2General Ian Aird said “Good pathology makes mighty surgeons proud.” Incidence – common (17% at time of death)Age – any age, mostly 40sAetiology – bile constituents, infective, bile stasisSex ratio – female>maleGeography – Western dietPredisposing factors – “fat, fair, fertile, flatulant, forties”Macroscopy – cholesterol, mixed (90%), pigmentMicroscopy – histology of gallbladder wallSpreadPrognosis
5Biliary colicDefinition: colicky abdominal pain due to the presence of gallstones in gall bladderInvestigationsNormal blood resultsUSS: gallstones within thin-walled gall bladder, no CBD dilatationManagementSymptomaticCholecystectomy
6CholecystitisDefinition: constant abdominal pain and tenderness due to an infected gall bladderInvestigationsRaised WBC, Normal LFTsUSS: gallstones within thick-walled gall bladder, no CBD dilatationManagementSymptomaticCholecystectomy
7Jaundice Definition: obstructive jaundice due to CBD stone InvestigationsRaised LFTs: Alk Phos > ALT,USS: gallstones, CBD dilatation ± CBD stoneManagementERCPCholecystectomy
9Acute Pancreatitis Definition Presentation Investigations acute inflammation of the pancreas, primarily due to intracellular activation of trypsinogen to trypsin.PresentationEpigastric pain, radiating to back, nausea ± vomiting, dehydration, renal failureInvestigationsAmylase >3x normal rangeScoring of severity
10Causes of Acute Pancreatitis Obstruction:Gallstones (30-70%)Ampullary or pancreatic tumours (3%)Congenital abnormalities (5%)Sphincter of Oddi hypertension (1-2%)AscariasisDrugs/Toxins:Alcohol (30-70%)Azathioprine, 6-mercaptopurine, some antibiotics (metronidazole, tetracycline), H2 blockers, othersIatrogenic/Trauma:ERCPCardiopulmonary bypassBlunt abdominal traumaMetabolic:Hypertriglyceridaemia (2%)Hypercalcaemia, hyperparathyroidism (rare)Infection:AIDS, secondary infectionMumps, Coxsackie virus, hepatitis A, B and CIdiopathic (10%)
11Modified Glasgow Score Indication of severity of pancreatitisFactors:Age > 55 PaO2 < 8.0 kPaWBC > 15 Calcium < 2 mmol/lGlucose > 10 Albumin < 32Urea > 16 LDH > 600A score of 3 or more indicates severe pancreatitis and requires anaesthetic input regarding HDU careCompete score on admission and 48 hours later
12ManagementSupportive – analgesia, iv rehydration, catheterise, fluid balance, NBM (± NG tube). Consider Antibiotics.Observe for complications:Systemic: cardiovascular, pulmonary, renal, haematological, metabolic, neurological, gastrointestinalLocal: fluid collections, pseudocyst, necrosis, ascites, infection, pseudoaneurysmEstablish and remove cause:ERCP, CholecystectomyStrongly advise patient to stop drinking alcohol
13Rarities Gallstone ileus: Large gallstone erodes through gall bladder wall into neighbouring duodenum, passes along small bowel until it lodges and causes small bowel obstructionAXR: distended loops of small bowel, typically to terminal ileum, with air in biliary tree
15Rarities Mucocoele: Perforation Carcinoma Gallstone lodges in neck of gall bladder, preventing drainage of mucous.May become infected, causing empyemaRequire drainage and later cholecystectomyPerforationCarcinoma
16Mirizzi’s syndrome:In 1948, P. L. Mirizzi described an unusual presentation of gallstones which, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct (CHD), causing symptoms of obstructive jaundice (Mirizzi, 1948).Pathophysiology: Impaction of a large gallstone (or multiple small gallstones) in the Hartmann pouch or cystic duct results in the Mirizzi syndrome in 2 ways: (1) Chronic and/or acute inflammatory changes lead to contraction of the gallbladder, which then fuses with and causes secondary stenosis of the CHD, or (2) large impacted stones lead to cholecystocholedochal fistula formation secondary to direct pressure necrosis of the adjacent duct walls. Increasingly, these phenomena are seen not as distinct and separate steps but as part of a continuum (Pemberton, 1997; Hazzan, 1999).
18This is a case of a 42 year old male with a previous history of abdominal pain for 6 months. He was admitted to the hospital with nausea but vomiting or fever. An ultrasound study showed gallstones with some thickening of the gallbladder wall. The diagnosis of cholecystitis was made and the patient was scheduled to undergo a laparoscopic cholecystectomy. This picture shows the omentum partially covering the gallbladder in its normal position.
19Due to significant distention of the gallbladder, a needle is used to drain some bile so grasper clamps can be applied for dissection and manipulation.
20The Hartmann'a pouch is rectracted laterally and upward, exposing the triangle of Calot where the cystic artery can be identified branching off the right hepatic artery.
21A short cystic duct is dissected free using a "right angle" clamp.
22Clips are applied to the cystic duct away from the common bile duct.