Overview of gallstone

disease and management

Presenter: Yeo Deng Xin
Supervisor: Mr Jackson
Outline
• Overview of biliary anatomy
• Bile content
• Stages of cholelithiasis
• Complication of cholelithiasis
• Management
Overview of biliary anatomy
 Anterior view of
liver
• - falciform ligament: attach
to diaphragm and anterior
abdominal wall
• - round ligament of liver
(ligamentum teres hepatis) :
lies within the free edge of
falciform ligament , include
the remains of umbilical
vein
• - ligamentum venosum : is
the fibrous remnant of the
foetal ductus venosus
• - other ligament : coronary
ligament and right and left
triangular ligament
 Liver lifted

Foramen of Winslow:
- cuts in lesser omentum
- contain: proper hepatic
artery, common bile duct and
portal vein
 Blood supply of liver
- hepatic artery
- portal vein
- hepatic vein : 3 main
branches (left, Intermediate,
right ), all drain into inferior
vena cava
 Gall Bladder
• 7-10cm long
• Lies in gallbladder fossa of liver
visceral surface
• Can hold up to 50mL of bile
• Peritoneum completely surrounds
the fundus of the gallbladder
• The hepatic surface of the
gallbladder attaches to the liver by
connective tissue of the fibrous
capsule of the liver
• Non-mobile
 Gall Bladder
The gallbladder has three parts, the:
• Fundus: the wide blunt end that
usually projects from the inferior
border of the liver at the tip of the right
9th costal cartilage in the MCL.
• Body: main portion that contacts the
visceral surface of the liver, transverse
colon, and superior part of the
duodenum.
• Neck: narrow, tapering end, opposite
the fundus and directed toward the
porta hepatis; it typically makes an S-
shaped bend and joins the cystic duct.
 Calot’s triangle

-Triangle of Calot has

boundaries include common
hepatic duct medially, cystic
duct laterally, and the inferior
edge of the liver superiorly. It is
main route of lymphatic
drainage of the gallbladder.
- according to Jean-Francois
Calot in 1891, Calot’s triangle is
the space bordered by the
cystic duct inferiorly, common
hepatic artery medially, and
the superior border of cystic
 Hartmann’s pouch

• Dilatation of gallbladder outlet

• common site for impaction of
gallstones is in an abnormal
sacculation (Hartmann pouch)
 Variation in the cystic
and hepatic ducts

• The cystic duct may be short or

even absent
• low union of the cystic and
common hepatic ducts
• high union of the cystic and
common hepatic ducts near the
porta hepatis
• cystic duct spirals anteriorly over
the common hepatic duct before
joining it on the left side
Blood Supply & Venous
drainage
• Cystic artery: supplying the
proximal part of the duct.
• Right hepatic artery:
supplying the middle part of
the duct.
• Posterior superior
pancreaticoduodenal artery
and gastroduodenal artery:
supplying the retroduodenal
part of the duct.

• Cystic vein (Portal venous

system) take blood from
gallbladder to the liver.
Bile content
• Bile, an aqueous solution produced and secreted by the liver, consists mainly
of bile salts, phospholipids (lecithin), cholesterol, conjugated bilirubin,
electrolytes, and water.

• Bile salts are conjugated bile acids.

 Cholelithiasis
3 clinical stages:
asymptomatic, symptomatic, complicated
Stages Sign and symptoms
1) Asymptomatic 80-90% patient ;expectant management
gallstone
2) Symptomatic gallstone - Epigastric or RHC pain
- Biliary colic(lasting 30 min to several hours, often resolves
spontaneously) (*if >6 hr of pain or constant pain: suspect
complication)
- Waxing-waning in nature, rarely have pain free interval
- Radiating to inferior angle of right scapula and tip of right
shoulder
- Waxing-waning in nature, rarely have pain free interval
- Within hours of meals
- Get better after vomiting
- Fever
- Tenderness over RHC/epigastrium
- Positive Murphy’s sign
- Non – palpable gallbladder
 Courviosier’s law
• States that, in patient with enlarge, palpable non tender gallbladder, is unlikely to be stone.
• Explanation: gallstones is formed over extended period of time. The presence of stone will
cause fibrosis, thus the gallbladder will be shrunken and fibrotic which does not distend
easily.
• Exception for this law:
- Double impaction of stone (one in CBD and one in cystic duct)
- Stone with primary oriental cholangiohepatitis (ductal stone form secondary to infestation
of liver fluke)
- Pancreatic calculus obstructing ampulla of vater
- Mucocele/empyema of gallbladder
- Mirizzi’s syndrome
Complication from
cholelithiasis
-in gallbladder
-in CBD
-in gut
Complications in gallbladder
Acute cholecystitis -stone impaction cause inflammation of gallbladder

Empyema of gallbladder -filled with pus due to bacterial infection of stagnant bile

Hydrops of gallbladder -cystic duct obstruction leads to tense gb filled with

mucus
-gb wall necrosis if pressure exceeds capillary BP

Porcelain’s gallbladder/ chronic -chronic inflammation associated with high risk of

cholecystitis gallbladder cancer

Mirizzi’s syndrome -stone impact at Hartmann’s pouch, causing compression

to CBD

Gangrene and perforation -localized perforation(abscess confined by omentum)

-Free perforation (generalized peritonitis
and sepsis): need emergency laparotomy
Complications in CBD
( choledocholithiasis )
Obstructive jaundice -tea-colored urine & pale stool
-pain prolonged than biliary colic

Ascending cholangitis -can cause multiorgan failure and sepsis if delay

treatment
-Charcot triad: fever+ RHC pain+jaundice
-Reynold’s pentad: Charcot triad + mental
obtundation + hemodynamically instability
-common causative organism: Klebsillae, E.coli,
Enterobacter, enterococcus

Gallstone pancreatitis -serum amylase raised

Complications in gut

Cholecystoenteric fistula Intestinal obstruction

formation (gallstone - inflammation of gallbladder can cause
ileus) adhesion to small bowel, which converted to
fistula overtime, impacted at ileocecal valve

Gallstone dyspepsia Fatty food intolerance, dyspepsia and

flatulence
Investigation
Blood investigation
-FBC: raised WCC
-LFT: ALP, AST, ALT
-Coag: coagulopathy
-RP: electrolyte imbalance
-amylase: TRO pancreatitis

Imaging of choice: Ultrasound HBS (>92% sensitivity)

-posterior acoustic shadowing
-dilatation of CBD
-pericholecystic fluid
-contracted gallbladder
-thickened gallbladder wall
Management
Principle of treatment in acute cholecystitis
1. Supportive care/resuscitation
2. Conservative care (infection control)
3. Cholecystectomy
 Supportive care
• Hydration(IV fluid resus if needed)
• Correction of electrolyte abnormalities
• Analgesics

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 Conservative care (infection control)
Antibiotics
• Continue therapy until the gallbladder is removed or
cholecystitis clinically resolved
• Antibiotic used: Empiric Antibiotics
- Should cover Enterobacteriaceae family, including gram -ve
rods and anaerobes
- Most common pathogen: E. coli, Enterococcus, Klebsiella,
Enterobacter

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 Conservative care (infection control)
3rd generation Cephalosporins:
Cefoperazone 1-2gm IV q12h
PLUS
Metronidazole 500mg IV q8h

Duration: 4-7 days

Complication like empyema/septic shock: Augmentin, Tazosin,

Imipenem

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 Definitive management (responsive to
conservative treatment)
Open/Laparoscopic Cholecystectomy
This is the preferred technique because of early recovery and quick
convalescence
• Elective Cholecystectomy ***
- Patient responsive to conservative treatment. This is done after 6 weeks of
conservative treatment
• Emergency Cholecystectomy
- in sick patient not responsive to antibiotic treatment/ resuscitation

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How can we know if patients did not respond to
conservative treatment?
Symptoms:
Persistent high fever (Above 38℃)
Severe right upper quadrant pain (Intractable pain)
Alternative treatment
• PTBD
-involve percutaneous catheter placement in gallbladder lumen under
imaging guidance
-indication: in patient who are not fit for surgery(old age or early
surgery is difficult due to extensive inflammation)
Treatment in choledocholithiasis
Emergency biliary decompression
• ERCP
- by endoscopic sphincterectomy + stenting

Definitive therapy(if ERCP failed/ failed to remove all stones)

• Laparoscopic cholecystectomy with CBD exploration KIV open
- cholangiogram(injection of dye) or choledochoscopy
- removal of stone: flushing/forcep/balloon catheter/Dormia basket
- T –tube (post-op oedema will cause obstruction& built up of bile->biliary
leakage )
 Complication of cholecystectomy
• Complication rate: 3-6%
• Bleeding from cystic artery or gallbladder bed (may
required re-operation)
• Leakage of bile from cystic duct or gallbladder bed
• Jaundice due to retained ductal stones
• Injury to Common Bile Duct; requires major constructive
surgery
- incidence of ductal injury is reported at 0. 1-0. 8% compared
to 0. 1 % for conventional cholecystectomy

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Thank you for
your attention