Date post: | 03-Jun-2015 |
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Presented by Vd. Devendra Sancheti
GuideDr.R.R.Patil
HOD ROGNIDAN DEPARTMENT
Types of gallstone Cholesterol stones (20%) Pigment stones (5%) Mixed (75%)
Epidemiology Fat, Fair, Female, Fertile, Fourty inaccurate, but
reminder of the typical patient F:M = 2:1 10% of Indian women in their 40s have gallstones
Composition of bile: Bilirubin (by-product of haem degradation) Cholesterol (kept soluble by bile salts and lecithin) Bile salts/acids (cholic acid/chenodeoxycholic acid):
mostly reabsorbed in terminal ileum(entero-hepatic circulation).
Lecithin (increases solubility of cholesterol) Inorganic salts (sodium bicarbonate to keep bile
alkaline to neutralise gastric acid in duodenum) Water (makes up 97% of bile)
Cholesterol Imbalance between bile salts/lecithin and cholesterol
allows cholesterol to precipitate out of solution and form stones
Pigment Occur due to excess of circulating bile pigment (e.g.
Heamolytic anaemia) Mixed
Same pathophysiology as cholesterol stones
Other Factors Stasis (e.g. Pregnancy) Ileal dysfunction (prevents re-absorption of bile salts) Obesity and hypercholesterolaemia
80% Asymptomatic 20% develop complications and do so on
recurrent basis
Gallstone disease (and its related complications) Gastritis/duodenitis Peptic ulcer disease/perforated peptic ulcer Acute pancreatitis Right lower lobe pneumonia Miyocardial Infarction
If presenting with RUQ pain all patients should get
Blood tests Abdominal xray / CXR (to exclude perforation/pneumonia) ECG
Can differentiate between gallstone complications based on:
History Examination Blood tests
CBC LFT CRP Clotting Amylase
Complication History Examination Blood testsBiliary Colic - Intermittent RUQ/epigastric
pain (minutes/hours) into back or right shoulder
-Tender RUQ-Murphy’s –-HR and BP (N)
-Wbc (N) CRP (N)- LFT (N)
Acute Cholecystitis -Constant RUQ pain into back or right shoulder-Feverish
-Tender RUQ-Murphy’s +-Pyrexia, HR (↑)
-Wbc and CRP (↑)-LFT (N or mildly (↑)
Empyema -Constant RUQ pain into back or right shoulder-Feverish
-Tender RUQ -Murphy’s +-Pyrexia, HR (↑), BP (↔ or ↓)-More septic than acute cholecystitis
-Wbc and CRP (↑)-LFT (N or mildly (↑)
Obstructive Jaundice -Yellow discolouration-Pale stool, dark urine-painless or associated with mild RUQ pain
-Jaundiced-Non-tender or minimally tender RUQ-No peritonism-Murphy’s –-Apyrexial, HR and BP (N)
-Wbc and CRP (N)-LFT: obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔)-INR (↔ or ↑)
Ascending Cholangitis Becks triad-RUQ pain (constant)-Jaundice -Rigors
-Jaundiced-Tender RUQ -Peritonism RUQ-high pyrexia (38-39)-HR (↑), BP (↔ or ↓)-Can develop septic shock
-Wbc and CRP (↑)-LFT : obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔)-INR (↔ or ↑)
Gallstone Ileus - 4 cardinal features of Small Bowel Obstruction
-distended tympanic abdomen-hyperactive/tinkling bowel sounds
Blood Tests Abdominal Xray (10% gallstones are radio-opaque) Chest Xray (to exclude perforation – MUST!) ECG (to exclude MI) Ultrasound Sonography: first line investigation in gallstone disease
Confirms presence of gallstones Gall bladder wall thickness (if thickened suggests cholecystitis) Biliary tree calibre (CBD/extrahepatic/intrahepatic) – if dilated suggests stone in CBD (normal
CBD <8mm). Sometimes CBD stone can be seen.
MRCP: To visualise biliary tree accurately (much more accurate than ultrasound) Diagnostic only but non-invasive Look for biliary dilatation and any stones in biliary tree
ERCP: Diagnostic and therapeutic in biliary obstruction Diagnostic and therapeutic but invasive Look for biliary tree dilatation and stones in biliary tree Stones can be extracted to unobstruct the biliary tree and perform sphincterotomy Risk of pancreatitis, duodenal perforation
CT Abdomen: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene, or perforation and in acute pancreatitis (ultrasound not good for looking at pancreas)
Pathogenesis Stone intermittently obstructing cystic duct
(causing pain) and then dropping back into gallbladder (pain subsides)
Ultrasound confirms presence of gallstones
Pathogenesis: Due to obstruction of cystic duct by gallstone:
Cystic duct blockage by gallstone Obstruction to secretion of bile from gallbladder Bile becomes concentrated Chemical inflammation initially Secondarily infected by organisms released by liver into
bile stream
Ultrasound confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid)
Complications of acute cholecystitis Empyema of gallbaldder Gangrene of gallbladder (rare) Perforation of gallbaldder (rare)
Pathogenesis: Stone obstructing CBD with infection/pus
proximal to the blockage
Pathogenesis: Gallstone causing small bowel obstruction
(usually obstructs in terminal ileum) Gallstone enters small bowel via cholecysto-
duodenal fistula (not via CBD)
Abdominal Xray – dilated small bowel loops May see stone if radio-opaque
Diagnosis of gallstone ileus usually made at the time of surgery.
Questions?
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