amjad gallbladder

8/7/2019 amjad gallbladder

http://slidepdf.com/reader/full/amjad-gallbladder 1/28

Gallstones Disease

Gallstone Disease

Dr.Amjad Maslamani

General Surgeon



Gallstones Disease

Overview

Anatomy of galllbladder

Gallstone pathogenesis

Definitions Differential Diagnosis of RUQ pain

7 Cases



Gallstones Disease

ANATOMY OF GALLLADDER

Gallbladder is located in a fossa on the inferior border of

the liver.

Divided into fundus, body,infundibulum,and the neck.

Supplied by the cystic artery ( branch of the right hepatic

in 90%). That runs in Calots triangle( area bounded by the

cystic duct, common hepatic duct and liver margin).

Venous return by small veins directly to the liver.



Gallstones Disease

Anatomy of gallbladder

ANATOMY OF GALLLADDER



Gallstones Disease

The Gallbladder and Biliary System with Pancreas



Gallstones Disease

Gallstone Pathogenesis

Bile = bile salts, phospholipids, cholesterol

± Also bilirubin which is conjugated b4 excretion

Gallstones due to imbalance rendering

cholesterol & calcium salts insoluble

Pathogenesis involves 3 stages:

± 1. cholesterol supersaturation in bile

± 2. crystal nucleation

± 3. stone growth



Gallstones Disease

DefinitionsSymptomatic

cholelithiasis

Wax/waning postprandial epigastric/RUQ pain

due to transient cystic duct obstruction by stone,no fever/WBC, normal LFT

Acute

cholecystitis

Acute GB inflammation due to cystic duct

obstruction. Persistent RUQ pain +/- fever,

WBC, LFT, +Murphy¶s = inspiratory arrestChronic

cholecystitis

Recurrent bouts of colic/acute chol¶y leading to

chronic GB wall inflamm/fibrosis. No fever/WBC.

Acalculous

cholecystitis

GB inflammation due to biliary stasis(5% of time)

and not stones(95%). Seen in critically ill pts

Choledocho-

lithiasis

Gallstone in the common bile duct (primary

means originated there, secondary = from GB)

Cholangitis Infection within bile ducts usu due to obstrux of

CBD. Charcot triad: RUQ pain, jaundice, fever

(seen in 70% of pts), can lead to septic shock



Gallstones Disease

Differential Diagnosis of RUQ pain

Biliary disease

± Acute chol¶y, chronic chol¶y, CBD stone,

cholangitis

Inflamed or perforated duodenal ulcer

Hepatitis

Also need to rule out: ± Appendicitis, renal colic, pneumonia or

pleur isy, pancreatitis



Gallstones Disease

Case 1

46yo F w RUQ pain x4hr, after a fatty

meal, radiating to the R scapula, also w

nausea. Pt is pain-free now.

No prior episodes

Minimal RUQ tenderness, no Murphy¶s

WBC 8, LFT normal

RUQ U/S reveals cholelithiasis without GBwall thickening or pericholecystic fluid

Diagnosis: ?



Gallstones Disease

Case 1

denotesgallstones

denotes theacoustic shadowdue to absenceof reflected

sound wavesbehind thegallstone



Gallstones Disease

Symptomatic cholelithiasis

aka ³biliary colic´

The pain occurs due to a stone obstructing

the cystic duct, causing wall tension; pain

resolves when stone passes Pain usually lasts 1-5 hrs, rarely > 24hrs

Ultrasound reveals evidence at the crime

scene of the likely etiology: gallstones Exam, WBC, and LFT normal in this case

Treatment: Laparoscopic cholecystectomy



Gallstones Disease

Spectrum of Gallstone Disease

Cholelithiasis

Asymptomatic

cholelithiasis

Symptomatic

cholelithiasis

Chronic

calculous

cholecystitis

Acute

calculous

cholecystitis

Symptomatic

cholelithiasis can

be a herald to:

± an attack of acutecholecystitis

± or ongoing chronic

cholecystitis

May also resolve



Gallstones Disease

Case 2

Same case, except pt has had multiple

prior attacks of similar RUQ pain

No fever or WBC Ultrasound reveals gallstones, thickened

GB wall, no pericholecystic fluid

Diagnosis: ?



Gallstones Disease

Chronic calculous cholecystitis

Recurrent inflammatory process due to

recurrent cystic duct obstruction, 90% of

the time due to gallstones

Overtime, leads to scarring/wall thickening

Treatment: laparoscopic cholecystectomy



Gallstones Disease

Case 3

Same pt, now > 24hrs of RUQ painradiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever

Exam: Palpable, tender gallbladder,guarding, +Murphy¶s = inspiratory arrest

WBC 13, Mild LFT

U/S: gallstones, wall thickening (>4mm),

GB distension, pericholecystic fluid,sonographic Murphy¶s sign (very specific)

Diagnosis: ?



Gallstones Disease

Case 3

Curved arrow ± Two small stones

at GB neck

Straight arrow

± Thickened GB wall

± pericholecystic

fluid = dark lining

outside the wall



Gallstones Disease

Case 3

denotes the GB

wall thickening

denotes the

fluid around the

GB

GB also appears

distended



Gallstones Disease

Acute calculous cholecystitis

Persistent cystic duct obstruction leads to

GB distension, wall inflammation & edema

Can lead to: empyema, gangrene, rupture

Pain usu. persists >24hrs & a/w N/V/Fever

Palpable/tender or even visible RUQ mass

Nuclear HIDA scan shows nonfilling of GB

± If U/S non-diagnostic, obtain HIDA

Tx: NPO, IVF, Abx (GNR & enterococcus)

Sg: Cholecystectomy usu within 48hrs



Gallstones Disease

Case 4

87yo M critically ill, on long-term TPN w

RUQ pain, fever, WBC

Ultrasound: GB wall thickening,pericholecystic fluid, no gallstones

Diagnosis: ?



Gallstones Disease

Acute acalculous cholecystitis

In 5-10% of cases of acute cholecystitis

Seen in critically ill pts or prolonged TPN

More likely to progress to gangrene,

empyema, perforation due to ischemia

Caused by gallbladder stasis from lack of

enteral stimulation by cholecystokinin

Tx: Emergent cholecystectomy usu open

If pt is too sick, perc cholecystostomy tube

and interval cholecystectomy later on



Gallstones Disease

Complications of acute cholecystitis

Empyema of gallbladder

Pus-filled GB due to bacterial proliferation inobstructed GB. Usu. more toxic, high fever

Emphysematous

cholecystitisMore commonly in men and diabetics. Severe

RUQ pain, generalized sepsis. Imaging

shows air in GB wall or lumen

Perforated

gallbladder

Occurs in 10% of acute chol¶y, usually

becomes a contained abscess in RUQ

Less commonly, perforates into adjacentviscus = cholecystoenteric fistula & the stone

can cause SBO (gallstone ileus)



Gallstones Disease

Choledocholithiasis

Can present similarly to cholelithiasis,except with the addition of jaundice

DDx: cholelithiasis, hepatitis, sclerosingcholangitis, less likely CA with pain

Tx: Endoscopic retrogradecholangiopancreatography (ERCP)

± Stone extraction and sphincterotomy Interval cholecystectomy after recovery

from ERCP



Gallstones Disease

Case 6

46yo F p/w fever , RUQ pain, jaundice(Charcot¶s tr iad)

If also altered mental status and signs of

shock = Raynaud¶s pentad VS tachycardic, hypotensive

ABC¶s, Resuscitate

± 2 large bore IV, Foley, Continuous monitor

± 1-2L fluid bolus, repeat until resuscitated

Diagnosis: ?



Gallstones Disease

Cholangitis

Infection of the bile ducts due to CBDobstruction 2ndary to stones, strictures

Charcot¶s triad seen in 70% of pts

May lead to life-threatening sepsis andseptic shock (Raynaud¶s pentad)

Tx: NPO, IVF, IV Abx

Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC)

Used to require emergency laparotomy



Gallstones Disease

Case 7

46yo F p/w persistent epigastric & backpain

Known history of symptomatic gallstones

No EtOH abuse

Exam: Tender epigastrum

Amylase 2000, ALT 150

Ultrasound: Gallstones

Diagnosis: ?



Gallstones Disease

Gallstone pancreatitis

35% of acute pancreatitis 2ndary to stones Pathophysiology

± Reflux of bile into pancreatic duct and/or

obstruction of ampulla by stone ALT > 150 (3-fold elevation) has 95% PPV

for diagnosing gallstone pancreatitis

Tx: ABC, resuscitate, NPO/IVF, pain meds Once pancreatitis resolving, ERCP w stone

extraction/sphincterotomy

Cholecystectomy before hospital discharge



Gallstones Disease

Take Home Points

As always, ABC & Resuscitate before Dx

Understanding the definitions is key

Is this acute cholecystitis? (fever, WBC, tender on

exam with positive Murphy¶s)

Or simply cholelithiasis vs ongoing chroniccholecystitis? (no fever/WBC)

Is patient sick or toxic-appearing, to suspect

empyema, gangrene or even perforation?

Elicit h/o jaundice, acholic stools, tea-colored urine

Rule out cholangitis, because this will kill the

patient unless dx & tx early

amjad gallbladder

Documents

Transcript of amjad gallbladder