Cholelithiasis

Gallstones are found in approximately 10% of the

adult population.

In some countries (Sweden, Chile) and among

certain ethnic groups (Pima Indians), the
incidence of gallstones may approach 50%.

Cholesterol gallstones account for 85% of all

stones, pigment stones 15%.
Biliary Tracts
Anatomy
Triangle of Calot
 Risk factors
Cholesterol gallstones
• a. There is a steady increase in prevalence with age.

• b. Gender. Cholelithiasis is more common in females

at all ages, the female-male ratio being 2:1

• c. Obesity is an independent factor affecting the

prevalence of gallstone.

• d. Western diet Cholesterol gallstones are more

prevalent in Western societies, are increasing in
Japan with dietary changes, and are rare among
vegetarians.
 Risk factors
Pigment stones

• a. Black stones. Risk factors include

hemolytic anemia, cirrhosis, and ileal resection.

• b. Brown stones are associated with biliary

stasis and infection.
Harvest Time
 Causes
• Fair, fat, female, fertile of course.
• High fat diet
• Obesity
• Rapid weight loss, TPN, Ileal disease,
NPO.
• Increases with age, alcoholism.
• Diabetics have more complications.
• Hemolytics
 Complications of cholelithiasis
• Acute cholecystitis
• Hydrops of gallbladder
• Cholangitis
• Fistula
• Mechanical jaundice
• Pancreatitis
 Acute cholecystitis
Acute cholecystitis is an inflammatory
complication of cholelithiasis that
involves the gallbladder with a variable
degree of severity
 Classification
• Cataral

• Phlegmonic

• Destructive
(gangrenous, perforated, empyema of
gallbladder)
 CLINICAL FEATURES

• pain in trie right upper quadrant or epigastrium,

• anorexia,
• nausea,
• vomiting
• fever,
• right upper quadrant tenderness,
• in some cases, peritoneal signs in the right
upper quadrant or more diffusely
 Signs (simptoms)
• Murphy's sign (stoppage of breathing)

• Ker’s sign (Ker point)

• d’Mussi’s sign (m. sterno cleido mastoideus)

 Laboratory abnormalities
• leukocytosis (typically 12,000-15,000
cells/ut)

• Liver function tests,

including a serum bilirubin, alkaline
phosphatase, and serum
amylase, also may be abnormal.
 Instrumental investigations
• Ultrasonography

• Radionuclide cholescinticiraphv

• I.V. cholecystocholangiography (cold period)

• CT scan
(CT scan may demonstrate evidence of acute
cholecystitis, including gallbladder wall thickening,
pericholecystic fluid and edema)
Plain Films
Ultrasound
 Management for patients with acute
cholecystitis
• Hospital admission
• Diet
• Intravenous hydration
• Systemic antibiotics (the antibiotic regimen
should be appropriate for typical bowel flora -
gram-negative and anaerobes)
• Monitoring of the patient's: fever, physical
examination, and laboratory values
 Differentials
• AAA
• Appendicitis
• Cholangitis, cholelithiasis
• Diverticulitis
• Gastroenteritis, hepatitis
• IBD, MI, SBO
• Pancreatitis, renal colic, pneumonia
 Cholecystectomy
• If the diagnosis of acute cholecystitis is firmly
established and the patient is an acceptable
anesthetic risk, cholecystectomy should be
performed within 48 hours of admission.
Delayed operation is preferred only for those
with coexistent medical problems that make
surgical risk prohibitive, such as myocardial
infarction, congestive heart failure, or
pneumonia.
Laparoscopic Cholecystectomy
 Prognosis
• Uncomplicated cholecystitis as a low
mortality.
• Emphysematous GB mortality is 15%
• Perforation of GB occurs in 3-15% with up
to 60% mortality.
• Gangrenous GB 25% mortality.
Cholecystectomy
 Cholecystostomy
• Alternative procedure and is preferred if
cholecystectomy is technically hazardous or if
the patient is a poor anesthetic risk.

• Patients with a compromised cardiovascular

system or chronic lung disease
Cholecystostomy
Cholecystostomy