Cholelithiasis

Gallbladder

• The gallbladder is a relatively

small but surgically important
organ of the body.

• Cholecystectomy (open or
laparoscopic surgical removal of
the gallbladder as a treatment
for stones) is one of the most
common surgical procedures
performed the world over.
Gallbladder

• The gallbladder is a pyriform

(pear-shaped) organ that
straddles the undersurface of
segments IVB and V of the liver.

• It has an inferior peritoneal

surface and a superior hepatic
surface that is closely applied to
the gallbladder bed in the liver.

• The cystic plate is a

condensation of fibro-areolar
tissue that separates the
gallbladder from the liver
parenchyma.
 Anatomy of gallbladder and biliary tree
• It is a pear-shaped structure, 7.5–12 cm
long, with a normal capacity of about
35–50 ml

• The cystic duct is about 3 cm in length

but variable

• The mucosa of the cystic duct is

arranged in spiral folds known as the
valves of Heister

• The cystic lymph node of Lund

• The ‘caterpillar turn’ or
‘Moynihan’s hump’
Anatomy of gallbladder and biliary tree
• Bile
• Contains:
• Water(97%)
• Cholesterol
• Bile pigments
• Bile acids
• Fatty acid
• The liver excretes bile at a rate estimated
to be approximately 40 ml/hr

• Gall bladder : three functions

a. reservoir of bile
b. concentration of bile
Calot’s triangle
c. secretion of mucus
Gallstones {Cholelithiasis}

 Gallstones are the most common biliary

pathology

 It is present in 10–15% of the adult population

in the USA.

 Small, pebble-like substances

 Multiple or solitary

 May occur anywhere within the biliary

tree

 Have different appearance - depending

on their contents
Three types

• Cholesterol,
• Pigment (brown/black) or
• Mixed stones
• In the USA and Europe 80% are cholesterol or mixed stones, whereas
in Asia, 80% are pigment stones.

• Cholesterol or mixed stones contain 51–99% pure cholesterol plus an

admixture of calcium salts, bile acids, bile pigments and
phospholipids
Pigment stones
• Small
• Friable
• Irregular
• Dark
• Made of bilirubin and
calcium salts
• Less than 20% of cholesterol
• Risk factors:
• Haemolysis
• Liver cirrhosis
• Biliary tract infections
• Ileal resection
 Cholesterol stones
• Large

• Often solitary

• Yellow, white or green

• Made primarily of cholesterol (>70%)

• Risk factors:
• 4 “F” :
• Female
• Forty
• Fertile
• Fat
• Fair (5th “F” - more prevalent in
Caucasians)
• Family history (6th “F”)
Mixed stones
• Multiple
• Faceted
• Consist of:
• Calcium salts
• Pigment
• Cholesterol (30% - 70%)
• 80% - associated with chronic
cholecystitis
Natural history
 Pathogenesis of gall stones

• Cholesterol is insoluble in water

• Solubility of cholesterol depends on the concentration of phospholipids and bile
acids in bile

Three factors play

a. supersaturated bile (age, sex, genetics, obesity)
b. cholesterol nucleating factor (mucin,glycoprotein,infection)
c. impaired gallbladder function( emptying, absorption,excretion)

Nucleation of cholesterol monohydrate crystals is crucial step in gall stone

formation

Sludge is crystals without stones. It may be a first step in stones, or be

independent of it.
Pathogenesis of gall stones

Nucleation of cholesterol
monohydrate crystals is
crucial step in gall stone
formation

• Pigment stones (15%) are

from calcium bilirubinate.
Diseases that increase RBC
destruction will cause these.
Also in cirrhotic patients,
parasitic infections
Symptoms
• Pain in the right upper quadrant
• Most common and typical symptom
• May last for a few minutes to several hours
• Mostly felt after eating a heavy and high-fat meal

• Pain under right shoulder when lifting up arms

• Fever, nausea and vomiting

• Jaundice (obstruction of the bile duct passage)

• Acute pancreatitis
Examination

• Vital signs and physical findings in asymptomatic

cholelithiasis are completely normal

• Fever, tachycardia, hypotension, alert you to more serious

infections, including cholangitis, cholecystitis

• Murphy’s sign
Complications of gallstones
 In the GB:
◦Biliary colic
◦Acute cholecystitis( Most
common)
◦Chronic cholecystitis
◦Empyema
◦Mucocoele
◦Carcinoma
 In the bile ducts:
◦Obstructive jaundice
◦Cholangitis

• In the pancreas
acute pancreatitis
chronic pancreatitis
 In the gut:
◦Gallstone ileus
Biliary colic Cholecystitis

• Pain that is severe in • Severe continuos pain in

epigastrium or RUQ that last epigasrtic or RUQ more than
< 6 hrs, often waking patient 24hrs
at night
• Associated with fever,
• May be associated with
tachycardia, hypotension
nausea/vomiting
• Raised total count
• Derranged LFT
Differential diagnosis of cholecystitis

Common
 Appendicitis
 Perforated peptic ulcer
 Acute pancreatitis

Uncommon
 Acute pyelonephritis
 Myocardial infarction
 Pneumonia – right lower lobe
 Ultrasound scan aids in diagnosis
 Uncertain diagnosis – do CT scan
 Diagnosis
• Ultrasound
• Most sensitive and specific test for
gallstones

• Computerized tomography (CT) scan

• May show gallstones or complications,
such as infection and rupture of GB or
bile ducts

• Cholescintigraphy (HIDA scan)

• Used to diagnose abnormal
contraction of gallbladder or
obstruction of bile ducts

• Endoscopic retrograde
cholangiopancreatography (ERCP)
• Used to locate and remove stones in
bile ducts
• Blood tests
• Performed to look for signs of
infection, obstruction, pancreatitis, or
jaundice
Hida scan
Plain film
 Treatment
• Surgery: Cholecystectomy

5 - 20% of patients develop

postcholecystectomy syndrome
(gastrointestinal distress and
persistent pain in the RUQ)

• Two surgical options

• Open cholecystectomy
• Laparoscopic cholecystectomy
Preparation for operation

 Full blood count

 Renal profile and liver function tests

 Prothrombin time

 Chest X-ray and electrocardiogram (if over 45 years or medically

indicated)

 Antibiotic prophylaxis

 Deep vein thrombosis prophylaxis

 Informed consent
• First described in 1882 by Langenbuch, open
cholecystectomy (OC)

• In 1985, Mühe in Germany performed the first

laparoscopic cholecystectomy
Indications lap cholecystectomy
Asymptomatic cholelithiasis Symptomatic
cholelithiasis
 Sickle cell disease
 Biliary colic

 Total parenteral nutrition

 Acute cholecystitis

 Chronic immunosuppression ( diabetics)

 Gallstone pancreatitis

 Acalculous cholecystitis (biliary dyskinesia)

 Gallbladder polyps >1 cm in diameter

 Porcelain gallbladder
Contraindications to LC
Relative Absolute

 Previous upper abdominal surgery  Unable to tolerate general anesthesia

 Cholangitis  Refractory coagulopathy

 Diffuse peritonitis  Suspicion of gallbladder carcinoma

 Cirrhosis and/or portal hypertension

 Chronic obstructive pulmonary disease

 Cholecystoenteric fistula

 Morbid obesity

 Pregnancy
American set
 Golden rules in case of difficult
cholecystectomy
• When the anatomy of the triangle of Calot is unclear, blind dissection should stop

• Bleeding adjacent to the triangle of Calot should be controlled by pressure and not
by blind clipping or clamping.

• When there is doubt about the anatomy, a ‘fundus-first’ or ‘retrograde’

cholecystectomy dissecting on the gall bladder wall down to the cystic duct can be
helpful.

• If the cystic duct is densely adherent to the common bile duct and there is the
possibility of a Mirizzi syndrome , the infundibulum of the gall bladder should be
opened, the stone removed and the infundibulum oversewn.

• A cholecystostomy is rarely indicated but, if necessary, as many stones as possible

should be extracted, and a large Foley catheter (14F) placed in the fundus of the gall
bladder with a direct track externally
• Nonsurgical treatment:
• Only in special situations
• When a patient has a serious medical condition preventing surgery

• Oral dissolution therapy

• Ursodeoxycholic acid ( actibile) - to dissolve cholesterol gallstones

• Months or years of treatment may be necessary before all stones dissolve

• Contact dissolution therapy

• Experimental procedure
• Involves injecting a drug directly into the gallbladder to dissolve cholesterol stones
Thank you