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Gallstone Disease.

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Presentation on theme: "Gallstone Disease."— Presentation transcript:

1 Gallstone Disease

2 Objectives Basic biliary anatomy and physiology
Pathophysiology of gallstone disease Clinical manifestations of gallstone disease Complications of gallstone disease Investigation and management of gallstone disease

3 Gallbladder Surface Anatomy
Lies in the right upper quadrant, under the costal margin at the level of the 9th costal cartilage The level of the 9th costal cartilage can be palpated as a distinct notch







10 Gallstones Common (20% population) Cholesterol stones in West
Female proponderance (3/1) Risk factors Obesity Oestrogen Hypercholesterolaemia Increasing age 5 F’s

11 Clinical Manifestations
Asymptomatic Cholecystitis Biliary colic Complications Jaundice Pancreatitis Cholangitis Gallstone ileus Carcinoma of gallbladder

12 Acute Cholecystitis Acute inflammation of the gallbladder
Usually associated with calculi (stones) Calculus causes obstruction at Hartmann's pouch or cystic duct Less commonly with biliary sludge A-calculus (no-stone) cholecystitis rare Bacterial infection in 50% only Recurrent attacks result in fibrosed thickened gallbladder (chronic cholecystitis)

13 Acute Cholecystitis Clinical Features
Pain Sudden onset Post-prandial RUQ—around to back Constant Associated nausea and vomiting May last several hours to days Recurrent attacks common

14 Acute Cholecystitis Signs Pyrexia (37.5-38.5)
Associated jaundice signifies CBD blockage CBD stone or Mirrizi’s Syndrome Abdominal tenderness localized to RUQ Murphys’ sign positive

15 Murphys’ Sign Inspiratory arrest with manual pressure below the gallbladder

16 Murphy’s Sign

17 Biliary Colic Pain associated with passage of stone
Usually not colicky but constant (a misnomer) As cholecystitis but not associated with fever/ leucocytosis and positive Murphys’ sign Usually resolves after minutes- few hours

18 Complications Empyema/ mucocele Obstructive jaundice
Ascending cholangitis Pancreatitis

19 Charcots’ Triad- Ascending cholangitis
Pain Fever Jaundice

20 Courvoisiers’ Law In the presence of jaundice a palpable gallbladder is most likely due to malignant obstruction of the bile duct Based on presumption that patients with gallstones have chronically inflammed, fibrosed gallbladders incapable of distension Does not always hold true e.g. Empyema + CBD stone

21 Acute Cholecystitis - Investigation
Bloods FBC (WCC) LFT’s (Bilirubin, GGT, Alk Phos) Amylase Imaging CXR Ultrasound CT Special tests

22 Acute Cholcystitis – Special tests
Endoscopic Retrograde Cholecystogram (ERCP) Diagnostic and therapeutic Magnetic Resonance Imaging (MRC) Other forms of Cholangiography Intra-operative Percutaneous Transhepatic (PTC) Oral cholangiogram

23 Acute Cholecystitis – Management
Restrict Oral intake (NPO) Intravenous fluids Ng tube aspiration (for vomiting) Analgesia Morphine Intravenous antibiotics Gram negative cover (co-amoxiclav—gentamicin—piperacillin) Cholecystectomy after resolution

24 Biliary Colic - Management
Acute attack usually resolves spontaneously Analgesia Investigations as for cholecystitis Prolonged attacks treated as cholecystitis Elective cholecystectomy

25 Ascending Cholangitis
Charcots’ Triad Investigations FBC, LFT's, Amylase, US Management Resuscitation (IV fluids) Antibiotics (G-negative cover) Intensive monitoring (urometry)

26 Ascending Cholangitis
Definitive management ERCP and stone removal +/- stent Cholecystectomy after resolution

27 Gallstone Pancreatitis
Commonest cause of Pancreatitis More severe than alcohol Pancreatitis Due to CBD stones irritating pancreas Obstruction at ampulla of Vater Irritation in pancreatic portion of CBD

28 Gallstone Pancreatitis
Supportive Fluid resuscitation Antibiotics Analgesia Definitive ERCP & stone retrieval Elective cholecystectomy

29 Laparoscopic Cholecystectomy
Commonest elective surgical procedure Standard treatment for gallstone disease May be performed as daycase Converted to open in small number






35 Complications Trauma Common bile duct (CBD) Intestine Liver
Haemorrhage Vessel injury Liver injury Cystic artery clips Infection Biliary peritonitis

36 Late Complications Post cholecystectomy syndrome Rare Pain
Occasionally due to stones in the biliary tree Port site hernia Umbilical 10mm port sites

37 ERCP Endoscopic Retrograde Cholangio Pancreato Graphy
Usually performed by gastroenterologists Diagnostic and therapeutic Indicated in jaundiced patients Ampulla of Vater cannulated Demonstrates ductal anatomy Allows biopsy of malignant lesions Therapeutic in relieving obstruction Stone retrieval or Stenting


39 Summary Gallstones are common Usually asymptomatic
Clinical manifestations Cholecystitis Biliary colic Complications Ascending cholangitis (Charcots' Triad) Treatment Laparoscopic cholecystectomy ERCP

40 Back to Department of Surgery

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