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Gallstones Mrs. Kirsty Cattle MRCS SHO. General Ian Aird said “Good pathology makes mighty surgeons proud.” Ian Aird said “Good pathology makes mighty.

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Presentation on theme: "Gallstones Mrs. Kirsty Cattle MRCS SHO. General Ian Aird said “Good pathology makes mighty surgeons proud.” Ian Aird said “Good pathology makes mighty."— Presentation transcript:

1 Gallstones Mrs. Kirsty Cattle MRCS SHO

2 General Ian Aird said “Good pathology makes mighty surgeons proud.” Ian Aird said “Good pathology makes mighty surgeons proud.” Incidence – common (17% at time of death) Incidence – common (17% at time of death) Age – any age, mostly 40s Age – any age, mostly 40s Aetiology – bile constituents, infective, bile stasis Aetiology – bile constituents, infective, bile stasis Sex ratio – female>male Sex ratio – female>male Geography – Western diet Geography – Western diet Predisposing factors – “fat, fair, fertile, flatulant, forties” Predisposing factors – “fat, fair, fertile, flatulant, forties” Macroscopy – cholesterol, mixed (90%), pigment Macroscopy – cholesterol, mixed (90%), pigment Microscopy – histology of gallbladder wall Microscopy – histology of gallbladder wall Spread Spread Prognosis Prognosis

3 Anatomy

4 Presentation Asymptomatic (85-90%) Asymptomatic (85-90%) Biliary colic Biliary colic Cholecystitis Cholecystitis Obstructive jaundice Obstructive jaundice Ascending cholangitis Ascending cholangitis Pancreatitis Pancreatitis Rarities: Rarities: Gallstone ileus, Mucocoele, Perforation, Mirizzi’s syndrome, Carcinoma Gallstone ileus, Mucocoele, Perforation, Mirizzi’s syndrome, Carcinoma

5 Biliary colic Definition: colicky abdominal pain due to the presence of gallstones in gall bladder Definition: colicky abdominal pain due to the presence of gallstones in gall bladder Investigations Investigations Normal blood results Normal blood results USS: gallstones within thin-walled gall bladder, no CBD dilatation USS: gallstones within thin-walled gall bladder, no CBD dilatation Management Management Symptomatic Symptomatic Cholecystectomy Cholecystectomy

6 Cholecystitis Definition: constant abdominal pain and tenderness due to an infected gall bladder Definition: constant abdominal pain and tenderness due to an infected gall bladder Investigations Investigations Raised WBC, Normal LFTs Raised WBC, Normal LFTs USS: gallstones within thick-walled gall bladder, no CBD dilatation USS: gallstones within thick-walled gall bladder, no CBD dilatation Management Management Symptomatic Symptomatic Cholecystectomy Cholecystectomy

7 Jaundice Definition: obstructive jaundice due to CBD stone Definition: obstructive jaundice due to CBD stone Investigations Investigations Raised LFTs: Alk Phos > ALT, Raised LFTs: Alk Phos > ALT, USS: gallstones, CBD dilatation ± CBD stone USS: gallstones, CBD dilatation ± CBD stone Management Management ERCP ERCP Cholecystectomy Cholecystectomy

8 Ascending cholangitis Surgical emergency Surgical emergency Definition: jaundice, rigors, RUQ tenderness Definition: jaundice, rigors, RUQ tenderness Investigations Investigations Raised WBC, raised LFTs Raised WBC, raised LFTs USS: gallstones, CBD dilatation ± CBD stone USS: gallstones, CBD dilatation ± CBD stone Management Management Urgent resuscitation, iv Antibiotics (e.g. Ciprofloxacin) Urgent resuscitation, iv Antibiotics (e.g. Ciprofloxacin) Urgent ERCP Urgent ERCP Cholecystectomy Cholecystectomy

9 Acute Pancreatitis Definition Definition acute inflammation of the pancreas, primarily due to intracellular activation of trypsinogen to trypsin. acute inflammation of the pancreas, primarily due to intracellular activation of trypsinogen to trypsin. Presentation Presentation Epigastric pain, radiating to back, nausea ± vomiting, dehydration, renal failure Epigastric pain, radiating to back, nausea ± vomiting, dehydration, renal failure Investigations Investigations Amylase >3x normal range Amylase >3x normal range Scoring of severity Scoring of severity

10 Causes of Acute Pancreatitis Obstruction: Obstruction: Gallstones (30-70%) Gallstones (30-70%) Ampullary or pancreatic tumours (3%) Ampullary or pancreatic tumours (3%) Congenital abnormalities (5%) Congenital abnormalities (5%) Sphincter of Oddi hypertension (1-2%) Sphincter of Oddi hypertension (1-2%) Ascariasis Ascariasis Drugs/Toxins: Drugs/Toxins: Alcohol (30-70%) Alcohol (30-70%) Azathioprine, 6- mercaptopurine, some antibiotics (metronidazole, tetracycline), H 2 blockers, others Azathioprine, 6- mercaptopurine, some antibiotics (metronidazole, tetracycline), H 2 blockers, others Iatrogenic/Trauma: ERCP Cardiopulmonary bypass Blunt abdominal trauma Metabolic: Hypertriglyceridaemia (2%) Hypercalcaemia, hyperparathyroidism (rare) Infection: AIDS, secondary infection Mumps, Coxsackie virus, hepatitis A, B and C Idiopathic (10%)

11 Modified Glasgow Score Indication of severity of pancreatitis Indication of severity of pancreatitis Factors: Factors: Age > 55PaO2 55PaO2 < 8.0 kPa WBC > 15Calcium 15Calcium < 2 mmol/l Glucose > 10Albumin 10Albumin < 32 Urea > 16LDH > 600 Urea > 16LDH > 600 A score of 3 or more indicates severe pancreatitis and requires anaesthetic input regarding HDU care A score of 3 or more indicates severe pancreatitis and requires anaesthetic input regarding HDU care Compete score on admission and 48 hours later Compete score on admission and 48 hours later

12 Management Supportive – analgesia, iv rehydration, catheterise, fluid balance, NBM (± NG tube). Consider Antibiotics. Supportive – analgesia, iv rehydration, catheterise, fluid balance, NBM (± NG tube). Consider Antibiotics. Observe for complications: Observe for complications: Systemic: cardiovascular, pulmonary, renal, haematological, metabolic, neurological, gastrointestinal Systemic: cardiovascular, pulmonary, renal, haematological, metabolic, neurological, gastrointestinal Local: fluid collections, pseudocyst, necrosis, ascites, infection, pseudoaneurysm Local: fluid collections, pseudocyst, necrosis, ascites, infection, pseudoaneurysm Establish and remove cause: Establish and remove cause: ERCP, Cholecystectomy ERCP, Cholecystectomy Strongly advise patient to stop drinking alcohol Strongly advise patient to stop drinking alcohol

13 Rarities Gallstone ileus: Gallstone ileus: Large gallstone erodes through gall bladder wall into neighbouring duodenum, passes along small bowel until it lodges and causes small bowel obstruction Large gallstone erodes through gall bladder wall into neighbouring duodenum, passes along small bowel until it lodges and causes small bowel obstruction AXR: distended loops of small bowel, typically to terminal ileum, with air in biliary tree AXR: distended loops of small bowel, typically to terminal ileum, with air in biliary tree

14

15 Rarities Mucocoele: Mucocoele: Gallstone lodges in neck of gall bladder, preventing drainage of mucous. Gallstone lodges in neck of gall bladder, preventing drainage of mucous. May become infected, causing empyema May become infected, causing empyema Require drainage and later cholecystectomy Require drainage and later cholecystectomy Perforation Perforation Carcinoma Carcinoma

16 Mirizzi’s syndrome: Mirizzi’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). 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). 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).

17 Laparoscopic cholecystectomy

18 This 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.

19 Due to significant distention of the gallbladder, a needle is used to drain some bile so grasper clamps can be applied for dissection and manipulation.

20 The 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.

21 A short cystic duct is dissected free using a "right angle" clamp.

22 Clips are applied to the cystic duct away from the common bile duct.

23 The cystic duct is transected using scissors.

24 Same technique is used with the cystic artery which is dissected free using a "right angle" clamp and will be divided between clips.

25 Hook electrocautery is used to dissect the gallbladder off the liver bed.

26 The gallbladder is now free and will be placed into a Pleatman sac for retreival.

27 This picture shows the body of the gallbladder, that becomes distended during removal. Caution must be used to avoid rupture while pulling.

28 Thank you Questions?


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