WILLIAM L. OLALIA, M.D.
, FPCS, FPSG
Association Professor, Department of Surgery
UST Faculty of Medicine & Surgery
Anatomy & Physiology
Gallstone formation
– Types of stones
Diagnostic Studies
Gallstone Disease
– Natural history
– Complications
Acute/chronic cholecystitis
Choledocholithiasis
Cholangitis
Biliary pancreatitis
Operative interventions
Anatomy
Gallbladder
Bile ducts
Arteries
N.B. Anatomical variations
common
Anatomy
Anatomy
Gall Bladder
– pear-shaped sac in the fossa of
the liver
– 7-10 cms long
– 30-50 ml average capacity
– divides the liver into right and
left lobes
Anatomy
Blood supply of the gall bladder
cystic artery – a branch of the
right hepatic artery in 90% of
cases
Anatomy
The bile ducts
Extrahepatic ducts
right and left hepatic ducts
common hepatic duct
cystic duct
common bile duct
* The arterial supply to the bile ducts is
from the Gastroduodenal and Right
Hepatic Arteries
Anatomy
Common hepatic duct
- 1 to 4 cms length
- approx. 4 mm diameter
N.B.: the common hepatic duct is
joined at an acute angle by the
cystic duct to form the common
bile duct
Anatomy
Cystic duct
– variable length
– contains spiral valves of
Heister
Anatomy
Common bile duct is about 7- 11
cm in length and 5 to 10 mm in
diameter
Ampulla of Vater- opening of the
common bile duct into the
duodenum
Sphincter of Oddi- surrounds the
common bile at the ampulla of
vater
Anatomy
Anatomy
Gallbladde stomach
r
CBD
DUODENUM pancreas
jejunum
Physiology
Bile formation and Composition
500- 1000 mL of bile/day
mainly composed of water,
electrolytes, bile salts, proteins,
lipids, and bile pigments
Enterohepatic circulation (95% of bile
acid pool)
Digestion and absorption of fats in the
intestines
Physiology
Gallbladder function
– Concentrate & store hepatic
bile
– Deliver bile into the duodenum
in response to a meal
Gallstone Disease
One of the most common
problems of the GIT (11-36%)
Predisposing factors:
– age, gender, ethnic background
– obesity, pregnancy, diet
– terminal ileal resection, gastric
surgery, hemolytic disorders
* Females are three times more
likely to develop gallstones
* 4F’s (fat, female, fetus, family
history)
Gallstone formation
Dependent on the concentrations
of :
– Bile salts
– Cholesterol
– Lecithin
Gallstones form as a result of
solid settling out of solution
Gallstone formation
Two major types
– Cholesterol stones (80% of
cases)
– Pigment stones (15-20%)
Black pigment stones (hemolytic
disorders)
Brown pigment stones (bacterial
infection, parasites)
Gallstone Formation
Cholesterol stones
– usually multiple, variable size,
hard and faceted or irregular,
mulberry- shaped and soft.
– supersaturation of bile with
cholesterol
common primary event in the formation
of cholesterol stones
caused by cholesterol hypersecretion
Cholesterol Stones
Gallstone Formation
Pigmented stones
- small, brittle, black and
sometimes spiculated
- formed by supersaturation of
calcium bilirubinate,
carbonate and phosphate
- secondary to hemolytic
disorders
Pigmented Stones
Gallstone Disease
Natural History
Most patients with gallstones will
remain asymptomatic
About 3% become symptomatic
per year
3 to 5% of symptomatic patients
develop complications
Few patients develop
complications without previous
biliary symptoms
Diagnostic Studies
Ultrasound of
LGBPS
Sensitivity and
specificity of over
90%
Posterior acoustic
Posterior
shadowing Acoustic
shadow
Diagnostic Studies
Oral cholecystography
– stones noted on film as filling
defects
– seldom utilized nowadays
Diagnostic Studies
Biliary Radionuclide Scanning
(HIDA Scan)
– acute cholecystitis
– biliary leak after biliary surgery
– non-visualized gall bladder with
filling of the common duct and
duodenum
– Specificity and Sensitivity is 95%
Diagnostic Studies
Endoscopic
Retrograde
Cholangiography
- both diagnostic
and therapeutic
- invasive
- direct visualization
of the ampullary
region & distal CBD
- success rate 90%
Diagnostic Studies
Endoscopic Retrograde
Cholangiography
Success rate 90%
Complications:
- occur in 5% of cases
- pancreatitis
- cholangitis
Diagnostic Studies
Computed
Tomography ( CT
Scan)
- defines the course
and status of the
extra-hepatic biliary
tree and adjacent cholecystitis
structures
- test of choice in
evaluating patients
with suspected
malignancy of
biliary tree and
pancreas
Diagnostic Studies
Percutaneous
Transhepatic
Cholangiography
– Intrahepatic bile
duct is accessed
percutaneously with
a needle under
fluoroscopy
– It defines the biliary
tree proximal to the
affected segment
Diagnostic Studies
Magnetic
Resonance CBD
Pancreat
ic
Cholangiopancrea- duct
tography
– Offers a single
non invasive test
for the diagnosis
of biliary tract
and pancreatic
disease
– Sensitivity is 95%
Gallstone Disease
Complications
Acute /chronic cholecystitis
Choledocholithiasis
Cholangitis
Gallstone pancreatitis
Biliary-enteric fistulae (gallstone
ileus)
Gallbladder carcinoma
Symptomatic
Gallstones
Acute Cholecystitis
– secondary to gallstones in 90-
95%
– initiated by obstruction of the
cystic duct by a stone
– Distention →
inflammation/edema →
secondary bacterial infection
– Thickened gall bladder wall,
pericholecystic fluid on
Symptomatic
Gallstones
Acute Cholecystitis
– may progress to acute
gangrenous cholecystitis,
empyema, or emphysematous
cholecystitis
– Positive Murphy’s sign
– Mild to moderate leukocytosis
(12-15,000 wbc)
Symptomatic
Gallstones
Acute Cholecystitis
Diagnosis:
- Clinical profile
- Ultrasonography
- Biliary radio nuclide scanning
(HIDA)
Symptomatic
Gallstones
Acute Cholecystitis
Treatment:
- Fluid resuscitation
- Antibiotics VS gram (-) aerobes and
anaerobes
- Analgesics
- Cholecystectomy is the definitive
treatment
- Early cholecystectomy preferred over
interval/delayed cholecystectomy
Symptomatic
gallstones
- gallbladder
wall
becomes
grossly
thickened
and reddish
with
subserosal
hemorrhages
Symptomatic
Gallstones
Chronic Cholecystitis
– recurrent episodes of pain
– pain due to stone obstructing the cystic
duct
– pain in the epigastrium or RUQ area
radiating to the back
– pain associated with fatty/ heavy meal
– pathologic changes do not correlate well
with symptoms
– hydrops of the gallbladder
Symptomatic
Gallstones
Chronic Cholecystitis
Diagnosis:
same as acute
cholecystitis
Symptomatic
Gallstones
Chronic Cholecystitis
Treatment:
- elective open or laparoscopic
cholecystectomy (relief in about
90%)
- dietary advice while waiting for
surgery
- diabetic patients should have
prompt cholcystectomy
Symptomatic
Gallstones
Choledocholithiasis
– Found in 6 to 12% with
gallbladder stones
– 20-25% of patients > 60 years
old with symptomatic gallstones
– Majority are secondary stones
– Primary CBD stones more
common among asians
Symptomatic
Gallstones
Choledocholithiasis
Clinical Profile:
– Maybe silent or asymptomatic
– Biliary colic just like in gallbladder
stones
– Symptoms maybe intermittent (ball
valve mechanisms)
↑ bilirubin, alkaline phosphatase &
transaminases
– Impacted stone → progressive
jaundice
– Small stone may pass thru the ampulla
Symptomatic
Gallstones
Choledocholithiasis
Diagnosis:
– Ultrasonography: stones in the
gallbladder, dilated CBD (> 8mm)
– Biliary colic, jaundice, gallbladder
stones on ultrasound
– Magnetic Resonance Cholangiography
(MRC) 95% & 89% sensitivity and
specificity
– ERCP – gold standard in diagnosing
CBD stones with therapeutic options
Symptomatic
Gallstones
Choledocholithiasis
Treatment:
Plan A
pre-op endoscopic cholangiography
sphincterotomy + stone removal
laparoscopic cholecystectomy
Symptomatic
Gallstones
Choledocholithiasis
Treatment:
Plan B
open cholecystectomy
intraoperative cholangiogram
open common bile duct exploration
t-tube placement
Symptomatic
Gallstones
Acute Cholangitis
– Ascending bacterial infection from bile
duct obstruction
– Stones, strictures, parasites,
instrumentation
– Fever, abdominal pain & jaundice
(Charcot’s triad)
– May lead to septicemia and
disorientation (Reynolds pentad)
– Leukocytosis, increased bilirubin and
alkaline phosphatase
Symptomatic
Gallstones
Acute Cholangitis
Treatment:
– Fluid resuscitation, IV antibiotics
– ERCP/PTC diagnostic/therapeutic
– About 15% will require emergency
biliary decompression
ERCP
PTC
T-tube choledochostomy/cholecystostomy
– Definitive treatment done later
Symptomatic
Gallstones
Biliary Pancreatitis
– Another complication of CBD
stone
– Obstruction of the pancreatic
duct by an impacted stone
– Temporary obstruction by a
stone passing thru the ampulla
– Ultrasound of biliary tree
essential in patients with
pancreatitis
Symptomatic
Gallstones
Biliary Pancreatitis
Treatment:
– Severe pancreatitis: ERCP with
sphincterotomy & stone extraction
– Cholecystectomy (open or laparoscopic later
/same admission)
– Mild pancreatitis: elective cholecystectomy
N.B. possibility of spontaneous passage
of stone thru ampulla
Operative
Interventions
Cholecystostomy
– decompresses and drains the
distended, inflamed, hydropic, or
purulent gall bladder
– applicable to patients not fit to
undergo abdominal operation
– done either by open or
percutaneous ultrasound or CT
guided
Operative
Interventions
Cholecystectomy
ISSUE: OPEN vs. LAPAROSCOPIC
CHOLECYSTECTOMY
Parameters:
Operative
Interventions
Cholecystectomy
OPEN
vs.
LAPAROSCOPICCHOLECYSTECTOMY
Parameters:
– Patient’s choice
– Technical expertise
– Patient’s condition
– Cost
– Length of hospital stay
– Complications
Open cholecystectomy
Safe and
effective
treatment of
acute and
chronic
cholecystitis
Carl Langenbuch
performed the
first
cholecystectomy
in 1882
Laparoscopic
cholecystectomy
Introduced by Philippe Mouret in
1987
Pneumoperitoneum is introduced
to the abdominal cavity using
carbon dioxide
Surgery is video assisted using
trocars and special instruments
Laparoscopic
cholecystectomy
The mortality rate of for
laparoscopic cholecystectomy is
0.1%
Conversion to open
cholecystectomy is 5%
