1. GALL STONES BY DR. SEFEEN SAIF ATTYA SURGERY DEPARTMENT SOHAG TEACHING HOSPITAL

2. INTRODUCTION Anatomy and physiology Risk factors Types of gallstones IMAGING MODALITIES OF THE GALLBLADDER CLINICAL PRESENTATIONS OF GALLSTONES 3. a = right hepatic duct; b = left hepatic 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 theG.B. j = body of gallbladder; k = infundibulum; l = cystic duct; m = cystic artery; n = superior pancreaticoduodenal artery. 4. Bile secretion and flow The liver continually secretes bile (500- 1000 ML. daily) Bile secreted by the liver is mostly stored in the gall bladder where it is concentrated and periodically discharged into the duodenum both during fasting and in large quantities after meals 5. Regulation of Gallbladder Emptying The drainage channel for bile to flow away from the gallbladder into the common bile duct is the cystic duct, cholecystokinin stimulates rhythmical contractions of the gallbladder wall. 6. cholecystokinin (CCK( It has been known for decades that cholecystokinin (CCK) exerts a stimulatory effect on gallbladder emptying The stimulus for the release of cholecystokinin in the blood is a meal abundant in fat. Meal without fat cannot generate secretion with a sufficient quantity of cholecystokinin 7. Sphincter of Oddi guards the distal ends of the common bile duct and the pancreatic duct (either their common or their separate exit into the duodenum). 8. The effective emptying of the gallbladder is achieved by the cooperation of two mechanisms first, the strong contraction of the wall of the gallbladder (as mediated by the neurohormonal control) and second, the fall of the intraluminal pressure of the common bile duct as a consequence of the reduction sphincter of Oddi basal pressure. 9. The basal sphincter Pressure is 3mmHg above the pressure in the common bile duct and pancreatic duct, as a result of which even the stronger contractile activity of the gallbladder, cannot make emptying possible , Relaxation of the sphincter is a prerequisite for the emptying progress. 10. Vagal stimulation increases secretion of bile, and stimulates contraction of the gallbladder, Parasympathomimetic drugs contract the gallbladder, whereas atropine leads to relaxation. splanchnic sympathetic stimulation is inhibitory to motor activity of the G.B. Antral distention of the stomach causes both gallbladder contraction and relaxation of the sphincter of Oddi. Somatostatin and its analogues are potent inhibitors of gallbladder contraction. 11. Factors affecting relaxation of sphincter of oddi firstly, although cholecystokinin causes contraction of the gallbladder, it acts as relaxant factor on the sphincteric fibers, but this relaxation is not sufficient to allow significant emptying of gallbladder; second factor is the transmitted peristaltic waves coming from gallbladder contractions, which usually cause a leading wave of relaxation that acts on the sphincter of Oddi, 12. The third factor that causes relaxation of the sphincter is the intestinal peristaltic waves. When these waves travel over the wall of the duodenum itself, their relaxation phase exerts a strong relaxing effect of the sphincter This seems to be ,the most strong and significant factor of all the relaxant factors on the sphincter of Oddi. Subsequently, bile enters the duodenum in a squirt fashion, coinciding with the relaxation phase of the duodenal peristaltic waves. 13. INTRODUCTION Anatomy and physiology Risk factors Types of gallstones IMAGING MODALITIES OF THE GALLBLADDER CLINICAL PRESENTATIONS OF GALLSTONES 14. Risk Factors for GallstonesRisk Factors for Gallstones ObesityObesity Female sexFemale sex FirstFirst--degree relativesdegree relatives Increasing ageIncreasing age ChildbearingChildbearing High fat dietHigh fat diet MultiparityMultiparity Rapid weight lossRapid weight loss Oral contraceptionOral contraception DrugsDrugs:: ceftriaxone, postmenopausal estrogens,ceftriaxone, postmenopausal estrogens, Total parenteral nutritionTotal parenteral nutrition Ileal disease, (resection or bypass) Loss of bile saltsIleal disease, (resection or bypass) Loss of bile salts Biliary stasis and /or infectionBiliary stasis and /or infection Hemolytic diseaseHemolytic disease 15. TYPES OF GALLSTONES cholesterol stones composed mainly of cholesterol (> 50% of stone composition) and comprises multiple layers of cholesterol and mucin glycoproteins. Pure cholesterol stones are not common; they comprise less than 10% of all stones. Most other cholesterol stones contain variable amounts of bile pigments and calcium. 16. Biliary cholesterol is held in solution as a result of molecular aggregation with bile salts and phospholipids The relative proportion of these constituents is essential for the maintenance of cholesterol solubility If excessive cholesterol or insufficient bile acids are secreted , bile becomes supersaturaed with cholesterol which then preciptates out as cholesterol crystals and stones 17. Pigment stones are dark due to the presence of calcium bilirubinate. and are usually formed secondary to hemolytic disorders such as sickle cell disease and spherocytosis, and in those with cirrhosis. Two types are recognized, black and brown, Black pigment stones are small and brittle and they almost always formed in the gallbladder. They are the result of supersaturation of calcium bilirubinate, carbonate and phosphate. When the level of deconjucated bilirubin is increased in the bile, precipitation with calcium occurs. 18. Brown stones may form in the gallbladder or in the bile ducts usually after bacterial infection caused by bile stasis. The bacteria responsible for the infection enzymatically catalyze the conversion of bilirubin glucuronide to insoluble unconjugated bilirubin. The major constituents of these brownish-yellow soft stones are precipitated calcium bilirubinate and bacterial cell bodies. 19. INTRODUCTION - Anatomy and physiology - Risk factors - Types of gallstones IMAGING MODALITIES OF THE GALLBLADDER CLINICAL PRESENTATIONS OF GALLSTONES 20. Abdominal Plain X- Ray Plain abdominal X-ray is the simplest and oldest imaging modality. Gallstones can be shown, if they are calcified. It is estimated that the percentage of gallstones that are radiopaque reaches 20-30%. Gallstones with mixed constituents, namely "mercedes benz" gallstones, have a characteristic stellate faceted appearance with gas containing fissures. Another finding is a porcelain gallbladder, caused by calcification of its wall subsequent to chronic inflammatory irritation and predisposedto malignant change. 21. Plain radiograph showing radio-opaque stones in thePlain radiograph showing radio-opaque stones in the gall bladdergall bladder.. 22. Porcelain gall bladder. 23. Gas in the gall bladder and gall bladder wallGas in the gall bladder and gall bladder wall Emergency surgery is indicatedEmergency surgery is indicated.. 24. Oral Cholecystography has largely been replaced by ultrasonography. It involves oral administration of a radiopaque compound that is absorbed, excreted by the liver, and passed into the gallbladder. Stones are noted on a film as filling defects in a visualized, opacified gallbladder. Oral cholecystography is of no value in patients with intestinal malabsorption, vomiting, obstructed cystic duct, and hepatic failure. 25. Oral cholecystogram showing contracted gall bladder suggesting chronic calcular cholecystitis. 26. Oral cholecys togram. Multiple small stones 27. Ultrasonography Ultrasonography is the initial investigation of any patient suspected of disease of the biliary tree. It is noninvasive, painless, does not submit the patient to radiation, It is dependent upon the skills and the experience of the operator Adjacent organs can be examined at the same time. Obese patients, patients with ascites, and patients with distended bowel may be difficult to examine satisfactorily with an ultrasound. An ultrasound will show stones in the gallbladder with sensitivity and specificity of over 90%. 28. Stones are acoustically dense and produce an acoustic shadow Stones also move with changes in position. Polyps may be calcified and reflect shadows, but do not move with change in posture. A thickened gallbladder wall and local tenderness indicate cholecystitis. The patient has acute cholecystitis if a layer of edema is seen within the wall of the gallbladder or between the gallbladder and the liver. When a stone obstructs the neck of the gallbladder, the gallbladder may become very large, but thin walled. A contracted, thick-walled gallbladder indicates chronic cholecystitis. 29. ultrasound imageultrasound image demonstrate thedemonstrate the normalnormal gallbladdergallbladder The thin wall ofThe thin wall of the gallbladder isthe gallbladder is seen as a whiteseen as a white ring surroundingring surrounding bile, whichbile, which appears as aappears as a black fluid.black fluid. The wallThe wall thickness shouldthickness should be less than 3be less than 3 mm in adults. 30. Ultrasound examination. Single large gallstoneUltrasound examination. Single large gallstone castingcasting an acoustic shadowan acoustic shadow 31. Computerised tomography For benign biliary diseases, standard computerised tomography (CT) is not that useful investigation. Gallstones are often not visualised, and cholecystitis is underdiagnosed. However, improvements in CT technology such as multidetector helical scanners that allow for three-dimensional reconstruction of the biliary tree have led to greater diagnostic accuracy and may increase the use of this modality in the future. 32. CT imageCT image demonstratesdemonstrates largelarge gallstone ingallstone in thethe gallbladdergallbladder 33. Computed tomography. PorcelainComputed tomography. Porcelain gallbladdergallbladder.. 34. Radionuclide Scanning HIDA Scan Biliary scintigraphy provides a noninvasive evaluation of the liver, gallbladder and bile ducts with both anatomic and functional information Technetium-labeled derivatives of hydroxy iminodiacetic acid (HIDA) are injected intravenously, cleared by the Kupffer cells in the liver, and excreted in the bile. Uptake by the liver is detected within 10 minutes, and the gallbladder, is visualized within 60 minutes in fasting subjects. The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis, which appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and duodenum. 35. complications of gallstones Chronic cholecystitis acute cholecystitis choledocholithiasis cholangitis, gallstone pancreatitis, gallstone ileus, perforation of the gallbladder gallbladder carcinoma. 36. INTRODUCTION - Anatomy and physiology - Risk factors - Types of gallstones IMAGING MODALITIES OF THE GALLBLADDER CLINICAL PRESENTATIONS OF GALLSTONES 37. CLINICAL PRESENTATIONS OF GALLSTONES Symptomatic Gallstones Chronic Cholecystitis Acute Cholecystitis Asymptomatic gallstones Patients with suggestive symptoms but without gallstones (Acalculous cholecystitis) 38. Chronic Cholecystitis The diagnosis of symptomatic cholelithiasis is based on the sonographic examination of the gallbladder symptoms and signs, a steady upper abdominal pain, radiating to the upper back, occurring at least one hour after fatty meals and lasting at least 30 minutes, is the most sensitive clinical indicator of cholelithiasis. The confirmation or exclusion of gallstone disease in patients with symptoms attributable to gallstones is achieved by Ultrasonography which provides 95-98% sensitivity and specificity for the diagnosis of gallstone sgreater than 2 mm in diameter. Ultrasonography also provides additional anatomic information on the presence of gallbladder polyps, common bile duct diameter, or any hepatic parenchymal abnormalities. 39. The treatment of choice for patients with symptomatic cholelithiasis is elective laparoscopic cholecystectomy (LC). a mortality rate of approximately 0.1% with cardiovascular complications being the most common cause of death The morbidity of the procedure is less than 10%, with iatrogenic injury to the biliary tract presenting an infrequent but often disastrous complication requiring long hospitalization, multiple reoperations, repeated invasive procedures and long stenting of the common bile duct (CBD). The incidence of CBD injury ranges from 1/160 to 1/320 LCs, Conversion to laparotomy is necessary in less than 5% of patients with the elderly, obese, male and those with periumbilical scars from previous laparotomies being at greater risk. 40. The long-term results of laparoscopic cholecystectomy in appropriately selected patients with chronic cholecystitis are excellent. Nearly 90% of patients with typical biliary pain are rendered symptom-free after cholecystectomy. However, persistent dyspeptic symptoms (fatty food intolerance, flatulence), frequently occur following cholecystectomy, especially in patients with evidence of significant psychological distress and a prolonged history of such symptoms prior to surgery. 41. Acute Cholecystitis Acute calculous cholecystitis is the distinctive clinicopathological entity characterized by acute inflammation of the gallbladder caused by the obstruction of the Hartmann's pouch or cystic duct comprising impacted gallstones or biliary sludge. The inflammation of the gallbladder wall is chemical, at least during the early phase. The increase of intraluminal pressure and the presence of supersaturated bile along with trauma to the mucosa caused by the gallstone, trigger an acute inflammatory response. 42. Clinical diagnosis is based on the presence of symptoms and signs suggestive of localized peritonitis in the right upper abdominal quadrant. The presence of three features, namely: (1) constant biliary pain lasting for at least 12 hours, (2) tenderness in the right upper quadrant (with or without Murphy's sign and with or without a palpable mass) and (3) inflammatory response (fever, leucocytosis) implicates the diagnosis and requires ultrasound scanning to confirm or exclude acute cholecystitis. 43. Following this early phase, 20-50% of patients manifest a proliferation of aerobic enteric bacteria, and occasionally anaerobes, resultingin secondary bacterial infection of the organ. Microscopic features of the disease include necrosis of mucosa, edema and hemorrhages in the gallbladder wall. The gallbladder is distended, tense and vascular. gastrohepatic omentum can be edematous after 24-48 hours and adhesions of omentum (and probably of duodenum) to the distended gallbladder can be perceived as palpable mass. The course of the inflammatory process depends on the degree and the duration of obstruction, the severity of bacterial attack, the age of the patient and the concurrence of accompanyingdiseases. 44. Ultrasonography is the initial imaging modality of choice for the evaluation of acute pain in the right upper quadrant . Typical sonographic findings include Distended gallbladder with edematous wall, pericholecystic fluid (or even abscess), Elicitation of Murphy's sign during examination presence of gallstones Ultrasonography also permits an accurate diagnosis of other underlying causes of a patient's symptomatology, including hepatic, renal, pancreatic, adrenal and even pulmonary problems. At the present time, a firm diagnosis of acute calculous cholecystitis can be established in 90% of patients with suggestive symptoms based on the clinical and sonographic findings. 45. In the remaining uncertain cases, radionuclide cholescintigraphy HIDA scan is the best to confirm or rule out the presence of acute cholecystitis However, contrast-enhanced CT is the most often preferred imaimaging modality, complementary to US being valuable in the assessment of acute cholecystitis complications, in particular emphysematous cholecystitis and perforation of the gallbladder 46. Treatment of acute cholecystitis All patients with acute cholecystitis should be referred to hospital. Acute cholecystitis in the majority of patients subsides spontaneously or responds to conservative medical treatment. In approximately 10-20 percent of patients, acute cholecystitis progresses to the local complications of empyema formation with or without gangrene, or perforation with the formation of a pericholecystic abcess. 47. Conservative treatment followed by cholecystectomy 1 - Nil per mouth (NPO) and intravenous fluid administration. 2 - Administration of analgesics. 3- Administration of antibiotics. As the cystic duct is blocked in most instances, the concentration of antibiotic in the serum is more important than its concentration in bile. A broadspectrum antibiotic effective against Gram-negative aerobes is most appropriate (e.g. cefazolin, cefuroxime or gentamicin). 4 - Subsequent management. When the temperature, pulse and other physical signs show that the inflammation is subsiding, oral fluids are reinstated followed by regular diet. Ultrasonography is performed to ensure that no local complications have developed, that the bile duct is of a normal size and that no stones are contained in the bile duct. Cholecystectomy may be performed on the next available list, or the patient may be allowed home to return later when the inflammation has completely resolved. 48. Conservative treatment must be abandoned if the pain and tenderness increase; depending on the status of the patient, operative intervention and cholecystectomy should be performed If the patient has serious comorbid conditions, a percutaneous cholecystostomy can be performed under ultrasound control, which will rapidly relieve symptoms. A subsequent cholecystectomy is usually required. 49. Routine early operation some surgeons advocate urgent operation as a routine measure in cases of acute cholecystitis. Provided that the the surgeon is experienced and excellent operating facilities are available, good results are achieved. Nevertheless, the conversion rate in laparoscopic cholecystectomy is five times higher in acute than in elective surgery. If an early operation is not indicated, one should wait approximately 6 weeks for the inflammation to subside before proceeding to operate. 50. There is now firm evidence from several prospecive randomized trials that early cholecystectomy for acute cholecystitis (operation within the same hospital admission )is superior to delayed cholecystectomy (2-3 month after resolution of the attack )provided the patient is fit for surgery and anaesthesia 51. The benefits of early cholecystectomy include Reduced overall morbidity Reduced hospital stay Prevention of further attacks that may occur in patients managed by the delayed cholecystectomy policy Unfit patients should be treated conservatively in the first instance with the expectation that acute cholecystitis will resolve in 80% of cases 52. If this conservative treatment fails or in cases with empyema of the G.B. an ulrasound laparoscopically guided cholecystostomy or microcholecystostomy (under u/s guidance ) will tide the patient over the critical illness 53. Asymptomatic gallstones The majority of individuals (60- 80%) with gallstones are asymptomatic at the time of diagnosis and most of them will remain asymptomatic during their lifetime 54. Treatment Most authors suggest that it is safe to observe patients with asymptomatic gallstones, with cholecystectomy only performed for those patients who develop symptoms or complications of their gallstones. However, prophylactic cholecystectomy should be considered 1- in children 2- in young women who are at increased risk of presenting symptoms during a future pregnancy. 3-diabetic patients 4-those with congenital haemolytic anaemia 5-those who will undergo bariatric surgery for morbid obesity, 55. Patients with asymptomatic gallstones, at high risk of gallbladder carcinoma, would also benefit from prophylactic cholecystectomy: Patients with porcelanoid gallbladder, the estimated incidence of carcinoma is up to 25%. Patients with stones greater than 3 cm in diameter, as they present a tenfold risk of malignancy compared with the general population of patients with gallstones. Patients with gallstones and gallbladder polyps exceeding 10 mm in diameter. Patients with anomalous pancreatobiliary junction. Carriers of Salmonella typhi. 56. Acalculous Cholecystitis Chronic acalculous cholecystitis is a heterogeneous clinical syndrome characterized by typical biliary attacks in patients without cholelithiasis. Risk factors prolonged ileus, long-term opiate administration, multiple blood transfusions, total parenteral nutrition, presence of biliary sludge into the gallbladder, presence of cholesterol crystals in the bile, gallbladder motility disorders. This condition develops as a consequence of prolonged gallbladder distention, bile stasis, and sludge formation, followed by mucosal damage and vessel thrombosis. 57. Diagnosis and Radiology Findings Ultrasonography findings suggestive of acalculous cholecytitis include gallbladder distention, presence of sludge within the gallbladder, wall thickening, and pericholecystic fluid. If the diagnosis remains unclear then HIDA scintigraphy should be performed. 58. Management Laparoscopic cholecystectomy improves the clinicalcourse of selected patients with gallbladder dyskinesia but the symptoms persist in more than 50% of the remaining patients Detailed selection of patients is based on motility studies of gallbladder (cholecystokinin cholecystoscintigraphy) and a microscopic studyof bile collected during ERCP. 59. Non-Operative Treatment for Gallstones DISSOLUTION TREATMENT ESWL TREATMENT 60. DISSOLUTION TREATMENT Gallstones may be dissolved with oral ursodeoxycholate and chenodeoxycholate (bile acids). Treatment takes many months to complete, and has been shown to dissolve only small uncalcified stones successfully. Pre-requisites for the dissolution treatment are: (1)radiolucent stones, (2) stones no greater than 20 mm in diameter (3) a functioning gallbladder. Among patients with symptomatic cholelithiasis, only a small percentage (3-25%) would benefit from bile acid therapy and up to 50% of those patients with proven dissolution, can expect a recurrence of gallstones, during the next five years. At present, bile acid therapy is indicated only for patients unfit or unwilling to undergo surgery 61. ESWL TREATMENT After the disappointment of dissolution treatment and the successful application of Extracorporeal Shock Wave Lithotripsy (ESWL) in Urology, there was in the mid 1980' an interest in the use of lithotripsy in gallstone management. ESWL shatters the stone into small fragments that can either be dissolved more quickly using dissolution treatment with ursodeoxycholate or may pass spontaneously into the intestine. Analysis of stone fragments in the feces of patients who had undergone ESWL showed that 3 mm fragments can pass to the intestine without causing symptoms 62. Dissolution and ESWL treatment for gallstone disease are less cost-effective than laparoscopic cholecystectomy and should only be recommended in (1)elderly patients with symptomatic cholelithiasis unfit to receive general anesthesia and (2) patients with symptomatic cholelithiasis actively refusing to undergo operative treatment if they have noncalcified, solitary gallstones, no greater than 2 cm in diameter. 63. The ESWL procedure requires administration of propofol anaesthesia i.v., on an outpatient basis. Complications are minimal (petechiae, transient hematuria, liver hematoma) but almost half of the patients experience one or more episodes of biliary pain. Furthermore, biliary pancreatitis can develop in 1-2% of the patients. Urgent or elective cholecystectomy has to be performed in 3-7% of patients. 64. Operative Treatment for Gallstones Laparoscopic Cholecystectomy Open Cholecystectomy Cholecystostomy 65. KEY POINTS 1. The physiology of the gallbladder and sphincter of Oddi are regulated by a complex interplay of hormones and neuronal inputs designed to coordinate bile release with food consumption. 2. complications of cholelithiasis. include cholecystitis, choledocholithiasis, cholangitis, and biliary pancreatitis. In addition, cholelithiasis plays the role as the major risk factor for the development of gallbladder cancer 3. Laparoscopic cholecystectomy has been demonstrated to be a safe and effective alternative to open cholecystectomy and has become the treatment of choice for symptomatic gallstones. 66. 4. Common bile duct injuries, although uncommon, can be devastating to patients. Proper exposure of Calot's triangle and careful identification of the anatomic structures are keys to avoiding these injuries. 5. Carcinoma of the gallbladder and bile duct generally have a poor prognosis because patients usually present late in the disease process and have poor response to chemo and radiation therapies. Surgery offers the best chance for survival and has good long-term survival in patients with early- stage disease. 67. LaparoscopicLaparoscopic CholecystectomyCholecystectomy 68. THANK YOU