rest
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Ursodiol: used as
 Mechanism: supplemental bile acid decreases
lithogenicity of bile, dissolve existing stones
 Indications: bridge to LC/OC, too sick for OR,
cirrhotics, PSC, TPN
 Efficacy: may ↓LFT’s in PSC/cirrhotics, may
↓stones/sludge on UTZ, does not ↓symptoms,
prevent need for OR, stones recur after cessation
of medication
 Diet:
Cholesterol/Fatty acids
Carbohydrates
Legumes
Unsaturated fats
Coffee, Fiber
Vitamin C, Alcohol
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Failure of medical management in acute
cholecystitis 32%
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Recurrence rate of GSP 29-63%
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Surgical management results in reduced
HLOS
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Timing of surgery for acute cholecystitis
 Within 48hrs vs >72hrs no difference in
conversion rates, OR time, LOS
 Comparing first hospitalization (<7d) vs
delayed (>6wks)
▪ 17.5% rqr emergent cholecystectomy for
recurrent/unresolving sx’s
▪ No difference in conversion rates or CBD injury
 Timing of surgery for GSP
 Early operation safe with mild
pancreatitis Rason’s criteria <3
 Increased conversion rate, HLOS, and
operative complications in early
operation in severe pancreatitis
Ranson’s criteria ≥3
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Port placement
 Umbilicus
 Subxiphoid just to the right of the falciform
at the level of the inferior liver edge
 2-3cm below costal margin in midclavicular
line
 Anterior axillary line, below the fundus of
gallbladder
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Retraction and dissection of Triangle of
Calot prior to Gallbladder removal from
fossa
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CD may be clipped, sutured, tied,
stapled
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Remove gallbladder in fundus→dome
direction
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Right subcostal incision
 Mini-cholecystectomy (5-8cm) incision
associated with equivalent
outcomes/complications and less post-op
pain, decreased LOS
 Dome down dissection technique
 Isolate cystic artery/duct and suture ligate
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Conversion rate: 0.18-35% ave 4.7%
CBD injury rates
 Lap 0.2-0.6%
 Open 0-0.3%
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Complication rate
 Lap ~1.2%
 Open (bile leak 1%)
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LOS: shorter for Lap
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RF’s for conversion
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Male sex
Obesity
↑age
Wide short cystic duct
Low surgeon case load
Gangrenous or emphysematous chole
 ↑risk of conversion RR 3.2 (CI 2.5-4.2)
 No ↑risk of local complications or CBD injury
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Can be transhepatic or transperitoneal no
difference in outcomes
Technical success 96-98%
Resolution of symptoms 68-96%
Mortality 3-14%
Complications
 Dislodged catheter 16-33%
 Bleeding 1.5-1.8%
 Recurrent cholecystitis 7-41%
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Choledocholithiasis
 Stones in CBD in 10-15% of symptomatic pt’s
 55-70% pass spontaneously
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GSP20-30% of patients have CBD stones
 85-90% pass spontaneously
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Symptomatic cholecystitis
 4.6% +IOC at the time of LC
 97.8% pass spontaneously
 CBDE
 Can be performed
lap or open
 Transcystic or via
choledochotomy
 CBDE
 Imaging duct
▪ Fluorscopic guidance
▪ Choledochoscopy
 Clearing duct
▪ Basket, snare, flush
▪ +/- glucagon to relax sphincter
 CBDE
 Completion cholangiogram
 Clip, tie or staple cystic duct stump
 Close choledochotomy over T-tube
 +/-drain external
 Success rate of duct clearance 75-95%
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Efficacy
 1 procedure: 71-75%
 Multiple procedures: 84-95%
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Mortality 0.2-0.5%
Complication rate 5-8%
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Perforation
Bleeding
Pancreatitis
Cholangitis
 1-2% of patients will represent with
CBD stone following
cholecystectomy
 Dx <2yrs post-op = retained stone
 Dx > 2yrs post-op =recurrent stone
Ileus
Incisional/port site hernia
 Wound infection
 Abscess
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Biloma/bile leak
 Strasberg-Bismuth
classification
 A-CD stump, fossa
 B/C-aberrant RHD
 D-lateral injury
 E-circumferential
injury to major duct
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Increased risk of stones
 2-12% have stones
 0.05-1.2% symptomatic during pregnancy
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Risk of stones increased in:
 Hispanic
 Pre-pregnancy obesity (4x)
 Decreased by EtOH consumption
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Biliary disease the most common nonobstetrical cause of maternal
hospitalization
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Cholecystitis most common 40%
 GSP 30%
 CBD stone 20%
 Biliary colic 10%
 If symptomatic risk of recurrence
high
 40%-70% recur prior to delivery
 If symptomatic risk of fetal loss high
10-20%
 Treatment goals
 Treat infection
 Maintain nutrition
 Prevent contractions/preterm labor
 Prevent fetal loss
 Prevent maternal morbidity/mortality

Surgical management associated with
fewer complications than medical
management
 Contractions equivalent (~30%)
 Decreased preterm delivery, need for c-
section, and recurrent symptoms
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Fetal loss with LC 0-5%
 Ideal timing LC/OC 2nd trimester
 ↓preterm labor (0% vs. 40%)
 ↓ fetal loss
 ↓ risk of fetal malformation
 Technically easier
 1st delay to 2nd, 3rd delay to
postpartum
 ERCP can be performed safely with:
 Low radiation exposure
▪ Fluoro time 14sec-3.2min
▪ Radiation exposure 40-310 mrad
 Few complications ~7%
 Operative considerations
 Port placement to accommodate
uterus
 Hassan vs. Veress likely equivalent
 ↓insufflation pressure 10-12
 Stones more common in cirrhotics (2x)
 Diagnosis difficult
 Pain nonspecific
 Elevated LFT’s nonspecific
 Leukocytosis nonspecific
 GBW thickening nonspecific
▪ HIDA may be helpful
 Management differences
 Increased operative risk
▪ Morbidity 3x
▪ Conversion 2x
▪ Bleeding 8x
 Increased risk with cholecystostomy
▪ Bleeding
▪ Ascites/Leak
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Mortality
 Overall acceptable 0.6-0.8%
 Significantly increased in Child’s C patients (17%)
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LC safer than OC
 Less bleeding
 Shorter OR time
 Shorter HLOS
 Possibly lower mortality (open mortality 8-25%)
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Acalculous cholecystitis
 M>F 1.5:1
 4-8% of all cholecystitis
 Dx with UTZ/HIDA
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Gallbladder polyps
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Gallbladder cancer