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COMPLICATIONS OF GALLSTONE DISEASE
Shankar Zanwar
Jewellery from gall stone
BACKGROUND Reports of gall stones in history dates back
Babylonian era before 2000 yrs Prevalence of gall stones in India 4.3% half of the
western world percentage
RK Tandon WJG 2000
NATURAL HISTORY OF GALLS STONE DISEASE
COMPLICATIONS OF GALL STONES Cholecystitis Cholangitis Mirrizi’s syndrome Gall stone ileus Emphysematous cholecystitis Perforation Biliary pancreatitis Carcinoma gall bladder
CHOLECYSTITIS Of all patients with gall stones 2% will become
symptomatic every year (for first 5 years and later decrease)
Of symptomatic gall stones 2% will develop complications per year
Ranshoff Ann Int Med 1993
Acute cholecystitis is the most common complication of gall stone disease
ACUTE CHOLECYSTITIS Pathogenesis
Stone embedding in cystic duct
Chr. Obstruction
Stasis of bile in GB
Mucosal trauma by gall stones
Release of phospholipas
e A
Conversion of lecithin
lysolecithin
Luminal irritation
Release of cytokinins
cholecytitis
CLINICAL FEATURES Nearly 75% have prior attacks of biliary pain
Fever – but usually <102, higher – gangrene or perforation
Jaundice – 20%, in 40 % elderly patients, usually <4mg/dl if >4 suspect CBD stone
Murphy’s sign – sensitivity – 97%, specificity 48%Singer Ann Int Med 1996
GB is palpable in 33% of pts. more if the attack is for first time.
NATURAL HISTORY Untreated cholecystitis – pain relives in 7-10 days
Sequelae Resolution – 83% Gangrenous cholecystitis – 7% Empyema – 6% Perforation – 3% Emphysematous – 1%
DIAGNOSIS Hemtological and biochemical alterations
Mild amylase and lipase elevation may be seen in absence of pancreatitis
USG – Sonographic tenderness – 90% PPV Non specific
GB wall thickening >4mm (in absence of hypoalbu) Pericholecystitic fluid (in absence of ascites)
Cholescintigraphy – HIDA/DISIDA scan Assesses patency of cystic duct Normal scan – GB seen within 30 min Non visualisation – s/o cholecystitis Sensitivity – 95%, specificity – 90 % False positive – fasting, CLD, TPN, critically ill False negative virtually absent
CT can useful when complications like – perforation, emphysema abscess, or pancreatitis suspected.
TREATMENT IV fluids, Electrolyte replacement, cultures.
Broad spectrum antibiotic coverage, in complicated patient extend coverage for anerobes
Definitive therapy – cholecystectomy
Study from KMC, Manipal Bile culture + ve in 70% Aerobes - 56.8% Anerobes – 13.6%
CHOLANGITIS Most serious and lethal of all complications All causes of cholangitis 85% are due to stones
embedded in the CBD Same organisms as in cholecystitis
Thus urgent decompression needed
Obstruction
biliary pressur
e
regurg of bac.
from bile in hep.
venous sinuses
Bacteremia
fever and chills,
sepsis & shock
CLINICAL FEATURES AND LABS Charcots triad – pain, fever and jaundice – 70% of patients
Pitt WB Ac. Cholangitis 1987
Fever – 95%, - usually > 102
RUQ tenderness – 90%
Jaundice – 80%
Leucocytosis – 80%, Bil >2mg – 80%.
IMAGING Stones in CBD seen only in 50% cases, CBD dilatation
>6mm may give indirect evidence in remaining 25%Yusuff, GE clinic of N Amer 2003
MRC for stones Sensitivity 93%, specificity -94% Recommended when low to moderate clinical probability
EUS Sens – 95%, spec – 97%, NPV – 98% Recommended when low to moderate clinical probability
ERCP – sens and spec – 95% Recommended when high probability and therapeutic
intent
TREATMENT IV fluids, cultures, antibiotics in severe cases with
shock cover anerobes
Decompression ERCP Failed PTBD Cholecystectomy.
MIRRIZI’S SYNDROME. First described in 1948 by Mirrizi
Stone impacted in the neck or GB or cystic duct narrowing of CHD.
Occurs in 0.1 -0.7% of patients with gall stonesHazzan Surg Endo 1999
Risk of GB ca. In these group of patients is higher then the rest – 25%
Redaelli Surgery 1997
CLASSIFICATIONS
Older – McSherry Type 1 – external compression of CHD by calculus in cystic
duct/Hartmanns’s pouch Type 2 – Cholecysto-choledochal fistula partial/ complete
Newer - Csendes classification
Only external compression
Cysto-biliary fistula <1/3rd of circumference of CHD
Upto 2/3rd of CHD circum
Complete destruction
DIAGNOSIS
Symptoms and signs same as cholecystitis
Lab parameters mimic cholecystitis or cholangitis
USG – correct diagnosis – 8-62%
Nearly 100% can be diagnosed with ERCP or EUS
TREATMENT -
When preop diagnosis made – open preferred over lap chole
When found intra-op during lap surgery – mandate open conversion
Though reported(and sparsely) lap should be avoided unless expert is available
Type 1 - cholecystectomy alone If phlegmon or fibrous reaction at Calot’s triangle – stone
extraction & partial cholecystectomy – safe
Type 2-4 using remnant of GB to repair fistula with T-tube, Other safest alternative is Roux en Y bilio- enteric anastomosis
Prognosis of type – excellent
Higher types – poorer with complications like Increased postop morbidity Biliary fistulae – 10% or more Strictures Hepatic abscess
CHOLECYSTO-ENTRIC FISTULA - GALLSTONE ILEUS Not a true ileus – rather mechanical obstruction First description – Bartholin – 1654 Seen in 0.5% of gall stone patients Occurs in nearly 1-3% of all small bowel mechanical
obstructionsCooperman Ann Surg, 1986
Accounts for nearly 25% of all SB obstructions in elderly women (>65 y)
Reisner RM Am J Surg 1994 Females more common - 3-16 times Mortality – 15-18 %
PATHOGENESIS Fistula formation from bile duct to the intestine due to
pressure necrosis by gall stone against the biliary wall
Most common entry point into the bowel – duodenum followed by hepatic flexurestomachjejunum
Occur in 2-3% with cholecystitis
Mirrizi’s syndrome is associated in 90% of cases of cholecysto-enteric fistulae.
CLINICAL PRESENTATION Gall stone ileus results when gallstone is large in
size majority - >2.5cm
Commonest site of impact 50-70% – distal ileum, since narrowest
Presents as intermittent sub-acute obstruction
“Tumbling obstruction” – due to stone tumbling down the bowel lumen
Mean symptoms period before presentation – 5days
Occasional hematemesis due to hemorrhage at the entry site of the stone.
Bouveret’s syndrome – Gastric outlet obstruction due to impacted gall stone in duodenum or pylorus
DIAGNOSIS Clinical diagnosis made infrequently Prep-op diagnosis is made only in 20-50% of cases
Chou WJG 2007 Rigler’s triad on imaging
Partial or complete intestinal obs – 50% Pneumobilia – 30-60% Aberrant gall stones - <15%
X-ray – detects all 3 in 17-35% cases USG + X-ray 74% Plain CT – 93%
TREATMENT Surgery after intial resuscitaion
Ongoing debate – one stage vs 2 stage
One stage – treating obs, cholecystectomy and fistula division withor without CBD exploration
Two stage – only explorative laparotomy and enterolithotomy first in second stage rest all.
Benefits of one stage operation – prevents further biliary complications, recurrent ileus and treats fistula
Largest review of 1000 cases by Reissner – mortality rate 16.9% in one stage vs 11.7% for enterolithotomy alone
But recurrence of GS ileus is seen in only 5-9% of cases where enterolithotomy done
And only 10% require reoperation for biliary symptoms
Fistula may close spontaneously and unclosed fistula complicates rarely
A study by Tan (Singapore Med J 2004) Significantly increased operating time in one stage No significant morbidity and mortality differences in the
2 groups
Many authors conclude – one stage procedure should be reserved for otherwise
healthy patients and without serious fibrosis in RUQ Two stage – be considered in younger patients with risk
of further biliary complications
EMPHYSEMATOUS CHOLECYSTITIS Acute infection of gall bladder by gas forming
organisms
Surgical emergency
Seen in 1% of all cases of acute cholecystitis
Mortality rates between 15-25%
PATHOGENESIS Vascular compromise of the gall bladder – occlusion or
stenosis of vessels, usually arteriosclerotic cystic artery
More in male, DM(in up to 55%patients), elderly.
Vascular compromise facilitates growth of gas forming organisms
This is also reported in cases of pts. treated with sunitinib for GIST due to VEGF inhibition.
Common causative agents Clostridum spp – 46% E. coli – 40% Klebsiella Enterococci
Symptoms and presentation is similar to acute cholecystitis except for higher degree of fever
Lab findings are similar to acute cholecystitis
IMAGING X- ray – air in side the GB – can be
negative in 60% cases
USG sensitivity 90-95% Stage 1 - gas in lumen Stage 2 - gas in wall Stage 3 - gas in the pericholecystic tissue
Effervescent GB tiny foci floating on the
nondependent wall Curvilinear gaseous artifact, ring down
effect, comet-tail sign - diagnostic
CT confirms emphysematous cholecystitis, when USG is in doubt
HPE shows full thickness necrosis of GB, gangrene seen in 75% of cases.
Medical treatment same as for sever cholecystitis
In hemodynamically unstable patient and those who can not tolerate GA percutaneous cholecystectomy can be done to stabilize the patient.
Interval cholecystectomy after 4-6week can be done
Adjuvant therapy with hyperbaric oxygen- rationale – anerobes is cause in majority
HBO is given within 8 hours of surgery for 5 daysKraljevic Hepatogastroenterology 1999
GB PERFORATION Neimeier classification
Type 1 – Acute Type 2 – Subacute Type 3 – Chronic
Managed similarly as emphysematous cholecystitis
In a study by Hung stable patients can be taken up for early lap cholecystectomy with equal outcomes and lesser LOS as compared elective interval cholecystectomy after PTBD.
GALL STONE PANCREATITIS
Of all gall stone patients only 3-7% develop pancreatitis
But amongst the pancreatitis patients 40% are caused due to gall stones
In thesis – 17/53(32.07%) patients had biliary cause of pancreatitis, 3 severe, 3 moderate and rest 11 mild, no mortality
All underwent cholecystectomy except 2 severe ones
MANAGEMENT - TIMING OF CHOLECYSTECTOMY
mild pancreatitis – Review of studies with total of 998 patients
no readmissions if operated during index admission vs 18% readmission in patient with interval cholecystectomy(p<0.0001)
No difference in operative complications, conversion or mortality
Ann Surg 2012
Severe – of 187 patients 78 had early and 109 late cholecystectomy
William Ann Sur 2004Since the patients with acute severe pancreatitis often have peripancreatitic complications and SIRS operating is challenging and may invite complications should be avoided till 4-6 weeks till pancreatitis settles
Early(%) Late(%)Resolution of associated fluid collection
21 40
Percutaneous drainage required
50 18
Sepsis 47 6Complications of cholecystectomy
44 5.5
THANK YOU