GALLSTONE,

CHOLEDOCHOLITHIASIS,
ASCENDING
CHOLANGISTIS
SYIKIN
GALLSTONES
TYPES
CHOLESTEROL PIGMENT (BROWN/BLACK) MIXED
►Supersaturated with cholesterol BLACK STONE-most common MAJORITY
►Bile acid concentration is low ►Excessive hemolyis
►Obesity ►Composition- insoluble pigment polymer + calcium
►High calorie diet phosphate + calcium bicarbonate
►Abnormal emptying of the gall BROWN STONE
bladder
►Bile stasis and infected bile
RISK FACTOR (4F) ►Also associated with presence of foreign bodies within
4F : Female, forthy to fifty, fat, fertile the bile duct (stents, Ascaris)
►Composition- calcium salt of unconjugated bilirubin +
cholesterol + calcium bilirubinate

SEQUELAE ►Asymptomatic
►Acute and chronic cholecystitis
►Mucocele
►Empyema
►Biliary obstruction
►Acute cholangitis and pancreatitis
►Perforation
►Carcinoma
►Cholecystoenteric fistula- most commonly seen in duodenum and diagnosed by presence of air in the bile duct.
This may cause gall stone ileus. Other site of fistula is colon
PATHOGENESIS 1) LITHOGENIC BILE
►Bile salt and phospholipid in bile keep cholesterol in solution by forming micelle
►Normal ratio between bile acids and cholesterol 20: 1, when the ratio falls below 13: 1 →higher
chances for gallstone formation
►Increased cholesterol → Obesity or Clofibrate therapy
►Decreased bile salt → Primary biliary cirrhosis, Oral contraceptive pills/ estrogen, Genetic
( decreased 7a hydroxylase)
►Decreased enterohepatic circulation/ reduce bile salt → Ileal disease, Cholestyramine

2) NUCLEATION
►Cholesterol crystals formation
►Factors increase the formation of crystal
- Mucin & non mucin glycoprotein
- Infectious
- Reduced anti-nucleating factors (apolipoprotein A1 and A2)

3) STASIS
►Prolong Total Parental Nutrition/fasting
►Pregnancy, Oral contraceptive pills or drugs- Octreotides
►Trauma (burn) and surgery
GALL BLADDER CHOLEDOCHOLIATHIASIS
DISEASES Obstruction of common bile duct by gallstone leading to obstructing jaundice
ASCENDING CHOLANGITIS
Ascending bacterial infection of biliary tract in association with partial or complete obstruction of the bile ducts
ACUTE CHOLESCYSTITIS
Inflammation of the gall bladder that occur most commonly due to obstruction of cystic duct by gallstone
CLINICAL ►Asymptomatic
PRESENTATION ►Right upper quadrant or epigastric pain- colicky, dull and constant
►Guarding at right upper quadrant
►Pain may radiate to the right shoulder and tip of Scapula (Boas' sign), chest or to the back
►Fever, anorexia, nausea and vomiting
►Dypepsia, flatulence, food intolerance particularly to fats
►Jaundice may only present with choledocholiathiasis or Mirrizi's syndrome: Dark urine, pale stool and
itchiness.
►Positive Murphy's sign- inspiratory arrest with deep palpation at the right subcostal area
►Moynihan's method- similar to Murphy's sign but patient in sitting position
 S - EPIGASTRIC/ RHC

O - SUDDEN

C – WAXING-WANING, RARELY PAIN-FREE INTERVAL

R – INFERIOR ANGLE RIGHT SCAPULA, TIP OF RIGHT SHOULDER

History A – BACK PAIN, N/V, BLOATING, ABD DISTENSION

T – WITHIN HOURS OF EATING.

E - EATING

S – VARY
INVESTIGATIONS Confirmation of Diagnosis
• Transabdominal Ultrasound – dilated common bile duct (>8mm) and acoustic shadow of stone
and to differentiate other causes of obstructive jaundice.
• Endoscopic Retrograde Cholangiopancreatography (ERCP) – diagnostic and therapeutic
• Magnetic Resonce Cholangiopancreatography (MRCP) – diagnostic but not therapeutic
• MRI / CT– used only in uncertain case
• Percutaneous Transhepatic Cholangiogram (PTC) – diagnose pathologies higher up above the
cystic duct and for preoperative bile drainage
Importance Baseline Investigation
• Coagulation Profile – PT and APTT time increase due to malabsorption of vitamin K
• Liver Function Test – total bilirubin as patient having jaundice, direct bilirubin aspect to be
increase, alkaline phosphatase (ALP) will increase >10 times
• Serum amylase- to exclude pancreatitis
• Renal Function Test – bilirubin is nephrotoxic / exclude hepatorenal syndrome
• Urinalysis – able to detect urobilinogen

COURVOISIER'S LAW ►In patient with jaundice, a non-tender, palpable gall bladder is unlikely to be stone because stone
will cause fibrosis → gall bladder to be shrunken.
►Results from a distal common duct obstruction secondary to peripancreatic malignancy
►Exception to this law are
1) Double impaction of stone (one in common bile duct and one in cystic duct)
2) Stone with primary oriental cholaniohepatis
3) Pancreatic calculus obstructing the ampulla of vater
4) Mucocele of gall bladder
OPEN/LAPAROSCOPIC TYPES:
CHOLECYSTECTOMY Immediate
In cases of spreading gangrene wall which is evident when the patient is deterioting after 2 days of
conservative management

Emergency
In case where perforation is suspected. Conservative treatment is contraindicated

Delayed
This is done after 8 weeks of conservative management

METHODS:
Duct first
Cystic duct and artery dissected first and divided after gall bladder is removed
Less chance of injuring the cystic duct or the right hepatic artery

Fundus first
The gall bladder is resected first, followed by the ligation of cystic duct or right hepatic artery
Preferred when dissection in the region of the junction of cystic duct, common hepatic duct and
comon bile duct is difficult due to lots of adhesion and inflammaory exudates

POST-CHOLECYSTECTOMY Some of patients fail to relieve the symptoms after cholecystectomy

SYNDROME ERCP and or MRCP is done to exclude the presence of stones in common bile duct, stone in cystic
duct and operative damage of bile duct
CHOLEDOCHOLITHIASIS
INTRODUCTION ►Obstruction of common bile duct by gallstone leading to obstructing jaundice
►2 types of stones:
Primary (due to bile stasis): single, smooth, oval shaped, usually brown pigment stone
Secondary (gall stones): multiple, differ in shapes, originated gall bladder, black pigmented stone
CLINICAL • Nausea & vomiting
PRESENTATION • Intermittent painful obstructive jaundice: Dark urine, pale stool and itchiness.
INVESTIGATIONS Confirmation of Diagnosis
• Transabdominal Ultrasound – dilated common bile duct (>8mm) and acoustic shadow of stone and to
differentiate other causes of obstructive jaundice.
• Endoscopic Retrograde Cholangiopancreatography (ERCP) – diagnostic and therapeutic
• Magnetic Resonce Cholangiopancreatography (MRCP) – used only in uncertain case
• MRI – used only in uncertain case
• Percutaneous Transhepatic Cholangiogram (PTC) – diagnose pathologies higher up above the cystic duct and
for preoperative bile drainage
Importance Baseline Investigation
Coagulation Profile – PT and APTT time increase due to malabsorption of vitamin K
Liver Function Test – total bilirubin as patient having jaundice, direct bilirubin aspect to be increase, alkaline
phosphatase will increase >10 times
Renal Function Test – bilirubin is nephrotoxic / exclude hepatorenal syndrome
Urinalysis – able to detect urobilinogen
COMPLICATION • Pancreatitis
OF ERCP • Cholangitis
• Duodenal Perforation
• Duct stricture, Bleeding
• Allergic to dye
MISSED/RETAINED/RESID ERCP stone removal, if T tube is present in patient, then can remove stone via T-Tube (Burhenne
UAL STONES Technique), flushing it with heparinized saline or dissolve it with methyl-tertbutyl ether
(<2 YEARS)
RECURRENT STONES Most commonly due to non-absorbable suture which may cause brown stone where ERCP removal stone
(>2 YEARS) is done
MANAGEMENT CHOLEDOCHOLITHIASIS
Definite Treatment is by ERCP

Pre-Procedure
 Correction of coagulation profile (10mg IM Vitamin K 5-7 days/FFP)
 Nil by mouth for at least 6 hours
 Broad spectrum antibiotics (2nd generation cephalosporins) is given
Procedure
 Maintenance IV is start
 Topical anaesthetic is applied for patient oropharyngeal area
 Patient is position to left lateral position
 A narcotic or sedative is administered
 The endoscope is inserted into the mouth to reach duodenum
 There may be a mass obstructing the papula and papulatectomy must be done for it
 An anticholinergic drug (Glucagon) is given to prevent duodenal spasm
 Contrast media is injected and a few film should be taken
 Therapeutic measure can be done – stone can be taken out by dormia basket and for
unsuccessful attempt, put a stent to relieve the jaundice before other attempts

Post-Procedure
 Monitor vital sign for 24 hours
 Nil by mouth until patient Gag reflex return
 Stone >25mm

Intrahepatic stone

Large number of stones

ROLE OF SURGERY IN
CHOLEDOCHOLITHIAS Impacted stone
IS??
Dual pathology

Torturous duct
Previous Billroth II (unsuitable anatomy for
ERCP)
 ASCENDING CHOLANGITIS
DEFINITION Ascending bacterial infection of biliary tract in association with partial or complete obstruction of the bile
ducts
EPIDEMIOLOGY • Equal in both gender and reported in all races
• Mostly occurs in adults with median age at onset 50-60 years
• Overall mortality rate of approximately 5%
ETIOLOGY • Gallstones are the most common cause of obstruction
• Biliary tract manipulation, stricture, tumours
CLINICAL FEATURES • CHARCOT TRIAD???
• REYNOLDS PENTAD???
RUQ PAIN, FEVER, JAUNDICE
INVESTIGATION • Full blood count - Leucocytosis
CHARCOT’S TRIAD + MENTAL OBTUNDATION, HEMODYNAMIC
• Liver function test – Elevation of serum bilirubin, ALP
INSTABILITY
• Blood culture – To guide antibiotics
• Transabdominal ultrasound – Find etiology of obstruction
MANAGEMENT • Broad spectrum intravenous antibiotics
• Fluid resuscitation and correction of electrolyte imbalance
• The obstructed bile duct must be drained as soon as the patient has been stabilized
• Patients with periampullary malignancies are best approached endoscopically by placement of an
endoscopic biliary stent
COMPLICATION • Pyogenic liver abscess
• Acute real failure