galls stones

7/26/2019 Galls Stones

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GALLSTONES AND ITSGALLSTONES AND ITS

COMPLICATIONSCOMPLICATIONS


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PATHOGENESISPATHOGENESIS


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RISK FACTORSRISK FACTORS

AAge: Increasing age*ge: Increasing age* BBody habitus: Obesity, rapid weight lossody habitus: Obesity, rapid weight loss CChildbearing: Pregnancyhildbearing: Pregnancy DDrugs: Fibric acid derivatives (or fibrates), contraceptive steroids, postmenopausalrugs: Fibric acid derivatives (or fibrates), contraceptive steroids, postmenopausal

estrogens, progesterone, octreotide (andostatin), ceftria!one ("ocephin)estrogens, progesterone, octreotide (andostatin), ceftria!one ("ocephin)

EEthnicity: Pima Indians, candinaviansthnicity: Pima Indians, candinavians FFamily: #aternal family history of gallstonesamily: #aternal family history of gallstones GGender: Femalesender: Females HHyperalimentation: $otal parenteral nutrition,% fastingyperalimentation: $otal parenteral nutrition,% fasting IIleal and other metabolic diseases: Ileal disease (&rohn's disease), resection orleal and other metabolic diseases: Ileal disease (&rohn's disease), resection or

bypass,* high triglycerides, diabetes mellitus, chronic hemolysis,* alcoholicbypass,* high triglycerides, diabetes mellitus, chronic hemolysis,* alcoholiccirrhosis,* biliary infection,* primary biliary cirrhosis, duodenal diverticula,*cirrhosis,* biliary infection,* primary biliary cirrhosis, duodenal diverticula,*truncal vagotomy, hyperparathyroidism, low level of highdensity lipoproteintruncal vagotomy, hyperparathyroidism, low level of highdensity lipoproteincholesterolcholesterol

*"is factors for pigment gallstone formation*"is factors for pigment gallstone formation%"is factor for cholesterol and pigment gallstone formation%"is factor for cholesterol and pigment gallstone formation


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CaseCase

+yo F w "-. pain !+hr, after a fatty meal,+yo F w "-. pain !+hr, after a fatty meal,radiating to the " scapula, also w nausea Pt isradiating to the " scapula, also w nausea Pt is

painfree nowpainfree now

/o prior episodes/o prior episodes #inimal "-. tenderness, no #urphy0s#inimal "-. tenderness, no #urphy0s

12& 3, 4F$ normal12& 3, 4F$ normal

"-. -5 reveals cholelithiasis without 62"-. -5 reveals cholelithiasis without 62

wall thicening or pericholecystic fluidwall thicening or pericholecystic fluid


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CASECASE

denotesdenotes

gallstonesgallstones

denotes thedenotes the

acoustic shadowacoustic shadow

due to absence ofdue to absence of

reflected soundreflected soundwaves behind thewaves behind the

gallstonegallstone


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Symptomatic cholelithiasis

Symptomatic cholelithiasis

aa 7biliary colic8aa 7biliary colic8 $he pain occurs due to a stone obstructing the$he pain occurs due to a stone obstructing the

cystic duct, causing wall tension9 pain resolvescystic duct, causing wall tension9 pain resolves

when stone passeswhen stone passes Pain usually lasts ; hrs, rarely < =+hrsPain usually lasts ; hrs, rarely < =+hrs

-ltrasound reveals evidence at the crime scene-ltrasound reveals evidence at the crime scene

of the liely etiology: gallstonesof the liely etiology: gallstones >!am, 12&, and 4F$ normal in this case>!am, 12&, and 4F$ normal in this case

$reatment: 4aparoscopic cholecystectomy$reatment: 4aparoscopic cholecystectomy


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CASECASE

yearsold male with past medical history of yearsold male with past medical history ofdiabetes mellitus, c5o "-. pain < =+hrsdiabetes mellitus, c5o "-. pain < =+hrs

radiating to the " scapula, started after fattyradiating to the " scapula, started after fatty

meal, a5w nausea, vomiting, fevermeal, a5w nausea, vomiting, fever >!am: Palpable, tender gallbladder, guarding,>!am: Palpable, tender gallbladder, guarding,

?#urphy0s @ inspiratory arrest?#urphy0s @ inspiratory arrest

12& 3, #ild12& 3, #ild A4F$A4F$


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CaseCase

&urved arrow&urved arrow $wo small stones at$wo small stones at

62 nec62 nec

traight arrowtraight arrow $hicened 62 wall$hicened 62 wall

BB pericholecystic fluidpericholecystic fluid

@ dar lining outside@ dar lining outside

the wallthe wall


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-5: gallstones, wall thicening (


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EMPHSEMATO!S CHOLECSTITISEMPHSEMATO!S CHOLECSTITIS


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CASECASE

E = year old woman with heart faliure, hypertensionE = year old woman with heart faliure, hypertensionand diabetes came to the office with a chief complaintand diabetes came to the office with a chief complaintof chills, abdominal pain, nausea and vomitingof chills, abdominal pain, nausea and vomiting

followed by inability to pass flatus 3 hours prior tofollowed by inability to pass flatus 3 hours prior toconsultconsult

On physical e!amination the patient was febrile andOn physical e!amination the patient was febrile andappeared dehydrated Ebdominal e!am: distensionappeared dehydrated Ebdominal e!am: distension

and increased bowel sounds /o Gaundiceand increased bowel sounds /o Gaundice 4abs: Hyperglycemia, mild renal failure,4abs: Hyperglycemia, mild renal failure,

hypernatremia and leuocytosishypernatremia and leuocytosis


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CASECASE


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CHOLECSTOENTERIC FIST!LACHOLECSTOENTERIC FIST!LA


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CASECASE

E +yearold woman visited our

outpatient clinic in #arch

=JJ+ with a si!month history of colic

pain, nausea and vomiting he had a past

history of hyperthyroidism

Physical e!amination revealed a tenderright upper abdomen

and Gaundice $he laboratory blood tests

showed increased

levels of bilirubin K mg5dl

alaline phosphatase +; -5l (L+J -5l),

gglutamyltransferase -5l (L+J -5l), alanine transaminase

=+J -5l (L+J -5l), aspartate

transaminase 33 -5l (L; -5l)

and lactate dehydrogenase 333 -5l (L+3J

-5l), while the

serum amylase was normal-ltrasonography showed

slightly dilated intrahepatic ducts, an

e!tended gallbladder

with multiple stones


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MIRI""I#S SNDROMEMIRI""I#S SNDROME


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One study has shown that acute cholecystitis resolves withoutOne study has shown that acute cholecystitis resolves withoutcomplications in appro!imately 3M of patients but results incomplications in appro!imately 3M of patients but results in

gangrenous cholecystitis in M,gangrenous cholecystitis in M,gallbladder empyema in M,gallbladder empyema in M,

perforation in M, andperforation in M, andemphysematous cholecystitis in less than Memphysematous cholecystitis in less than M

1hen the level of leuocytosis e!ceeds ;,JJJ cells5mm,1hen the level of leuocytosis e!ceeds ;,JJJ cells5mm,particularly in the setting of worsening pain, high feverparticularly in the setting of worsening pain, high fever(temperature


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CASECASE

+yo F p5w "-. pain, Gaundice, acholic+yo F p5w "-. pain, Gaundice, acholic

stools, dar teacolored urine,stools, dar teacolored urine, $o %e&e's$o %e&e's

nown history of cholelithiasisnown history of cholelithiasis

>!am: unremarable>!am: unremarable

12& 3, $2ili 3, E$5E4$ KJ5;, Hep25&12& 3, $2ili 3, E$5E4$ KJ5;, Hep25&

negneg -ltrasound: 6allstones, &2C not dilated-ltrasound: 6allstones, &2C not dilated

Ciagnosis: DCiagnosis: D


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CASECASE MRCPMRCP

E!SE!S


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CHOLEDOCHOLITHIASISCHOLEDOCHOLITHIASIS Fi%tee$ pe'ce$t o% patie$ts (ith )all*la++e' sto$es also ha&e C,D sto$es-Fi%tee$ pe'ce$t o% patie$ts (ith )all*la++e' sto$es also ha&e C,D sto$es-

Co$&e'sely. o% patie$ts (ith +/ctal sto$es. 012 also ha&e )all*la++e' sto$esCo$&e'sely. o% patie$ts (ith +/ctal sto$es. 012 also ha&e )all*la++e' sto$es

Sto$es i$ the C,D /s/ally come to 'est at the lo(e' e$+ o% the amp/lla o% 3ate'-Sto$es i$ the C,D /s/ally come to 'est at the lo(e' e$+ o% the amp/lla o% 3ate'-O*st'/ctio$ o% the *ile +/ct 'aises *ile p'ess/'e p'o4imally a$+ ca/ses the +/cts toO*st'/ctio$ o% the *ile +/ct 'aises *ile p'ess/'e p'o4imally a$+ ca/ses the +/cts to+ilate- P'ess/'e i$ the C,D is $o'mally 56 to 51 cm H7O a$+ 'ises to 71 to 86 cm+ilate- P'ess/'e i$ the C,D is $o'mally 56 to 51 cm H7O a$+ 'ises to 71 to 86 cmH7O (ith complete o*st'/ctio$- 9he$ p'ess/'e e4cee+s 51 cm H7O. *ile %lo(H7O (ith complete o*st'/ctio$- 9he$ p'ess/'e e4cee+s 51 cm H7O. *ile %lo(+ec'eases. a$+ at :6 cm H7O. *ile %lo(+ec'eases. a$+ at :6 cm H7O. *ile %lo(

The *ile +/ct +ilates to the poi$t that it ca$ *e +etecte+ o$ eithe' /lt'aso$o)'aphyThe *ile +/ct +ilates to the poi$t that it ca$ *e +etecte+ o$ eithe' /lt'aso$o)'aphyo' a*+omi$al CT i$ app'o4imately ;12 o% cases- I$ the patie$t (ho has ha+o' a*+omi$al CT i$ app'o4imately ;12 o% cases- I$ the patie$t (ho has ha+'ec/''e$t *o/ts o% chola$)itis. the *ile +/ct may *ecome %i*'otic a$+ th/s /$a*le to'ec/''e$t *o/ts o% chola$)itis. the *ile +/ct may *ecome %i*'otic a$+ th/s /$a*le to+ilate-+ilate-Moreover, dilatation of the duct is sometimes absent in patients withMoreover, dilatation of the duct is sometimes absent in patients withcholedocholithiasis because the obstruction is low!rade and intermittentcholedocholithiasis because the obstruction is low!rade and intermittent


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CHOLEDOCHOLITHIASISCHOLEDOCHOLITHIASIS

Ac/te o*st'/ctio$ /s/ally ca/ses *ilia'y pai$ a$+


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CHOLEDOCHOLITHIASISCHOLEDOCHOLITHIASIS

>levated serum bilirubin and alaline>levated serum bilirubin and alaline

phosphatase levels are seen with &2Cphosphatase levels are seen with &2C

obstructionobstruction

erum bilirubin level


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TREATMENTTREATMENT


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CASECASE

8@yo F p( %e&e'. R!B pai$.


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CHOLANGITISCHOLANGITIS

Sto$e i$ the commo$ *ile +/ct ca/si$) *ile stasis ,acte'ialSto$e i$ the commo$ *ile +/ct ca/si$) *ile stasis ,acte'ials/pe'i$%ectio$ o% sta)$a$t *ile Ea'ly *acte'emias/pe'i$%ectio$ o% sta)$a$t *ile Ea'ly *acte'emia

Cha'cot#s t'ia+ pai$. eJ t(oa'e /s/ally positi&e. especially +/'i$) chills o' %e&e' spi>eJ t(oo')a$isms a'e )'o($ i$ c/lt/'es %'om o$e hal% o% patie$tso')a$isms a'e )'o($ i$ c/lt/'es %'om o$e hal% o% patie$ts


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CASECASE

+yo F w "-. pain !+hr, after a fatty meal,+yo F w "-. pain !+hr, after a fatty meal,radiating to the " scapula, also w nausea Pt isradiating to the " scapula, also w nausea Pt ispainfree now Has had multiple prior attacspainfree now Has had multiple prior attacs

of similar "-. painof similar "-. pain/o prior episodes/o prior episodes

#inimal "-. tenderness, no #urphy0s#inimal "-. tenderness, no #urphy0s

12& 3, 4F$ normal12& 3, 4F$ normal "-. -5 reveals cholelithiasis with 62 wall"-. -5 reveals cholelithiasis with 62 wall

thicening, no pericholecystic fluidthicening, no pericholecystic fluid


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CHRONIC CHOLECSTITISCHRONIC CHOLECSTITIS

&hronic inflammation of the gallbladder is the indication for nearly M of&hronic inflammation of the gallbladder is the indication for nearly M ofcholecystectomies in adultscholecystectomies in adults

Pathophysiology is poorly understoodPathophysiology is poorly understoodrepeated episodes of lowgrade gallbladder obstruction, resulting in recurrentrepeated episodes of lowgrade gallbladder obstruction, resulting in recurrentmucosal trauma mucosal trauma

$here is little correlation between the number of choleliths or their overall$here is little correlation between the number of choleliths or their overallvolume and the degree of gallbladder wall inflammationvolume and the degree of gallbladder wall inflammation In fact, =M to M of patients who haveIn fact, =M to M of patients who have ch'o$icch'o$iccholecystitischolecystitishave nohave no

demonstrable stonesdemonstrable stones /o role of 2acterial infection of the bile/o role of 2acterial infection of the bile Es each episode of acute inflammation resolves, neutrophilic infiltration isEs each episode of acute inflammation resolves, neutrophilic infiltration is

replaced with lymphocytes, plasma cells, macrophages, and eosinophils Focalreplaced with lymphocytes, plasma cells, macrophages, and eosinophils Focalulcerations and necrotic tissue are replaced by granulation tissue and collagenulcerations and necrotic tissue are replaced by granulation tissue and collagendeposits $he gallbladder wall may become thicened or remain thin $hedeposits $he gallbladder wall may become thicened or remain thin $hemucosa can remain intact, develop accentuated folds, or be flattenedmucosa can remain intact, develop accentuated folds, or be flattened


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CHRONIC CHOLECSTITISCHRONIC CHOLECSTITIS


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The symptoms o% ch'o$ic cholecystitisThe symptoms o% ch'o$ic cholecystitis

vary :vary :classic severe biliary colicclassic severe biliary colic vaguevagueor nonspecific complaintsor nonspecific complaints intermittentintermittentepisodes of nausea,episodes of nausea, reflu!reflu!

symptoms,symptoms, foodfoodintolerance, or bloatingintolerance, or bloating lowlowgrade fever,grade fever, mildmildupper abdominal discomfort, orupper abdominal discomfort, or chronicchronicfatiguefatigue

/ot infreuently patients who have/ot infreuently patients who have ch'o$icch'o$iccholecystitischolecystitishavehavebeen treated for gastritis, ulcer disease, or irritable bowelbeen treated for gastritis, ulcer disease, or irritable bowelsyndrome without appreciable improvement in theirsyndrome without appreciable improvement in theircomplaintscomplaints

HICE with && helpsHICE with && helps


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Dx: ?Dx: ?


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PORCELAIN GALL,LADDERPORCELAIN GALL,LADDER


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Ta>e Home Poi$tsTa>e Home Poi$ts Es always, E2& Q "esuscitate before C!Es always, E2& Q "esuscitate before C!

-nderstanding the definitions is ey-nderstanding the definitions is ey

Is this acute cholecystitisD (fever, 12&, tender on e!amIs this acute cholecystitisD (fever, 12&, tender on e!am

with positive #urphy0s)with positive #urphy0s)

Or simply cholelithiasis vs ongoing chronicOr simply cholelithiasis vs ongoing chroniccholecystitisD (no fever512&)cholecystitisD (no fever512&)

Is patient sic or to!icappearing, to suspect empyema,Is patient sic or to!icappearing, to suspect empyema,

gangrene or even perforationDgangrene or even perforationD

>licit h5o Gaundice, acholic stools, teacolored urine>licit h5o Gaundice, acholic stools, teacolored urine

"ule out cholangitis, because this will ill the patient"ule out cholangitis, because this will ill the patient

unless d! Q t! earlyunless d! Q t! early

galls stones

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