Download MBBS Surgery Presentations 21 Gall Stones Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 21 Gall Stones PPT-Powerpoint Presentations and lecture notes


Gal Stone disease:

Etiology, Clinical features, diagnosis,

Complications

Cholecystectomy:

Indications,

Procedure, Complications

What Are Gal stones?

? Smal , pebble-like

substances

? Multiple or solitary
? May occur anywhere within

the biliary tree

? Have different appearance -

depending on their contents




Pigment Stones

? Smal
? 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

Gal stone Prevalence

? 10% of people over 40 yrs.

? 90% "silent stones"

? Risk factors for becoming symptomatic:

? Smoking
? Parity
Risk Factors

? Women
? Age > 60 years
? American Indians & Mexican Americans
? Overweight or obese men and women
? People who tend to fast or lose weight quickly
? Family history of gallstones
? Diabetes
? Diet high in cholesterol
? Use of OCPs
? Pregnancy

Gal stone Pathogenesis

? Bile = bile salts, phospholipids, cholesterol
? Gallstones due to imbalance rendering cholesterol & calcium

salts insoluble

? Pathogenesis involves 3 stages:

Cholesterol supersaturation in bile

Crystal nucleation

Stone growth
Definitions

Symptomatic Wax/waning postprandial epigastric/RUQ pain due to transient

cholelithiasis cystic duct obstruction by stone, no fever/WBC, normal LFT

Acute

Acute GB inflammation due to cystic duct obstruction. Persistent

cholecystitis RUQ pain +/- fever, WBC, LFT, +Murphy's = inspiratory arrest

Chronic

Recurrent bouts of colic/acute chol'y leading to chronic GB wall

cholecystitis inflamm/fibrosis. No fever/WBC.

Acalculous

GB inflammation due to biliary stasis(5% of time) and not

cholecystitis stones(95%). Seen in critically ill pts

Choledocho- Gallstone in the common bile duct (primary means originated there,

lithiasis

secondary = from GB)

Cholangitis

Infection within bile ducts usu due to obstrux of CBD. Charcot triad:

RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic

shock

Differential Diagnosis Of RUQ Pain

? Biliary disease

? Acute cholecystitis, chronic cholecystitis, CBD stone,

cholangitis

? Inflamed or perforated duodenal ulcer

? Hepatitis

? Also need to rule out:

? Appendicitis, renal colic, pneumonia or pleurisy,

pancreatitis


Symptoms

? Pain in the RUQ

? 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 (gallstone enters the duct leading to pancreas

and blocks it)

Murphy's Sign: Inspiratory arrest with manual pressure

below the gal bladder


Complications Of Gal stones

? In the GB:

? Biliary colic

? Acute and chronic cholecystitis

? Empyema

? Mucocoele

? Carcinoma

? In the bile ducts:

? Obstructive jaundice

? Pancreatitis

? Cholangitis

? In the gut:

? Gallstone ileus

Mirizzi syndrome

0.1?0.7% of patients who have gallstones
Csendes classification :
? Type 1: external compression of the common bile duct ? 11%
? Type 2: cholecystobiliary fistula is present involving <1/3 rd the circumference

of the bile duct ? 41%

? Type 3: a fistula is present involving upto 2/3 the circumference of the bile

duct ? 44%

? Type 4: a fistula is present with complete destruction of the wall of the bile

duct ? 4%


Diagnosis

? Ultrasound

? 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

USG

CT Scan
Management

? Asymptomatic gallstones do not require operation

? Whilst awaiting for surgery

? Low fat diet
? Dissolution therapy (ursodeoxycholic acid) generally useless

Surgical options

? Cholecystostomy

? Subtotal cholecystectomy

? Open cholecystectomy

? Laparoscopic cholecystectomy
Cholecystostomy

? Patients at high risk related to multisystem organ failure
? Severe pulmonary, renal, or cardiac disease
? Recent myocardial infarction
? Cirrhosis with portal hypertension
? Acalculus cholecystitis after severe trauma, burns, or surgery
? Empyema or gangrene of the gal bladder

Subtotal Cholecystectomy

? Severe inflammation renders identification of the

anatomy impossible, eg. Gangrenous cholecystitis

? Scarred partial y intrahepatic gal bladder

? Severe cirrhosis and portal hypertension


Cholecystectomy

Laparoscopic Surgery

? Advantages:

? Less post-op pain

? Shorter hospital stay

? Quicker return to normal activities

? Disadvantages:

? Learning curve

? Inexperience at performing open cholecystectomies
Cholecystectomy when to perform?

? After acute cholecystitis, cholecystectomy traditionally performed after 6

weeks

? Arguments for 6 weeks later

? Laparoscopic dissection more difficult when acutely inflammed

? Surgery not optimal when patient septic/dehydrated

? Logistical difficulties (theatre space, lack of surgeons)

? Arguments for same admission

? Research suggests same admission lap chole as safe as elective chole (conversion to

open maybe higher)

? Waiting increases risk of further attacks/complications which can be life threatening

? Risk of failure of conservative management and development of dangerous

complication such as empyema, gangrene and perforation can be avoided

? National guidelines state any patient with attack of gallstone pancreatitis

should have lap chole within 3 weeks of the attack

Complications of Lap Cholecystectomy

? Trocar/Veress needle injury
? Hemorrhage
? Wound infection and/or abscess
? Ileus
? Bile leak
? Gallstone spillage
? Deep vein thrombosis
? Retained common bile duct (CBD) stone
? CBD injury & stricture
? Pancreatitis
? Conversion to open procedure


? Nonsurgical treatment:

? Only in special situations

? When a patient has a serious medical condition preventing surgery
? Only for cholesterol stones

? Oral dissolution therapy

? Ursodeoxycholic acid - 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

Prevention

A sensible diet is the best way to prevent gall stones

Avoid crash diet or very low intake of calories

Eat good sources of fiber

This post was last modified on 08 April 2022