GALL STONE

• It is a pear-shaped structure, 7.5–12 cm long, with a normal capacity of

about 35–50 ml
• The anatomical divisions are a fundus, a body and a neck that
terminates in a narrow infundibulum.
• The muscle fibres in the wall of the gall bladder are arranged in a criss-
cross manner, being particularly well developed in its neck.
• The mucous membrane contains indentations of the mucosa that sink
into the muscle coat; these are the crypts of Luschka.
• The cystic duct is about 3 cm in length
but variable.
• Its lumen is usually 1–3 mm in
diameter.
• The mucosa of the cystic duct is
arranged in spiral folds known as the
valves of Heister.
• Its wall is surrounded by a sphincteric
structure called the sphincter of
Lütkens.
• The common hepatic duct is usually less than 2.5 cm long and is formed by the union of the right and
left hepatic ducts.
• The common bile duct is about 7.5 cm long and is formed by the junction of the cystic and common
hepatic ducts.
• It is divided into four parts
• the supraduodenal portion, about
2.5 cm long, running in the free
edge of the lesser omentum
• the retroduodenalportion;
• the infraduodenal portion, which
lies in a groove, but at times in a
tunnel, on the posterior surface of
the pancreas;
• the intraduodenal portion, which
passes obliquely through the wall
of the second part of the
duodenum, where it is sur-
rounded by the sphincter of Oddi,
and terminates by opening on the
summit of the ampulla of Vater.
Function of Gall Bladder
• Reservoir for bile. After feeding, the resistance to flow through the sphincter
of Oddi is reduced, the gall bladder contracts, and the bile enters the
duodenum.
• These motor responses of the biliary tract are in part effected by the hormone
CCK.
• Concentration of bile by active absorption of water, sodium chloride and
bicarbonate,concentrated 5–10 times, with a corresponding increase in the
proportion of bile salts, bile pigments, cholesterol and calcium.
• Secretion of mucus – approximately 20 ml is produced per day.
Cholelithiasis • Gallstones are the most common biliary
pathology.
• It is estimated that gallstones are present in
10–15% of the adult population in the USA.
• cholecystectomy one of the most common
operations performed by general surgeons.
Aetiology
• In USA and Europe 80% are cholesterol or mixed stones, whereas in Asia,
80% are pigment stones.
• Cholesterol or mixed stones contain 51–99% pure cholesterol plus an
admixture of calcium salts, bile acids, bile pigments and phospholipids.
• Pigment stone is the name used for stones containing less than 30%
cholesterol.
• There are two types – black and brown.
• Black stones are largely composed of an insoluble bilirubin pigment
polymer mixed with calcium phosphate and calcium bicarbonate.
Overall, 20–30% of stones are black.
• Brown pigment stones contain calcium bilirubinate, calcium palmitate
and calcium stearate, as well as cholesterol.
• Brown stones are rare in the gall bladder.
• They form in the bile duct and are related to bile stasis and infected
bile.
Clinical feature

• Patients typically complain of right upper quadrant or epigastric pain,

which may radiate to the back.
• This may be described as colicky, but more often is dull and constant.
• Other symptoms include dyspepsia, flatulence, food intolerance,
particularly to fats, and some alteration in bowel frequency.
• Biliary colic is typi-cally present in 10–25% of patients.
• This is described as a severe right upper quadrant pain that ebbs and
flows associated with nausea and vomiting.
• Pain may radiate to the chest.
• The pain is usually severe and may last for minutes or even several hours.
• Frequently, the pain starts during the night, waking the patient.
• Minor episodes of the same discomfort may occur intermittently during the day.
• Dyspeptic symptoms may coexist and be worse after such an attack.
• As the pain resolves, the patient is able to eat and drink again, often only to suffer
further episodes.
• It is of interest that the patient may have several episodes of this nature over a
period of a few weeks and then no more trouble for some months
• In the acute phase, the patient may have right upper quadrant
tenderness that is exacerbated during inspiration by the examiner’s right
subcostal palpation (Murphy’s sign).
• A positive Murphy’s sign suggests acute inflammation and may be
associated with a leucocytosis and moderately elevated liver function
tests.
• A mass may be palpable as the omentum walls off an inflamed gall
bladder
• If resolution does not occur, an empyema of the gall bladder may result.
• The wall may become necrotic and perforate, with the development of
localised peritonitis.
• The abscess may then perforate into the peritoneal cavity with a septic
peritonitis – however, this is uncommon, because the gall bladder is
usually localised by omentum around the perforation.
• A palpable, non-tender gall bladder (Courvoisier’s sign) portends a more
sinister diagnosis.
• This usually results from a distal common duct obstruction secondary to
a peripancreatic malignancy.
Diagnosis • A diagnosis of gallstone disease is
based on the history and physical
examination with confirmatory
radiological studies such as
transabdominal ultrasonography
and radionuclide scans
Treatment

• Most authors would suggest that it is safe to observe patients with

asymptomatic gallstones, with cholecystectomy only being per- formed for
those patients who develop symptoms or complications of their gallstones.
• Prophylactic cholecystectomy should be considered in
• diabetic
• congenital haemolytic anaemia
• undergoing bariatric surgery for morbid obesity
• For patients with biliary colic or
cholecystitis, cholecystectomy is the
treatment of choice in the absence of
medical contra- indications.
Choledocolithiasis

• Duct stones may occur many years after a cholecystectomy or be related to

the development of new pathology, such as infection of the biliary tree or
infestation by Ascaris lumbricoides or Clonorchis sinensis.
• Any obstruction to the flow of bile can give rise to stasis with the formation of
stones within the duct.
• The consequence of duct stones is either obstruction to bile flow or infection.
• Stones in the bile ducts are more often associated with infected bile (80%)
than are stones in the gall bladder.
Clinical features

• The patient may be asymptomatic but usually has bouts of pain, jaundice and
fever.
• The patient is often ill and feels unwell.
• The term ‘cholangitis’ is given to the triad of pain, jaundice and fevers,
sometimes known as ‘Charcot’s triad’.
• Tenderness may be elicited in the epigastrium and the right hypochondrium.
• In the jaundiced patient, it is useful to remember Courvoisier’s law – in
obstruction of the common bile duct due to a stone, distension of the gall
bladder seldom occurs; the organ is usually already shrivelled.
• In obstruction from other causes, distension of the gall bladder is common by
comparison.
Diagnosis

• Ultrasound scanning, liver function tests, liver biopsy (if the ducts are not
dilated) and MRI or ERCP will delineate the nature of the obstruction.
Management

• Endoscopic papillotomy is the preferred first technique with a sphincterotomy,

removal of the stones using a Dormia basket or the placement of a stent if
stone removal is not possible.
• If this technique fails, percutaneous transhepatic cholangiography can be
performed to provide drainage and subsequent percutaneous
choledochoscopy.
• Surgery, in the form of choledochotomy, is now rarely used