1. Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus
CHOLECYSTITIS
Bernard M. Jaffe, M.D.
Professor of Surgery, Emeritus

2. GALLBLADDER Major Function- Concentrate, Store Bile
Supplied by Cystic Artery
Off Right Hepatic Artery
Off Common Hepatic Artery
Off Celiac Trunk
Many Arterial Variations
Replaced Right Hepatic Takes Off From Superior Mesenteric

3. DUCTS Right and Left Hepatic Ducts Join ↓ Common Hepatic Duct
Cystic Duct Comes Off
Common Bile Duct
Ampulla, Duodenum

4. GALLSTONES Autopsy Prevalence 11-36% Female:Male Ratio is 3:1
First Degree Relatives Have Twice the Rate
Cholecystectomy One of Commonest Operations

5. PREDISPOSING FACTORS Obesity Pregnancy Dietary Factors
Crohn’s Disease, Ileal Resection
Hemolytic Diseases
Gastric Surgery

6. GALLSTONE CONSTITUENTS
Bilirubin
Bile Salts
Phospholipids
Cholesterol
Calcium

7. CHOLESTEROL STONES Most Common Type Rarely Pure, >70% Cholesterol
Precipitation from Supersaturated Bile
Usually Multiple, Variable Sizes
Hard and Facetted to Irregular and Soft
Color White/Yellow to Brown/Black
Only 10% are Radio-opaque

8. PIGMENT STONES <20% Cholesterol
Dark Because of Calcium Bilirubinate
Usually Tiny to Small
Invariably Multiple
Two Types- Black Stones
Brown Stones

9. BLACK STONES Form ONLY in Gall Bladder
Secondary to Hematologic Diseases
Spherocytosis
Sickle Cell Disease
Thalassemia
Common in Cirrhosis
More Common in Asia

10. BROWN STONES Form in Gall Bladder AND Bile Ducts
Small, Soft, Often Mushy
Secondary to Bacterial Infection Caused by Bile Stasis
Bacterial Cell Walls Prominent in Stones
More Common in Asia

11. NATURAL HISTORY Most Are Asymptomatic
Asymptomatic Stones Detected On Evaluation For Other Illnesses
Ultrasound CT
Plain Abdominal X-Ray
Laparotomy
2/3 Stay Asymptomatic >20 Years

12. COMPLICATIONS Biliary Colic- Initial Symptom Acute Cholecystitis
Choledocholithasis
Cholangitis
Biliary Pancreatitis
Cholecysto-Duodenal Fistula
Gall Bladder Carcinoma

13. CHOLECYSTECTOMY Indicated for Symptomatic Patients
Rare Indications in Asymptomatic Ones
Elderly Diabetics
Before Transplantation
Isolation From Medical Care
Gallbladder Polyp (Controversial)
Porcelain Gall Bladder Absolute Indication

14. CHRONIC CHOLECYSTITIS
Recurrent Attacks of Pain
Frequently After a Meal (Fatty?)
Radiates to Back and Shoulder
Nausea and Vomiting
Gall Bladder- Minor Inflammation to Small, Shrunken With Fibrosis, Adhesions
Mucosa Becomes Atrophied

15. DIAGNOSIS Stones on Ultrasound Gall Bladder May Have Sludge
Cholesterolosis- Strawberry Gall Bladder
Adenomyomatosis- Thick Wall
Normal Ducts
Cholecystectomy Cures >95%

16. ACUTE CHOLECYSTITIS Obstruction of Cystic Duct By Stone
Gall Bladder Distention, Inflammation, Edema
Mucus Secretion- Hydrops, Milk of Bile (Pearly White)
5-10% Progress to Ischemia, Necrosis
Perforation Occurs in Body (Widest Part)

17. MANIFESTATIONS Biliary Colic → Lasting, Constant Pain
Anorexia, Nausea, Vomiting, Fever
Focal RUQ Tenderness, Guarding
Murphys’ Sign is Suggestive
Palpable Gall Bladder is Diagnostic
Normal LFTs, ?Minimal Bilirubin Elevation
White Blood Cell Count Often Elevated

18. DIAGNOSIS Ultrasound Stones Thickened Gall Bladder Wall
Distended Gall Bladder
Peri-Cholecystic Fluid
Sonographic Murphy’s Sign
If HIDA Scan Fills Gall Bladder- Precludes Diagnosis

19. TREATMENT Antibiotics- Gram Negative and Anaerobic Coverage
Early laparoscopic Cholecystectomy
Late Presentation >4-5 Days- Antibiotics Alone with Delayed Cholecystectomy
Very Ill, Elderly patients- Percutaneous Cholecystostomy

20. LAP CHOLE Mortality 0.1%, Morbidity 0.3% Can Add Choledochotomy
Conversion to Open in Acute Disease Reasons for Conversion
Inability to Visualize Adhesions
Duct Injury Bleeding
Abnormal Anatomy

21. CHOLEDOCHOLITHIASIS Primary Stones Form in Ducts
Associated with Biliary Dysfunction, Infection
Brown Stones
Secondary Stones Form in Gall Bladder
Migrate to Common Bile Duct
6-12% Cholelithiasis Patients
20-25% in Patients >60

22. MANIFESTATIONS Symptomatic or Can Be Silent
Colicky Pain, Nausea, Vomiting, ICTERUS
Stones Single or Multiple, Small or Large
Can Cause Common Duct Obstruction
Cholangitis
Biliary Pancreatitis

23. DIAGNOSIS Elevated Bilirubin, Alkaline Phosphatase, Transaminases
Ultrasound- Dilated Ducts
Magnetic Resonance Cholangiogram- Sensitivity 95%, Specificity 89%
ERCP- Successful >90%, Morbidity <5%
Therapeutic and Diagnostic

24. TREATMENT ERCP With Sphincterotomy Common Bile Duct Exploration
Open or Laparoscopic
T-Tube Left in Place
Missed Stones Can Be Retrieved Choledochoscope

25. CHOLANGITIS Ascending Infection Associated With Bile Duct Obstruction
Commonest Organisms
E. coli
Klebsiella
Strep faecalis
Bacteroides
5-10% Mortality

26. MANIFESTATIONS Charcot’s Triad Abdominal Pain Jaundice Fever
Reynold’s Pentad
Same Plus Septic Shock
Mental Status Changes

27. TREATMENT Immediate Antibiotics, Resuscitation
Duct Drainage (Cholangitis is Closed Space Infection)
ERCP With Sphincterotomy
Percutaneous Transhepatic Cholangiogram With Catheter Placement
Open Common Duct Exploration