CHOLECYSTITIS & CHOLELITHIASIS

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CHOLECYSTITIS &

CHOLELITHIASIS

BY: ZICHRI KEREN O. PEROCHO

Group 2- MHAM Senior Clerk



outline

cholecystitis

Cholelithiasis

INTRODUCTIONANATOMY PHYSIOLOGY



ANATOMY- GB & BILE DUCTS

• Gallbladder

• PARTS: (4)

• Histology:

• Blood Supply:

• Triangle of Calot

• Nerve Supply:

• BILE DUCTS:

• Cystic Duct

• CBDAnterior aspect of the biliary anatomy. a = right hepatic duct; b = lefthepatic duct; c = common hepatic duct; d = portal vein; e = hepatic artery;f = gastroduodenal artery; g = left gastric artery; h = common bile duct; i =

fundus of the gallbladder; j = body of gallbladder; k = infundibulum; l =cystic duct; m = cystic artery; n = superior pancreaticoduodenal artery





Biliary Colic

Impulses from the liver, gallbladder, and the bile ducts pass bymeans of sympathetic afferent fibers through the splanchnicnerves and mediate the pain of biliary colic.



Gallbladder functions

The gallbladder, the bile ducts, and thesphincter of Oddi act together to store andregulate the flow of bile.

The main function of the gallbladder is to

concentrate and store hepatic bileand to deliver bile into theduodenum in response to a meal.



Gallbladder function

• Absorption & Secretion80% of bile stored in GB (fasting)

Secretion:

1. Mucus glycoprotein-

prevents GB from the lyticaction of bile; facilitate thepassage of bile through thecystic duct. "white bile“-hydrops”

2. hydrogen ions- decrease inthe bile pH promoting Casolubility preventing itsprecipitation as calcium

salts.

Motor activity:Sphincter of ODDIFasting: Filling and empties small

volumes of bile into theduodenum: motilin.

AFTER A MEAL:

CCK is released endogenously fromthe duodenal mucosa

- facilitates GB emptying 50 to70% of its contents within 30 to40 minutes

Defects in the motor activity of thegallbladder are thought to play arole in cholesterol nucleation andgallstone formation



• The classic description ofthe extrahepatic biliarytree and its arteriesapplies only in about one

third of patients.

• The gallbladder may haveabnormal positions, beintrahepatic, be

rudimentary, haveanomalous forms, or beduplicated



Sphincter of ODDI

During fasting, with the sphincter of Oddicontracted and the gallbladder filling.

In response to a meal, the sphincter of

Oddi relaxed and the gallbladder emptying



Bile Production

• Volume: (500- 1000mL)• The secretion of bile is

responsive to neurogenic,humoral, and chemical stimuli.

• pH:

• enterohepatic circulation

• COMPOSITION:• Water

• Electrolytes (Na, K, Ca, Cl)

• Bile salts: (D & A of fats)

a. Primary: cholate andchenodeoxycholate (80%)

b. Secondary: (20%)

deoxycholate and lithocholate

• Proteins• Lipids (Cholesterol and

phospholipids)

• Bile pigments (bilirubin

diglucuronide- color)



• Presence of stones in the gallbladder is referred to as

cholelithiasis.• If gallstones migrate into the ducts of the biliary tract,

the condition is referred to as choledocholithiasis .

•

Choledocholithiasis is frequently associated withobstruction of the biliary tree, which in turn can lead to

acute ascending cholangitis a serious infection of the

bile ducts.

• Gallstones within the ampulla of Vater can obstructthe exocrine system of the pancreas, which in turn can

result in pancreatitis.





GALLSTONE DISEASE

11-30% prevalence rate

Females> males

Predisposing factors:

-Obesity-Pregnancy

-Dietary

- Thalassemia

- Hereditary Spherocytosis

- Sickle cell disease

- Crohn’s Disease

-Gastric Surgery

-Resection of the terminal ileum

Organic Components:

Bilirubin Phospholipids

Bile salts Cholesterol

Cholesterol Stones: 80% inWestern Countries

Pigment Stones: 15-20%

incidence (Asians)a. Black

b. Brown



Cholesterol Stones

- single, large, & smooth

- Multiple, hard,multifaceted, irregular,variable sizes,

- White yellow to black

- Radioluscent

- Form due tosupersaturation of bile with

CHOLESTEROL(70%w/w) due toincreased cholesterolsecretion

- 2 to 3 cm





Pigment stones

• <20% cholesterol content

• BLACK STONES:(Japan)

- found in the GB- small, brittle, spiculated

- due to cirrhosis &hemolytic d/o e.g SCD,

HS- Inc levels of unconjugated

bilirubin

• BROWN STONES:

- Primarily bile duct stones

- Small, brownish yellow,

soft- Due to bacterial or

parasitic infections orbiliary strictures from

BILE STASIS- Composed of calcium

bilirubinate & bacterialcell bodies



Pigment stones



symptoms

Gallstones may be asymptomatic, even for years. These gallstones are called "silent stones" and do not require

treatment

Symptoms commonly begin to appear once the stones reach a

certain size (>8 mm )Biliary colic – constant, long lasting

Obstruction of cystic duct or CBD – visceral pain, which is a steady

or fullness in epigastrium or RUQ with, frequent radiation to

interscapular area, right scapula and shoulderNausea and vomiting

Fever or chills with biliary pain usually imply a complication, i.e.,

cholecystitis, pancreatitis, or cholangitis



sign

• Positive MURPHY SIGN :

• Patient is asked to inhale while theexaminer's fingers are hooked under theliver border at the bottom of the rib cage.

• The inspiration causes the gallbladder todescend onto the fingers, producing pain ifthe gallbladder is inflamed.



Murphy’s sign



PRESENTATION:- Majority are

asymptomatic

- Symptoms: 3-5%

secondary to Cystic DuctObstruction (BILIARYCOLIC)

- Complications: 3-5% of

symptomatics

• COMPLICATIONS:

- Acute Cholecystitis

- Choledocholithiasis w/ or w/o Cholangitis

- Gallstone Pancreatitis

Cholecystocholedochalfistula

- Cholecystoentericfistula w/ Gallstoneileus

- Gallbladder Carcinoma



Lab work-up

• Polymorphonuclear leukocytosis (acutecholecystitis)

• Elevated level of serum bilirubin

• Elevated alkaline phosphatase



diagnosis

Ultrasound gall bladder

Oral Cholecystography- filling defects in avisualized, opacified gallbladder

Biliary Radionuclide Scanning (HIDA scan)-nonvisualized GB (acute chole)>95%

CT scan- malignancy

MRI with MRCPERCP – locate and remove stones in bile duct



ultrasound

Dense with posterior acoustic shadowingthat moves w/ change in position. Ultrasound:

• - 90% sensitivity/ specificity for stones:



Endoscopic Retrograde Cholangiography

and Endoscopic Ultrasound

Using a side-viewing endoscope, the common bile duct can becannulated and a cholangiogram performed using fluoroscopy Theprocedure requires IV sedation for the patient.

Advantages of ERC: include direct visualization of the ampullaryregion and direct access to the distal common bile duct, with thepossibility of therapeutic intervention. The test is rarely needed foruncomplicated gallstone disease, but for stones in the common bileduct, in particular, when associated with obstructive jaundice,cholangitis, or gallstone pancreatitis, ERC is the diagnostic andoften therapeutic procedure of choice. Once the endoscopiccholangiogram has shown ductal stones, sphincterotomy and stoneextraction can be performed, and the common bile duct cleared ofstones.



ERCP

Side-viewing endoscope in the duodenumand a catheter in the common bile duct.

An endoscopic cholangiography showingstones in the common bile duct.



Cholecystectomy?

Prophylactic

cholecystectomy

in asymptomaticpersons withgallstones is

rarely indicated.

Indications:

1. Elderly Diabetics

2. Individuals who will

be isolated frommedical care forextended periods oftime

3. Increased risk ofgallbladder cancer

4. Porcelain gallbladder





Laparoscopic Cholecystectomy

The trocar placement.

The fundus has been grasped and retracted cephalad to expose the

proximal gallbladder and the hepatoduodenal ligament. Another grasperretracts the gallbladder infundibulum posterolaterally to better expose thetriangle of Calot (hepatocystic triangle bound by the common hepatic duct,cystic duct, and the liver margin).



Laparoscopic cholecystectomyThe triangle of Calot has been opened and the neck of the

gallbladder and part of the cystic duct dissected free. A clipis being placed on the cystic duct –gallbladder junction.

A small opening has been made into the cystic

duct, and a cholangiogram catheter is to beinserted.



Laparoscopic cholecystectomy

The cystic duct has been divided, andthe cystic artery is being divided.

An intraoperative picture showing a grasper pulling theinfundibulum of the gallbladder laterally, exposing thetriangle of Calot that has been dissected. The cysticartery can be seen crossing the dissected area upward

and to the left.



ACUTE CHOLECYSTITIS

• -due to GALLSTONES in 90-95%

• Acalculous Cholecystitis- systemic disease

Pathogenesis: Cystic Duct Obstruction (mucosal

toxin lysolecithin)Characteristics:

1. Grossly thickened gallbladder wall

2. Pericholecystic fluid accumulationOutcomes:

- Spontaneously resolved

- Complications: perforation (5-10%)



ACALCULOUS CHOLECYSTITIS

• CRITICALLY-ILL PATIENTS IN ICU- Total parenteral nutrition

- Massive burns - multiple injury

- Sepsis - Multiple organ failure

- Major operationsCLINICAL MANIFESTATION:

- Gallbladder distension

- Bile Stasis

- Ischemia

TREATMENT:

- Percutaneous ultrasound/ CT-guided cholecystectomy



CLINICAL PRESENTATION- PAIN

SYMPTOMS

- biliary colic – unremitting

- Right upper quadrant orepigastrium radiate to the right

upper part of the back or theinterscapular area

- Severe

- Febrile, anorexia, N & V

SIGNS: PE

- focal tenderness and guarding(RUQ), reluctant to move

- mass

- A Murphy's sign- inspiratory arrest

with deep palpation in the right

subcostal area

LABORATORY RESULTS:

mild to mod leukocytosis (12,000 to15,000 cells/mm3)

Serum liver chemistries usuallynormal, but a mild elevation of

serum bilirubin, <4 mg/mL, may bepresent along with mild elevationof alkaline phosphatase,transaminases, and amylase.

Severe jaundice CBD stones orobstruction of the bile ducts bysevere pericholecysticinflammation secondary toimpaction of a stone in theinfundibulum of the gallbladderthat mechanically obstructs thebile duct (Mirizzi's syndrome).



Murphy’s sign



diagnosis

1. Ultrasonography i- most useful radiologic test -; sensitivity andspecificity of 95

- +/- stones

- thickening of the gallbladder wall and the pericholecystic fluid

2. HIDA scan- - Lack of filling after 4 hours indicates an obstructedcystic duct and, in the clinical setting of acute cholecystitis, is highlysensitive and specific for acute cholecystitis. A normal HIDA scanexcludes acute cholecystitis.

3. CT scan - acute abdominal pain- thickening of the gallbladder wall,

pericholecystic fluid, and the presence of gallstones as well as air inthe gallbladder wall, but is less sensitive than ultrasonography.



Acute cholecystitis



treatment

- IV Fluids

- Analgesics

- Antibiotics

- 3rd

Gen Cephalosporins- 2nd Gen Ceph +Metronidazole

- Aminoglycoside +

Metronidazole (allergic)Treatment option:

Tube Cholecystostomy

Definitive treatment:

Early Cholecystectomy

(Open vs

LAparoscopic)Early cholecystectomy performed

within 2 to 3 days of the illnessis preferred over interval ordelayed cholecystectomy that

is performed 6 to 10 weeksafter initial medical treatmentand recuperation.



Cholecystostomy

Cholecystostomy decompresses and drains the distended,inflamed, hydropic, or purulentgallbladder. applicable if thepatient is not fit to tolerate an

abdominal operation.

Ultrasound-guidedpercutaneous drainage with apigtail catheter is theprocedure of choice. The

catheter is inserted over aguidewire that has beenpassed through the abdominalwall, the liver, and into thegallbladder

Ch i h l i i / bili



Chronic cholecystitis/ biliarycolic

• - recurrent attacks of pain (develops when a stoneobstructs the cystic duct, resulting in a progressive

increase of tension in the gallbladder wall.)• - The mucosa is initially normal or hypertrophied, but

later becomes atrophied, with the epithelium protrudinginto the muscle coat, leading to the formation of the so-

called Aschoff-Rokitansky sinuses .



Clinical presentation

SYMPTOMS:

Pain- constant and increases in

severity over the first half hourlasts 1 to 5 hours

- epigastrium or RUQ radiates tothe right upper back or betweenthe scapulae

- severe and abrupt, typically duringthe night or after a fatty meal.

- is associated with nausea and

sometimes vomiting, episodic.

Signs (PE)

- mild RUQ tendernessepisode of pain

Laboratory values, such asWBC count and liverfunction tests, are usuallynormal in patients with

uncomplicated gallstones.



Hydrops of the gallbladder

An impacted stone without cholecystis will result in what iscalled hydrops of the gallbladder . The bile getsabsorbed, but the gallbladder epithelium continues tosecrete mucus, and the gallbladder becomes distended

with mucinous material.- palpable but usually is not tender.

- may result in edema of the gallbladder wall,inflammation, infection, and perforation.

- early cholecystectomy is generally indicated to avoidcomplications.



diagnosis

• - depends on the presence of typicalsymptoms and the demonstration of stones ondiagnostic imaging.

• abdominal ultrasound is the standarddiagnostic test for gallstones

• - thickened and contracted gallbldder



management

• 1. symptomatic gallstones - electivelaparoscopic cholecystectomy (avoid dietary fatsand large meals.)

• 2. Diabetic patients with symptomatic gallstonesshould have a cholecystectomy promptly,

• 2. Pregnant women with symptomaticgallstones who cannot be managed expectantly

with diet modifications can safely undergolaparoscopic cholecystectomy during the secondtrimester.



Choledocholithiasis- CBDstones

• 6 to 12%

• increases with age.

SECONDARY STONES

- westerns

- formes within the GB andmigrate – cystic duct- CBD

- Cholesterol stones

PRIMARY stones form in the bileducts

- brown pigment type.

- associated with biliary stasisand infection and are morecommonly seen in Asianpopulations.

Causes of biliary stasis:

- biliary stricture

- papillary stenosis,- tumors,

- or other (secondary) stones.



DIAGNOSIS

A dilated CBD (>8 mm in diameter) on ultrasonography in a patientwith gallstones, jaundice, and biliary pain is highly suggestive ofcommon bile duct stones.

Magnetic resonance cholangiography (MRC) provides excellentanatomic detail and has a sensitivity and specificity of 95 and 89%,

respectively, at detecting choledocholithiasis >5 mm in diameter.

Endoscopic cholangiography is the gold standard for diagnosingcommon bile duct stones. It has the distinct advantage of providing atherapeutic option at the time of diagnosis.

Endoscopic ultrasound has been demonstrated to be as good as ERCP

for detecting common bile duct stones (sensitivity of 91% andspecificity of 100%), but it lacks therapeutic intervention andrequires expertise, making it less



TREATMENT

Endoscopic cholangiogram - reveals stones, sphincterotomy andductal clearance of the stones is appropriate, followed by alaparoscopic cholecystectomy. An intraoperative cholangiogram atthe time of cholecystectomy will also document the presence orabsence of bile duct stones.

Laparoscopic common bile duct exploration via the cystic duct or withformal choledochotomy allows the stones to be retrieved in thesame setting

If a choledochotomy is performed, a T tube is left in place. Stonesimpacted in the ampulla may be difficult for both endoscopic ductal

clearance as well as common bile duct exploration (open orlaparoscopic). In these cases the common bile duct is usually quitedilated (about 2 cm in diameter).

A choledochoduodenostomy or a Roux-en-Y choledochojejunostomymay be the best option under this circumstance.



endoscopic sphincterotomy

sphincterotome in place Completed sphincterotomy.



endoscopic sphincterotomy

Endoscopic picture of completed sphincterotomy



cholangitis

- one of the two main complications of choledochal stones, the otherbeing gallstone pancreatitis.

- Acute cholangitis is an ascending bacterial infection in associationwith partial or complete obstruction of the bile ducts. Thecombination of both significant bacterial contamination and biliary

obstruction is required for the development of cholangitis.- Gallstones are the most common cause of obstruction in cholangitis;

other causes are benign and malignant strictures, parasites,instrumentation of the ducts and indwelling stents, and partiallyobstructed biliary-enteric anastomosis.

- The most common organisms cultured from bile in patients withcholangitis include E. coli , Klebsiella pneumoniae , Streptococcus faecalis , Enterobacter, and Bacteroidesfragilis .



Clinical presentation

• present as anything from a mild, intermittent, and self-limited disease to a fulminant, potentially life-threateningsepticemia

• typically older and female.

• The most common presentation is fever, epigastric orright upper quadrant pain, and jaundice CHARCOT’s

TRIAD.

-- two thirds of patients.

The illness may progress rapidly with septicemia anddisorientation, known as Reynolds pentad (e.g., fever,

jaundice, right upper quadrant pain, septic shock, andmental status changes).



diagnosis

• Leukocytosis• Hyperbilirubinemia

• Elevation of alkaline phosphatase and transaminases

• Ultrasonography – (+) of gallbladder stones, dilated

ducts, and possibly pinpoint the site of obstruction• The definitive diagnostic test is ERC. (PTC)

- show the level and the reason for the obstruction,allow culture of the bile, possibly allow the removal of

stones if present, and drainage of the bile ducts withdrainage catheters or stents.

CT scanning and MRI will show pancreatic andperiampullary masses, if present, in addition to the ductal

dilatation.



management

• IV antibiotics and fluid resuscitation.• Biliary decompression - accomplished endoscopically, via the

percutaneous transhepatic route, or surgically.

• - selection based on the level and the nature of the biliaryobstruction.

• When neither ERC nor PTC is available, an emergent operation fordecompression of the common bile duct with a T tube may benecessary and lifesaving. Definitive operative therapy should bedeferred until the cholangitis has been treated and the properdiagnosis established. Patients with indwelling stents and

cholangitis usually require repeated imaging and exchange of thestent over a guidewire.

• Acute cholangitis is associated with an overall mortality rate ofapproximately 5%. When associated with renal failure, cardiacimpairment, hepatic abscesses, and malignancies, the morbidity and

mortality rates are much higher.



Thank you and Godbless…..

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CHOLECYSTITIS & CHOLELITHIASIS