begum Types of gall stone Cholesterol Pigment a black b brown Mixed Composition of stones Cholesterol chl Ca salts bile acid amp pigments phospholipid Black pigment insoluble ID: 1007144
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1. Gall stone diseaseDr.Mahbuba begum
2. Types of gall stoneCholesterolPigment – a) black b) brownMixedComposition of stonesCholesterol – chl, Ca salts, bile acid & pigments, phospholipidBlack pigment – insoluble bilirubin pigment, CaPO4, CaCo3.Brown pigment – ca bilirubinate, ca palmitate, Ca stearate, cholesterolMixed – mainly cholesterol, ca bilirubinate, Ca PO4, CaCo3, Ca palmitate, protein.Etiology Metabolic – diet, drugs, obesity, pregnancy, terminal ileum dis. Etc. ► lithogenic bile – supersaturated with cholesterol - Chl : bile acid, phospholipid = 1 : 25 > normal, 1 : 13 > lithogenic - haemolysis ( haem. Disease) – black pigment stone.
3. ►Stasis – impaired GB functionInfection – brown pig. Stone – deconjugation of bilirubin diglucoronide by bacterial beta glucoronidase → insoluble unconjugated bilirubinate precipitate complex with Cholesterol. ( gall stone is a tomb stone erected to the memory of organism within it )Common organisms for infection – E. coli, proteus, pseudomonus, salmonellla, non haemolytic streptococci, clostridium,Biliary sludge – aggregation of nucleated cholesterol crystals. Sequle or complications of GSIn GB –Silent stoneBiliary colicChronic cholecystitis.
4. ►Acute cholecystitisMucocoelEmpyemaGangrenePerforation ( fundus, neck of GB due to pressure necrosis) → biliary peritonitisFistula (cholecystoduodenal, cholecystocolic )MalignancyIn bile duct Obstructive jaundiceCholangitis → septicaemia, liver abscessAcute pancreatitis ( stone impacted in ampulla of vater )In intestineIntestinal obstruction (gall stone ileus )
5. Ductal stonePrimary – form in bile duct – brown pigmentSecondary – stone that form in GB → migrate into bile ductRetained / residual stone – stone in CBD detected within 2 yrs of operative intervention (missed stone) – second, bile duct stoneRecurrent stone – stone in CBD detected after 2 yrs of operation – primary ductal stone.Unsuspected stone – (5 – 10%) –accidentally discovered stone in CBD(normal calibre on routine IOFC) during colecystectomy for symptomatic GSD.Pathogenesis of Acute cholecystitis – obstruction of cystic duct by stone → inflammation within GB ( initially by chemical irritant in bile followed by bacterial infection) ► phospholipase released from GB mucosa by irritation → acted on lecithin in bile → convert to lysolecithin (toxin) causing inflammation.Mucocoel – neck of GB or cystic duct obstructed by stone or growth(rarely) → contents(bile – sterile) absorbed & replaced by mucus secreted by GB epithelium. ( Ram’s horn – enormous in size).
6. Empyema GB – when GB is filled with pus as a result of acute cholecystitis or due to infection of mucocoel.Acalculus cholecystitis ( acute or chronic inflammation ) - major surgery, trauma, major burn, pancratitis, immunocompromized pt in ICU. - acute – intense & severe nonspecific inflammation → rapidly progressive → gangrene → perforation ( mortality : 20%).Long cases related to GS diseasesChronic cholecystitis ( D/D Ch. PUD, Ch. pancratitis, hiatus hernia etc)Acute cholecystitis (D/D A, pancratitis, A. gastritis, A. exacerbation of Ch. PUD, perforation of Ch. DU.)GB mass – mucocoel, empyema, carcinomaObstructive jaundice due to choledocholithiasis, Ca head of pancras ( D/D periampullary Ca, cholangio Ca, bile duct stricture, biliary ascariasis, GI malignancy with metastasis in portahepatis or liver.)
7. A fatty, fertile fair female of forty/fifty presented with sudden pain in rt upper abdomen with radiation to inferior angle of rt scapula & referred to tip of rt shoulder with h/o fatty food intolerance & flatulent dyspepsia. - pain lasting more than 12 hrs & increasing in intensity, with fever & leucocytosis. Mild jaundice±, positive murphy’s & Boas sign, tender palpable GB (inflammatory phlegmon), or guarding, rigidity in RHR.Same pt presented with intermittent colicy / gripping pain lasting for few hrs followed by pain free interval, no fever, no leucocytosis, no ms guarding (no abd. Sign ).Same pt presented with recurrent attack of mild to moderate pain(above mentioned), no sign.Patient presented with painless lump in RHR, may have previous h/o acute cholecystitis,sign - nontender palpable GB.Presented with aute attack not improving on conservative Rx, pt is toxic with high fever having guarding in RHR & tender palpable GB.
8. 6. Pt may presented with acute cholecystitis or ch. biliary tract disease, initially colicky pain now persistent dull aching pain or long h/o GS with recent changes in symptoms, h/o anorexia, weight loss, generalized weakness; sign – anaemia, jaundice±, cervical lymphadenopathy± hard, irregular palpable GB; liver – palpable hard irregular±, ascites±.7. Pt presented with charcot’s triad ( colicky rt upper abdominal pain, fluctuating /intermittant jaundice, fever with chills & rigor ), with itching, pale stool, dark urine; or Reynold’s pentad ( charcot’s triad with sepsis) or associated with pancratitis ( GS pancreatitis ). Sign: jaundice (mild), during attack - ↑temt, tenderness in RHR. GB – not palpable.8 . Short h/o painless progressive jaundice, may have diarrhoea, steatorrhoea, new onset DM; anorexia, weight loss. Sign : deep jaundice, anaemia, cervical LN±, palpable smooth nontender GB, liver met±, ascites±. - few pt may have pain – dull aching epigastric, worse at night & in supine position, get relieved in leaning forward (due to nerve compression, invasion to adjacent organ ).
9. 9. Obstructive jaundice – fluctuating with general features of malignancy with melaena (triad of sandblom – biliary pain, jaundice, melaena). Dx : 1) acute cholecystitis 2) biliary colic 3) ch. Cholecystitis 4) mucocoel GB 5) empyema GB 6) Ca GB 7) obst. Jaundice due to choledocholithiasis 8) obst. Jaundice due to Ca head of pancreas 9) periampullary ca.Causes of palpable GB a) Tender – acute cholecystitis, empyema, Ca GB b) nontender – mucocoel, Ca head of pancreas, cholangio caCourvoisier’s Law – “ in obstruction of common bile duct due to stone, distention of GB seldom occurs, organ usually is already shrivelled.”Fallacy or exception to law >
10. Investigations Image –USG of HB system & pancreas or whole abdomen ( suspected malignancy) – GB – shrunken/contracted, thickened (Ch. Cholecystitis),or distended, edematous thick walled ( ac. Cholecystitis), any polyp, mass - stone ( single or multiple echogenic structures within the lumen of GB casting posterior acoustic shadow)CBD – diameter ( > 8mm suggestive of dilatation), stoneLiver – intrahepatic biliary tree( dilatation), any mass( solid/ cystic)Pancreas – mass, pan. Duct diameter, stoneIn malignancy – LN, ascites, peritoneal/pelvic seedling.►in ch. Cholecystitis & uncomlicated ac. Cholecystitis – no further image investigations.2. ERCP – indication : a) suspicion of stone in CBD or dilatation on USG b) h/o jaundice c) ↑Alk. Phosphatase.
11. ►Diagnostic role : delineation of biliary tree & pan. Duct, stone, growth, cytology ( exfoliative, brush ), biopsy.Therapeutic role : sphincterotomy, stone extraction, biliary stenting.Complications: cholangitis, pancreatitis, perforation of duodenum.Prerequisite : overnight fasting, normal prothrombine time, HBsAg (-)ve, antibiotic prophylaxis.This is an invasive procedure require introduction of side viewing gastroduodenoscope, cannulation of bile & pancreatic duct & inj. Of dye.3. MRCP : provides very good picture of entire biliary tree by way of virtual reconstruction of the whole biliarytree from the slices of MRI of hepatobiliary tree. Non invasive, no radiation exposure, no dye. Detect biliary tract dilatation, any obstruction by stone or growth.Disadvantage : only diagnostic ,no intervention.Meniscus sign : stone in lower end of CBDDouble duct sign: both bile duct & pancreatic duct (ERCP, MRCP) show dilatation & constriction in the region of head of pancreas.
12. 4. PTC ( percutaneous transhepatic cholangiography) – under image control a needle ( chiba / okuda) inserted through rt 8th intercostal space I midaxillary line, advance through liver to intrahepatic biliary tree. External biliary drainage, biopsy, stone removal by choledochoscope. Indicated if ERCP failed / better visualization of upper tract.5. CECT : for added evaluation in malignant conditions. To assess grrowth in pancreas, CBD, any vascular invasion (PV, SMV ), level of obstruction, LN enlargement, liver met., ascites.Crescent or target sign – stone in CBD.6. Liver function test - S. bilirubin, ALT, ALP, PT, total protein,albumin,globulin,HBsAg.7. Routine investigation for general assessment of the patient – CBC, FBS & 2hrs ABF, s. creatinine, urine R/E, CXR, ECG.s. Electrolytes – in obst.jaundice. Bld grouping & cross matching – in malignancy.
13. Ba meal X-ray( routinely not done ) – - ampullary Ca – rose thorn appearance of medial border of duodenum, inverted 3 appearance - Ca head of pancreas – widening of C-loop, gastric distention.Treatment.Acute cholecystitis Initial conservative Rx followed by interval ( after 6 wks) cholecystectomy (open / lap ).Early cholecystectomy ( 48hrs / 3 – 5 days )Emergency cholecystectomy ( empyema, biliary peritonitis )Emergency cholecystostomy – ( tube drainage of GB after removal of stone & sludge from GB by surgical technique.) followed by cholecystectomy after 2 months.Ch. Cholecystitis – cholecystectomy (Lap / open)Laparoscopic ports No.,site, size ►
14. ► laparoscope introduce through umbilical port(10mm), working ports – epigastric (10mm surgeon’s rt hand), rt upper (5mm, surgeon’s lt hand), rt lower port(5mm) – fundus of GB retracted by assistant.Co2 gas – for creation of pneumoperitoneum.GB extraction – usually through umbilical port.Advantage :↓ wound size having cosmatic benefit, → ↓wound pain↓in wound infection, dehiscence, hernia, nerve entrapmentImproved mobility↓ heat lossImproved visionShort hospital stay – early return to work.Limitation Hand eye incoordinationLoss of tactile feedback
15. ►Difficulty with haemostasisExtraction of large specimenPost operative shoulder tip pain.Incision for open cholecystectomyRt subcostal ( Kocher’s incision )Rt upper paramedianUpper midline incisionRt upper abdominal transverse incision.Boundaries of calot’s triangleAbove by inferior surface of liver, medially by common hepatic duct, below by cystic duct > crossed by cystic artery ( related to LN of lund ). Complications related to cholecystectomy Bleeding, injury to ducts, injury to duodenum , colon.
16. Problems with obstructive jaundice (perioperative complications)Hepatobiliary dysfunction - ↓secretory, metabolic, synthetic function, ↓glycogen reserveCoagulation defect – chance of excessive intraoperative bleedingRenal failure – bilirubin, endotoxin, hypovolaemiaCardiovascular impairment – shock in perioperative periodDefective immune system - ↑ septic & infective complicationsDelayed wound healing → dehiscence → incisional hernia.Malnutrition Preoperative preparation Rehydration with correction of electrolyte imbalanceCorrection of nutritional deficiency – high carohydrate diet, correction of hypoalbuminaemiaCorrection of coagulation defectAntibiotic prophylaxis / control of sepsisCardiopulmonary stabilizationPreoperative biliary drainage ±
17. Rx of choledocholithiasisPreop preparation for obst, jaundice.ERCP removal of stone followed by lap. CholecystectomyOpen cholecystectomy with choledocholithotomy with T tube drainage with IOC.Laparoscopic cholecystectomy with choledocholithotomy ± T tube drainage.Trans duodenal spphicterotomy with removal of stone.( stone impacted in lower end)Choledochoduodenostomy – elderly pt with strictured lower end of CBD with multiple stones, provided CBD> 1cmCholedochojejunostomy – Roux n Y or Loop.T tube management Short split limb within CBD & long limb outside abdomen &connected with sterile closed system drainage bag.Allow to drain for 7 daysClamping from 8th POD > 1hr → 4hr → 24hr. Observe ►pain, fever with rigor, leakage of bile by side of tube, pale stool.
18. ► 11th POD – T tube cholangiogram → if normal( no negative shadow, no dilatation, dye reaches duodenum) > remove by gentle slow sustained traction with breath holding.Rx of Ca head of pancreas / periampullary CaPreoperative preparation for obst. JaundiceCorrection of anaemia by BTOperation – Whipple’s procedureStructures removed Whole of duodenumHead, neck of pancreas with uncinate process Lower end of CBD with GBDistal part of stomachLN around duodenum, pancreas, CBD. Continuity maintained by tripple bypass ►
19. ►PancreaticojejunostomyHepaticojejunostomyGastrojejunostomy.Periampullary Ca -Tumour arising at or near the ampulla -Head of pancreas within 2 cm of ampullaAmpulla of vaterDistal bile ductDuodenum adjacent to ampulla.Mirizzi syndrome -