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