Gallstone disease and complications

Kaya Saribeyoglu, MDIstanbul University, Cerrahpasa Medical Faculty

Department of General SurgeryHPB Surgery Unit

Gallstone Pathogenesis

• Bile = bile salts (acids), phospholipids, cholesterol, conjugated bilirubin, water, ions

• Pathogenesis involves 3 stages:1. cholesterol supersaturation in bile2. crystal nucleation3. stone growth

Bile salts

Cholic acidDeoxycholic acidCheno deoxycholic acidSodium taurocholic acidSodium glycocolic acid

GallstonesClinical Presentation

– RUQ (or epigastric) pain (colicky, referring to back) – Jaundice– Intestinal obstruction- Fever- Nausea- Vomiting

GallstonesComplications

– Inflammation of the gallbladder (cholecystitis),– Inflammation of the bile duct (cholangitis)– Inflammation of the pancreas (biliary pancreatitis)– Obstruction of the intestine (gallstone ileus)– Obstructive jaundice– Malignancies

Symptomatic cholelithiasis• Biliary colic• Pain: 1-5 hrs, rarely > 24hrs• Ultrasound reveals gallstones• Treatment: Laparoscopic cholecystectomy

Chronic calculous cholecystitis

• Recurrent inflammatory process• Overtime, leads to scarring/wall thickening of

the gallbladder• Treatment: laparoscopic cholecystectomy

Acute calculous cholecystitis• Persistent cystic duct obstruction leads to GB

distension, wall inflammation & edema• May be associated with empyema, gangrene,

rupture of the GB• Pain usually + >24hrs • Palpable/tender or even visible RUQ mass• US: Thickened wall (DD!!: CHI, hypoalbuminemia) • Nuclear HIDA : nonfilling of GB• Treatment: Cholecystectomy (early or delayed);

cholecystostomy (rarely)

Acute acalculous cholecystitis

• 5-10% • Critically ill patients or prolonged TPN• Complications: gangrene, empyema,

perforation• Decreased enteral stimulation = low

cholecystokinin = gallbladder stasis • Emergent cholecystectomy• Or cholecystostomy and delayed

cholecystectomy

Choledocholithiasis

• Gallstones within common bile duct (or common hepatic duct

• DD: cholelithiasis, hepatitis, sclerosing cholangitis, cholangiocarcinoma

CholedocholithiasisManagement

• ERCP• Laparoscopic procedures– Trancystic exploration– Laparoscopic choledochotomy

• Open procedures

Surgeon Endoscopist Radiologist

CholedocholithiasisManagement

ERCP• Success rate for the clearance of

choledocholithiasis is 70-90%

Overall complication rate: 5% to 10%Mortality: 0.02% to 0.5%

Freeman et al. N Engl J Med 1996Cotton PB et al. Gastrointest Endosc 1991

ERCP

RisksEarly: Perforation, bleeding, infection, pancreatitis

Late: Papillary stenosis, stricture due to cautery,

cholangitis, biliary malignancy due to enterobiliary reflux

ERCP

Risk of malignancy transformation

ERCP: 27 708ES: 11,617 1976 - 2003

The risk of malignancy in the bile ducts, liver, or pancreas is elevated after ERCP in benign disease. However, endoscopic sphincterotomy does not seem to affect this risk.

Luo et al. Clin Gastroenterol Hepatol 2008

ERCP

Difficult bile duct stones at ERCP

• Stones >15 mm,• Intrahepatic stones• Multiple stones• Impacted stones• Stone proximal to a biliary stricture• Tortuous bile duct• Duodenal diverticulum• Prior Billroth II• Prior surgical duodenotomy

Management of preoperatively “suspected” CBD stones

• Jaundice• Elevated cholestatic liver function tests• History of pancreatitis• Dilated biliary system on radiographic imaging

Negative ERCP: 40-70% !!Kroh M. Surg Clin North Am 2008

Reducing negative ERCP

• EUS• MRCP• Intraoperative cholangiography• Laparoscopic US

Endoscopic Ultrasound

Meta-analysis including 27 papers

Sensitivity: 0.94; speficifity: 0.95EUS should be used to select patients for a

therapeutic ERCP and to minimize the risk of complications associated with unnecessary diagnostic ERCP

Tse et al. Gastrointest Endosc 2008

MRCP

Detection of CBD stones before LC

Sensitivity: 90% Speficifity: 96%

Boraschi et al. Acta Radiologica 2002

IOC

Routine IOC or Selective IOC for CBD stones

There would be only 1.5%of the patients having missed CBD stones if selective IOC was to be performed

Singh et al. Aust NZ Surg 2000

Laparoscopic US

Less invasive, quick, no radiation,

Identification of CBD stonesSensitivity 92%, Specificity 100%

Could replace IOC

Management of diagnosed CBD stones

PREOPERATIVE PERIOD

No particular difficulty /contraindication ERCP

DifficultiesFailed attempts SurgeryContraindications

Management of diagnosed CBD stones

DIAGNOSIS OF CBD STONES DURING OP• Experience of the surgeon• Number, size, type of the CBD stones

Management of diagnosed CBD stones

DIAGNOSIS OF CBD STONES DURING OP

Options• Laparoscopic trancystic CBD exploration• Laparoscopic choledochotomy• Open CBD exploration• Postoperative ERCP

Laparoscopic trancystic CBD exploration

• CBD is left intact• Successful CBD clearance in 60-70%

• Usually requires specific instruments• Requires experience• Not appropriate in multiple large stones, small caliber

CD, impacted stones etc.

Laparoscopic Choledochotomy

• Effective exploration• Enables bilioenteric drainage / decompression• Residual stones may be removed via T-tube tract (4 -

6w later)

• Compications of T-tube or bilioenteric anastomosis• Requires advanced laparoscopic skills

Open CBD exploration

• Unsuccessful transcystic CBD expl• Unsuccessful laparoscopic choledochotomy• Multiple (>10) stones• Large stones• Impacted stones• Failed or unavailable ERCP

Management of diagnosed CBD stones

POSTOPERATIVE PERIOD

No particular difficulty /contraindication ERCP

DifficultiesFailed attempts SurgeryContraindications

Stone removal from T-tube tract

Laparoscopic bile duct exploration

Cholangitis

• Infection of the bile ducts (CBD obstruction due to stones, strictures, tumors, bilioenteric anastomoses ascariasis etc.)

• Charcot’s triad 70% +: fever, RUQ pain, jaundice • May lead to life-threatening sepsis and septic shock

(Reynolds’ pentad= Charcot’s triad + hypotension and altered mental status)

Treatment• Broad-spectrum antibiotherapy• Emergent decompression via ERCP or perc

transhepatic cholangiogram (PTC)• Surgery

Gallstone pancreatitis

• Acute pancreatitis is related to galltones in most cases in Turkey

• Pathophysiology – Reflux of bile into pancreatic duct and/or

obstruction of ampulla by stone

Tretament: • Resuscitation• ERC:P stone extraction/sphincterotomy• Cholecystectomy during hospital stay

The End