Gallstones

Presence of stones in the gallbladder is called as cholelithiasis

Prevalence is gradually increasing
More common in old age


Biliary System

 
Fig : Biliary System




Enterohepatic Circulation

Fig : Enterohepatic circulation



Bile salts circulate up to 10 times a day
95% of bile salts are reabsorbed in the distal small intestine
Only 5% is lost through the body


Composition Of Bile

  1. Cholesterol 
  2. Phospholipid (Majority is lecithin)
  3. Bile salts 
    • Primary
      • Cholic acid
      • Chenodeoxycholic acid
    • Secondary
      • Deoxycholic acid
      • Lithocholic acid 
  4. Water 
 
 
Types Of Gallstones
  1. Pure cholesterol 10%
    • Solitary, large and round
  2. Pure pigment 10%
    • Black – Associated with haemolytic disease
    • Brown – Associated with chronic cholangitis and biliary parasites
  3. Mixed 80%
    • Most common
    • Usually multiple 
 



Predisposing Factors For Gallstones

  1. Increasing age
  2. Female
    • OCP 
    • Pregnancy
  3. Obesity
  4. Multiparity
  5. Haemolytic anaemia
  6. Long term parenteral nutrition
  7. Previous surgery 
    • Vagotomy
    • Resection of terminal ileum
    • Crohn’s disease


Fates Of Gallstones
  1. Asymptomatic / slient
  2. Impaction in gallbladder
    • Cholecystitis
    • Mucocele of gallbladder
    • Empyema of gallbladder 
  3. Choledocholithiasis 
    • When the gallstone enters the CBD. it is called as choledocholithiasis 
  4. Mirizzi’s syndrome 
    • When a gallstones gets impacted in the cystic duct or Hartmann’s pouch, it may cause obstruction of the common hepatic duct by external compression, resulting in obstructive jaundice 
  5. Gallstone ileus 
    • A large gallstone may ulcerate the wall of the gallbladder into the adjacent duodenum. The gallstone may pass per rectum or produce a gallstone ileus
    • Gallstone ileus is impaction of the stone in the narrowest part of the small bowel (the distal ileum) causing intestinal obstruction
    • CT scan finding- Frequent presence of air in the biliary tree
  6. Presence of gallstones in the biliary tree is associated with acute or chronic pancreatitis or carcinoma of gallbladder 



Clinical Manifestations Of Gallstones

  1. Biliary colic
  2. Acute cholecystitis 
  3. Chronic cholecystitis
  4. Mucocele
  5. Empyema 
  6. Choledocholithiasis 
  7. Ascending cholangitis
  8. Intestinal obstruction due to gallstone ileus 


Biliary Colic

  1. Biliary colic occurs when the gallbladder contracts in response to cholecystokinin release
  2. Onset is 2 – 3 hours after eating and resolves after 0.5 – 2 hours
  3. Severe colicky pain in right upper quadrant, may involve the epigastric region
  4. Radiates to the inferior angle of the right scapula
  5. During an attack, pain continuously rises and rise a plateau reflecting the release of cholecystokinin The pain is usually
  6. Nausea and vomiting 
  7. No constitutional symptoms 


Acute Cholecystitis
When a gallstone is impacted in the gallbladder outlet, it can cause chemical cholecystitis due to irritation with concentrated bile

  1. Severe colicky or continuous pain in the right upper quadrant 
  2. Radiates to the right flank and back
  3. Anorexia, nausea and vomiting
  4. Constitutional symptoms – Fever, tachycardia  
  5. Tenderness over the gallbladder (Murphy’s sign positive)
  6. Palpable mass in the region of gallbladder


Chronic Cholecystitis
Occurs due to repeated episodes of inflammation and result in thickening and fibrosis of gallbladder 

  1. Recurrent bouts of abdominal pain 
  2. Fever may or may not be present 
  3. Discomfort after fatty food 

Choledocholithiasis
Occurs due to a stone in the common bile duct 

  1. Can be asymptomatic
  2. Biliary colic
  3. Obstructive jaundice
    • Anorexia, nausea
    • Itching
    • Intermittent jaundice
    • Dark urine
    • Pale stools
    • Fever 
    • Epigastric pain 


Ascending cholengitis
Infection of the bile duct is called as cholengitis
Characterized by Charcot’s triad. It includes….

  1. Jaundice
  2. Fever acompained by rigors
  3. Right hypochondriac pain 
 
Empyema
Abscess of gallbladder 
  1. High swinging fever 
  2. Severe localized pain in right upper quadrant of the abdomen
  3. Painful swelling in the gallbladder region
  4. Tenderness in right hypochondriac region 


Differnce Between Mucocele And Empyema Of Gallbladder

Traits
Mucocele
Empyema
1. Definition It is defined as the distension of the gallbladder by a clear watery mucinous secretion due to total obstruction of the cystic duct It is an inflamed, obstructive gallbladder filled with creamy pus like substance containing calcium carbonate, cholesterol crystals & epithelial cells
2. Symptoms
Usually asymptomatic
No pain / mild abdominal discomfort
Patient is non toxic
No fever
No vomiting

Painless abdominal lump

Symptomatic
Pain
Patient is toxic
High swinging fever
Nausea, vomiting

Painful abdominal lump

3. Examination
Non tender lump in right hypochondriac region

No muscle guard

Tender lump in right hypochondriac region

Muscle guard



Courvoisier’s Law
 
In a patient with obstructive jaundice, if the gallbladder is palpable the cause of jaundice is unlikely to be due to gallstones
It is due to obstruction of the CBD, such as in carcinoma of head of the pancreas
 
Exceptions to this law
  1. Gallbladder palpable, but stones
    • Two stones
    • Mirizzi syndrome
  2. Gallbladder not palpable, but malignant
    • Cholangio carcinoma above cystic duct 
 
 
Complications Of Acute Cholecystitis
  1. Empyema 
  2. Gangrene of gallbladder
  3. Perforation of gallbladder
  4. Peritonitis
  5. Cholecysto-enteric fistula 
    • Gallstone ileus
  6. Jaundice due to Mirizzi syndrome 
 
 
Investigations For Gallstones
  1. Ultrasonography
    • Investigation of choice 
  2. Plain X-Ray abdomen 
    • Radio-opaque gallstones can be diagnosed
    • Radio-opaque stones are only  10%
  3. Full blood count
  4. Urea and electrolytes
  5. Liver function tests
    • Done in case of obstructive jaundice 
    • ALP – Raised 
    • PT 
  6. MRCP – Magnetic resonance cholangiopancreatography
  7. ERCP – Endoscopic retrograde cholangiopancreatography
 
 
Treatment Of Gallstones / Cholelithiasis
  • Non surgical 
    1. Gallstone dissolution 
      • By using chenodeoxycholic or ursodeoxycholic acid, orally 
      • Treatment takes months
      • Used for small, non calcified cholesterol stones
    2. Extracorporeal Shock Wave Lithotripsy
      • Not used due to risk of injuries other viscera
  • Surgical 
    1. Cholecystectomy (Open or laparoscopic) 



Treatment Of Acute Cholecystitis

  • Conservative treatment
    1. Nothing by mouth
    2. IV fluids
    3. IV antibiotics 
    4. Analgesics 
    5. Continuous monitoring of the patient 
  • Surgical treatment
    1. Cholecystectomy 
      • If there is increasing pain & tenderness – Cholecystectomy on same admission
      • If pain subsides, elective cholecystectomy is done after 6 weeks 



Treatment Of  Empyema Gallbladder

  • Emergency management 
    1. Emergency drainage or percutaneous drainage under ultrasonography or CT guidance
    2. Conservative management (Same as above) 
  • Surgery
    1. Cholecystectomy 
      • If the patient improves with medical treatment – Done after 6 weeks
      • If not, emergency cholecystectomy 
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