CHOLELITHIASIS AND IT’S COMPLICATION

A.WEISS M.DD.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.

ANATOMY OF THE DUCT SYSTEM

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.

ANATOMY OF THE GALLBLADDER

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.

ANATOMY OF THE GALLBLADDER

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.

COMPOSITION OF BILE The main constituents of bile

are: 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.

Bile acids, produced endogenously or taken orally, reduce cholesterol synthesis and increase cholesterol absorption from the intestine.

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.

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.

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.

GALLSTONES Composition :

The major elements involved in the formation of gallstones are : 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 :

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.

GALLSTONES

GALLSTONE DISEASE 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.

Risk factors:

Obesity. Pregnancy. Dietary factors. Crohn's disease. Terminal ileal resection. Gastric surgery. Hereditary spherocytosis. Sickle cell disease. Thalassemia

GALLSTONE DISEASENATURAL HISTORY

ASYMPTOMATIC GALLSTONES

The liberal use of ultrasonography has resulted in the diagnosis of calculi in patients without symptoms referable to the biliary tract.

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.

Management : There is no role for prophylactic cholecystectomy in most patients

with asymptomatic gallstones, with a few exceptions.1. Patients with a porcelain gallbladder .2. Children with gallstones have a relative indication for cholecystectomy .3. Patients with diabetes mellitus, spinal cord trauma, and sickle cell

anemia, prophylactic cholecystectomy is generally not indicated for asymptomatic or uncomplicated gallstone disease.

4. Management of gallstones discovered at laparotomy remains controversial .

SYMPTOMATIC GALLSTONES( BILIARY COLIC )

Diagnosis largely depends on correlating symptoms with the presence of stones on imaging.

Symptoms :

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 :

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.

SYMPTOMATIC GALLSTONES

( BILIARY COLIC ) Physical signs :

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).

Differential diagnosis:

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 right-

lower-lobe pneumonia ).

SYMPTOMATIC GALLSTONES

SYMPTOMATIC GALLSTONES ( BILIARY COLIC )

Management : Laparoscopic

cholecystectomy (LC) is the appropriate treatment for the vast majority of patients with symptomatic gallstones .

COMPLICATIONS OF CHOLELITHIASIS

1. Acute calculous cholecystitis .

2. Choledocholithiasis .

3. Biliary pancreatitis .

4. Cholangitis is often caused by choledocholithiasis .

5. Gallstone ileus (bowel obstruction caused by a gallstone) .

ACUTE CALCULOUS CHOLECYSTITIS

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. Diagnosis :

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 : leukocytosis (typically 12,000 to 15,000 cells/µL). Liver function tests (LFTs), including serum bilirubin, alkaline phosphatase,

alanine transaminase (ALT), aspartate transaminase (AST), and serum amylase, also may be abnormal.

Diagnostic imaging : Ultrasonography :is the most commonly used test for diagnosing acute

cholecystitis and any associated cholelithiasis. Findings indicative of acute cholecystitis include : Gallbladder wall thickening. Pericholecystic fluid. Sonographic Murphy sign

Radionuclide cholescintigraphy. Computed tomographic (CT) scanning.

ACUTE CALCULOUS CHOLECYSTITIS

Management :Depends on available expertise and clinical situation.

Initial management : Hospitalization. NPO Intravenous fluid . Parenteral antibiotics .

Patients with acute cholecystitis should have cholecystectomy as definitive treatment : 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.

CHOLEDOCHOLITHIASIS 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.

Diagnosis : 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.

CHOLEDOCHOLITHIASIS

Management :Depends on available expertise

and clinical situation.

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.

CHOLEDOCHOLITHIASIS

BILIARY PANCREATITIS Blockage of pancreatic secretions by passage of a gallstone into

the common biliary-pancreatic channel.

The greatest risk is carried by small (~2 mm) stones.

Once the acute episode of pancreatitis has resolved, the gallbladder should be removed as expeditiously as possible to avoid recurrent pancreatitis.

A longer delay may be justified in patients who have had severe pancreatitis and in whom local inflammation or systemic illness contraindicates surgery.

An IOC should always be done at the time of the cholecystectomy to confirm that the bile duct is free of stones.

In patients in whom cholecystectomy is contraindicated, endoscopic sphincterotomy (ES) may be protective against further attacks of pancreatitis.

ACUTE CHOLANGITIS Acute cholangitis is a potentially life-threatening bacterial infection

of the biliary tree typically associated with partial or complete obstruction of the ductal system.

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 biliary-enteric anastomoses, parasites, and indwelling tubes or stents, also have a causative relationship.

Diagnosis :

Greater than 90% of patients present Charcot's triad (fever, jaundice, and right-upper-quadrant 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.

ACUTE CHOLANGITIS Management :

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

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.

Cholangitis in patients with indwelling tubes or stents generally requires stent removal and replacement.

Definitive operative therapy for benign or malignant biliary tract strictures should be deferred until a later date.

GALLSTONE ILEUS (BOWEL OBSTRUCTION

CAUSED BY A GALLSTONE) Uncommon complication that results from a gallstone eroding

through the wall of the gallbladder into the adjacent bowel (usually duodenum).

Usually the stone migrates until it lodges in the narrowest portion of the small bowel, just proximal to the ileocecal valve.

Patients present with symptoms of bowel obstruction and air in the biliary tree (from the cholecystoenteric fistula).

Treatment is exploratory laparotomy and removal of the obstructing gallstone by milking it back to an enterotomy made in healthy intestine.

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.

THANK YOUABDUL.KADER WEISS 2009