CHOLELITHIASIS

(GALL BLADDER STONES)

Dr Shaji . K
MS(ayu)
GALL BLADDER

 Small pouch
 Stores bile

 Attached to liver

 Stores bile

 After meal empty and flat

 Before meal filled with bile

 Signals squeezing of bladder release of bile

helps in digestion
CHOLELITHIASIS

 Common
 Up to 20 yrs. not common

 After 20years common

 5th and 6th decade – reaches peak

 Women:men-4:1

 4 F’s- fat

fertile more vulnerable group

forty
female
COMPOSITION
 Cholestrol
 Bile

 Calcium

 Iron

 Carbonates

 Phosphorous

 Proteins

 Cellular debris

 Mucus

 carbohydrates
 ETIOLOGY
 METABOLIC FACTOR
- bile acid :cholesterol ratio reduces from 25:1 to 13:1
leading to precipitation of cholesterol .
- in hemolytic disorders Hb breakdown increases leading to increased
bile pigment which gets precipitated

 REFLUX FACTOR
-reflux of pancreatic enzyme leads to disturbed colloidal balance
which further leads to convertion of lecithin to toxic lysolecithin

 STASIS FACTOR
-interupption in natural flow of bile from gall bladder to intestine
leads to decreased output of bile salts and phospholipids leading to
decreased solubility of cholesterol

 INFECTIVE FACTOR
- E.coli , bacterium typhosum , streptococcus , slow growing
actinomyces reach GB through blood or lymph causing stasis
and finally stone formation
 TYPES

PURE STONES MIXED AND COMBINED STONES

10% 90%

• Cholesterol
stones Contain mixture
of pure stones in
• Pigment stones varying amount

• Calcium
carbonate stones
CHOLESTEROL PIGMENT CALCIUM
STONES STONES CARBONATE STONES

Pale yellow Black or dark brown Greyish white

Most common often rarest

CS shows radiating lines CS shows amorphous Sand grain to polyhedral

that cross circular strata structure shape of 2cm diameter

Smooth , oval or round Small , soft , putty like Smooth with articulated
surface

Usually found in aseptic Associated with Increased alkalinity of

static bile conditions increased haemolysis bile leads to
precipitation of CaCO3
PIGMENT
STONES

CHOLESTEROL
STONES
 MIXED AND COMBINED STONES

Contains cholesterol , bile pigment and calcium carbonate in

varying amounts

Combined is usually solitary

Mixed is multiple , faceted surfaces , size upto 2cm in diameter

Colour depends on predominant content

Frequently associated with cholecystitis

In half of the cases bacteria can be cultured

 EFFECT AND COMPLICATION
IN GALL COMMON BILE PANCREAS INTESTINE
BLADDER DUCT
Asymptomatic later Obstructive Acute Gall stone ileus
after a long time jaundice pancreatitis
may lead to
carcinoma
Hydrops of gall Liver failure Acute relaxing
bladder pancreatitis
Flatulent dyspepsia Cholangitis Chronic
pancreatitis
Mucocele,empyema, Acute /recurrent
gangrene pancreatitis
Chronic
cholecystitis
Carcinoma

Gall stone colic

HYDROPS OF GALL BLADDER
 DIFFERENTIAL DIAGNOSIS
 Appendicitis
 Bile duct strictures
 Bile duct tumours
 Cholangiocarcinoma
 Cholecystitis
 Gallbladder carcinoma
 Pancreatic cancer
 Peptic ulcer
GALL BLADDER CARCINOMA
 EXAMINATION
 Enlarged gall bladder on palpation
 Slight jaundice

 Pain in gall bladder region-colicy pain more during

night , in upper right quadrant of abdomen in
horizontal position.
 Referred pain- radiating pain to back at inferior
angle of right scapula or pain in right shoulders
 Relief from pain in tossed position

 Associated with nausea and vomiting

 Positive murphy’s sign

 INVESTIGATIONS
 Straight X-ray
 Oral cholecystogram

 ECG in above 40 yr. patient

 Blood report shows leucocytosis with high

polymorph nuclear count
 Increased serum bilirubin

 Increased serum amylase

 Cholecystography
 TREATMENT
 Cholecystectomy

 Cholecystectomy + choledocolithotomy – if stone

has migrated to common bile duct

 Conservative management-functional rest for gall

bladder and upper GI tract and relaxing spasm of
sphincter of oddi
CHOLECYSTECTOMY-
LAPROSCOPY
THANKYOU