Calculous biliary disease.ppt

CALCULOUS BILIARY DISEASE

Fabian Ovidiu

Gallbladder

Common hepatic duct

Choledocus

Cystic duct

Common bile duct

Sphincter of Oddi

The bile ducts, gallbladder and sphincter of Oddi act in concert to modify, store, and regulate the flow of bile

Biliary physiology

Biliary physiology

The functions of the gallbladder:-to concentrate …-to store … … the bile

Bile is concentrated 5-fold to 10-fold by the absorption of water and electrolytes a marked change in bile composition

The concentration of bile may affect the solubilities of two important components:

- cholesterol and - calcium

the gallbladder bile becomes concentrated

-several changes occur in the capacity

of bile to solubilize cholesterol.

Biliary physiology

The major organic solutes in bile are:

- bilirubin

- bile salts

- phospholipids

- cholesterol

Cholesterol

= highly nonpolar

= insoluble in water

Biliary physiology

Cholesterol is maintained in solution in some complex biochemical structures:

micelles

vesicles

The hidrophobic molecules of

cholesterol are surounded by

hidrophilic molecules

Cholesterol solubility

depends on the relative

concentration of cholesterol, bile

salts, and phospholipid

Gallstones formation

Supersaturated bile:

- the capability of these micelles and vesicles to solubilise the cholesterol is exceded

the precipitation (cristalisation) of the cholesterol occur

Pronucleating factors

-mucin glycoproteins

-immunoglobulins

-transferrin

accelerate the precipitation of cholesterol in bile


Sludge

= a mixture of cholesterol crystals, calcium bilirubinate granules, and a mucin gel matrix

The cristals of cholesterol growth,

include glicroproteins from mucin gel and calcium bilirubinate

gallstones

Gallstone types

gallstones

cholesterol gallstones

pigment gallstones

The pathogenesis of cholesterol gallstones involves four factors:

-cholesterol supersaturation in bile

-crystal nucleation

-gallbladder dysmotility

-gallbladder absorption

Black pigment stones = associated with -hemolytic conditions or -cirrhosis unconjugated bilirubin increased

Brown pigment stones -earthy in texture -some bacteria produces enzymatic hydrolysis of soluble conjugated bilirubin

free bilirubin it precipitates with calcium

Gallstone types


Gallstone types

black gallstones

Gallstone types

brown gallstones

Gallstone types

cholesterol and pigment gallstones

gallstones

asimptomaticgallstones

-discovered at the time of laparotomy or during abdominal imaging f or nonbiliary disease

-the vast majority of patients with gallstones are asymptomatic

simptomaticgallstones

biliary colic

complications

gallstone pancreatitis

gallstone ileus

acute cholecystitis

choledocholithiasis

during years

gallbladder carcinoma

Natural history of gallstones

Natural history of gallstones

Simptomatic gallstones

1.Pain

-tipical pain: biliary colic

-atipical pain

2.Other simptoms:

-nausea

-vomiting

-bloating

-belching

obstruction of the cystic duct results in a progressive increase in

tension in the gallbladder wall, leading to constant pain in the

majority of patients

Biliary colic

The pain:

-in the right upper quadrant and/or epigastrium

-frequently radiates to the back and right scapula

-the intensity of the pain = severe

-occurs following fatty meals (50% of patients)

-the duration of pain: 1 to 5 hours (tipically)

rarely persist for more than 24 hours

if > 24 hours suggests an acute cholecystitis)

rarely shorter than 1 hour

-the episodes of biliary colic = less frequent than one per week.

Atypical pain is common

-some patients do not relate their pain to meals or time of day

-not all attacks are necessarily severe

-the pain is continuous rather than episodic

-the pain located predominantly in the back

or the left upper

or right lower quadrant

-the less typical the pain

search for another cause,

even in the presence of stones

Treatment of atypical biliary colic is appropriate when other causes of pain have been eliminated.

Atipical pain

renal colic, peptic ulcer, hiatal hernia, abdominal wall hernia, liver disease, disease of the small bowell, disease of the large bowell

Diagnostic imaging

Abdominal X-ray-only 15% of gallstones contain sufficient calcium to appear on X-ray

Ultrasound-noninvasive, inexpensive, and widely available -identifies gallstones and bile duct dilation-gallstones create echoes and are free-floating -the ultrasound waves cannot penetrate the stones shadowing

gallstones

shadowing

sludge

Diagnostic imaging

Cholescintigraphy

-Tc99m labeled iminodiacetic acid - injected intravenously-the radionuclide is excreted into the bile

-delayed filling of the gallbladder and CBD or absent filling of the duodenum suggests an obstruction at CBD

Diagnostic imaging

Computerized Tomography

multiple distinct large stones ayering of small stones and sludge

In fact the role of CT scanning is limited to the diagnosis of complications of gallstone disease such as acute cholecystitis (gallbladder wall thickening, pericholecystic fluid), choledocholithiasis (intrahepatic and extrahepatic bile duct dilation), pancreatitis (pancreatic edema and inflammation) and gallbladder cancer

Treatment

Nonoperative Therapy

The nonsurgical options for the treatment of gallstone disease include:

-oral dissolution therapy with the bile acids (ursodeoxycholic acid and chenodeoxycholic acid)

-contact dissolution therapy with organic solvents (methyl tert-butyl ether)

-extracorporeal shock wave biliary lithotripsy.

These treatments are rarely used today.

Treatment

Nonoperative Therapy

The nonsurgical options for the treatment of gallstone disease include:

-oral dissolution therapy with the bile acids (ursodeoxycholic acid and chenodeoxycholic acid)


-contact dissolution therapy with organic solvents (methyl tert-butyl ether)

cannulation of the gallbladder with direct infusion of the agent

-only cholesterol gallstones

-extracorporeal shock wave biliary lithotripsy-0.5 to 2 cm diameter gallstone-risk of choledocholitiasis

These treatments are rarely used today.

Treatment – operative therapy

Laparoscopic cholecistectomy-pneumoperitoneum

-trocar placement


Laparoscopic cholecistectomy the Calot triangle

(on its area pass the cystic artery)

The peritoneum overlying the cystic duct gallbladder junction is opened


Laparoscopic cholecistectomy

The cystic duct is isolated The cystic duct is clipped proximal and distal and divided with the hook

scissors


Laparoscopic cholecistectomy

The cystic artery is dissected, clipped and

divided

The gallbladder is dissected from the liver by scoring

the serosa with electrocautery


Open cholecistectomy -upper midline or right subcostal incision

-identification and division of the cystic duct and artery

-removal of cholecist from the gallbladder bed

If the anatomy cannot be clearly identified,

the gallbladder should be dissected from the fundus downward towards the gallbladder neck,

making the ductal and vascular anatomy easier to identify.

Chronic calculous cholecystitis

Pathogenesis-gallstones lead to recurrent episodes of cystic duct obstruction

recurrent inflammatory proces-over time scarring and a nonfunctioning gallbladder-histopathologically: subepithelial and subserosal fibrosis and a mononuclear cell infiltrate

Clinical Presentation:-pain (biliary colic or atypical pain), nausea and vomiting

-physical examination: is usually completely normal during biliary colic, mild right upper quadrant tenderness

maybe present

-laboratory valuesbilirubintransaminasesalkaline phosphatase

are also usually normal

Chronic calculous cholecystitis

Diagnosis-requires two findings

abdominal pain consistent the presence of gallstones

-usualy documented by ultrasonography.

+

Management-the treatment of choice: elective laparoscopic cholecystectomy

-conversion to an open cholecystectomy is necessary in less than 5%

Acute calculous cholecystitis

Pathophysiology

-the most common complication of gallstones(20% to 30% of patients with symptomatic disease)

-results from a stone impaction at the gallbladder-cystic duct junction

-as in biliary colic

-primarily: inflammation (without bacteria)-secondary: bacterial infection

Escherichia coli = the most common organism


PathophysiologyGallstones

Cystic duct obstruction

Pain (biliary colic)

Inflammation

Obstruction not relieved (10%)Obstruction is relieved (90%)

Minimal histological changes(scarring and fibrosis)Cronic cholecystitis

Inflammation and edema

Vascular compromise

Ischemia, necrosis, perforation

acute calculous cholecystitis


Clinical Presentation-right upper quadrant pain

similar to that of biliary colic-the pain is usually unremitting

may last several days-often associated with nausea, emesis, anorexia, and fever

On physical examination:-low-grade fever-localized right upper quadrant tenderness and guarding

which distinguishes the episode from simple biliary colic-Murphy's sign

inspiratory arrest during deep palpation of the right upperquadrant

=the classic physical finding of acute cholecystitis-a palpable right upper quadrant mass is appreciated

in one third of patientsomentum that has migrated to the area around the

gallbladder-mild jaundice may be


Clinical Presentation

Laboratory evaluation can show

-a mild leukocytosis (white blood cell count [WBC] 12,000 to 15,000 cells/mm3)

-mild elevations in serum bilirubin (<4 mg/dL)alkaline phosphatasethe transaminasesamylase

… may also be seen with acute cholecystitis


Diagnosis

Ultrasound = the most useful examination when a cholecystitis is suspected - first: establish the presence or absence of gallstones

-additional findings suggestive of acute cholecystitis:thickening of the gallbladder wall (>4 mm)pericholecystic fluidfocal tenderness directly over the gallbladder

(sonographic Murphy's sign)

CT is less sensitive for these conditions than ultrasonography… may show

-gallbladder wall thickening-pericholecystic fluid and edema-gallstones-air in the gallbladder or gallbladder wall

(emphysematous cholecystitis)


Management

-preoperative:”nothing by mouth” intravenous hydration nasogastric tube

if there is persistent nausea and vomiting or abdominal distention

broad-spectrum antibiotics maintained into the immediate postoperative period

parenteral analgesia: nonsteroidal analgesics no narcotics! (increase biliary pressure)

The treatment of choice for acute cholecystitis is cholecystectomy.


Management

The treatment of choice for acute cholecystitis is cholecystectomy.

Open cholecystectomy has been the standard treatment for many years

Laparoscopic cholecystectomy can be performed safely in the setting of acute cholecystitis

The timing of cholecystectomy -delayed cholecystectomy – in the past

-patients were initially managed nonoperatively-elective cholecystectomy - 6 weeks later after the acute

inflammation had resolved -early laparoscopic cholecystectomy (within 3 days of symptom onset)

-within 24 to 72 hours of diagnosis-conversion to an open procedure should be considered if

dissection is difficult


Management

In certain high-risk patients whose medical conditions precludes cholecystectomy,

a cholecystostomy can be performed for acute cholecystitis.

After the acute episode resolves, the patient can undergo cholecystectomy.

Complications of acute cholecystitis

Several complications of acute cholecystitis are recognized in clinical practice:

-empyema of the gallbladder

-emphysematous cholecystitis

-perforation

-cholecystenteric fistula


Gallbladder empyema

= an advanced stage of cholecystitis- bacterial invasion of the gallbladder pus in the

lumen

Clinical presentation:-severe right upper quadrant pain-high-grade fever-significant leukocytosis cardiovascular collapse may be seen

Treatment:-broad-spectrum antibiotics (including anaerobic coverage)-emergent cholecystectomy or cholecystostomy


Emphysematous cholecystitis-develops more commonly in males and patients with diabetes mellitus

-severe right upper quadrant pain-eneralized sepsis

Abdominal films or CT scans may demonstrate air within the gallbladder wall or lumen

Treatement:-prompt antibiotic therapy -emergency cholecystectomy


Gangrene/Perforation

-gangrene occurs when the wall becomes ischemic and leads to perforation

-gallbladder perforation:-localized or -free

-localized perforation generally pericholecystic abscess

-free perforation spilling of bile into the peritoneal cavity

generalized peritonitis


Cholecystoenteric fistula-seldom the gallbladder will perforate into…

… duodenum or… hepatic flexure of the colon

If a large gallstone passes a mechanical bowel obstruction may result

= gallstone ileusThe site of obstruction is in the narrowest part of

the small intestine (ileum) or large intestine

(sigmoid colon).

Patients with gallstone ileus present with signs

and symptoms of intestinal obstruction.

Acute cholangitis

= a bacterial infection of the biliary ductal system

-it varies in severity

from mild and self-limited

to severe and life threatening

The clinical triad:

fever

jaundice = Charcot’s triad

pain

Acute cholangitis

Pathophysiology

-cholangitis results from a combination of two factors:

-significant bacterial concentrations in the bile

E. coli

Klebsiella pneumonia

the enterococci

Bacteroides fragilis.

-biliary obstruction

choledocholithiasis

benign strictures

biliary enteric anastomotic strictures

Acute cholangitis


-a wide spectrum of disease

self-limited illness and never seek attention

severe illness (toxic cholangitis)

jaundice

fever

abdominal pain = Reynolds' pentad

mental obtundation

hypotension

Fever is the most common presenting symptom and is often accompanied by shivers. Jaundice is a frequent physical finding but may be absent. Pain is also commonly present but is often mild.

Acute cholangitis

Diagnosis

-clinical diagnosis

-laboratory tests can support evidence of biliary obstruction. leukocytosis

hyperbilirubinemia

elevations of alkaline phosphatase

elevations of transaminases

-CT, ultrasound, and MRI scanning

evidence of biliary ductal dilation and occasionally CBD stones

Acute cholangitis

Management

-the initial treatment:

antibiotics

toxic cholangitis:

-intensive care unit monitoring

-vasopressors to support blood pressure

-emergency biliary decompression

endoscopically

or

via the percutaneous transhepatic route

Acute cholangitis

Management

Endoscopic biliary drainage

-endoscopic sphincterotomy

and stone extraction

-or simply placement of an endoscopic biliary stent

in the hemodynamically unstable patient

Laparoscopic cholecystectomy after 6 to 12 weeks.

Acute cholangitis

Management

Another option: percutaneous transhepatic biliary decompression

Laparoscopic cholecystectomy after 6 to 12 weeks.

Sphincter of Oddi dysfunction

= a structural or functional abnormality involving the sphincter-fibrosis of the sphincter due to gallstone migration-operative or endoscopic trauma-pancreatitis-other nonspecific inflammatory

elevated sphincter pressures.

-suspected in patients with typical episodic biliary-type pain without an obvious organic cause

Treatement:-endoscopic sphincterotomy-transduodenal sphincteroplasty with transampullary septotomy


endoscopic sphincterotomy


transduodenal sphincteroplasty


transduodenal sphincteroplasty

with transampullary septotomy

Choledocholithiasis

Classification and Etiology

CBD stones can be classified as

- primary

develop de novo within the bile ducts

occur in patients with bile stasis ( brown pigment stones)

-benign biliary strictures

-sclerosing cholangitis

-choledochal cyst disease

-sphincter of Oddi dysfunction

- secondary

develop in the gallbladder and subsequently fall into the

composition similar to gallbladder stones

Choledocholithiasis


-common duct stones

are often asymptomatic

-symptomatic choledocholithiasis

biliary colic

extrahepatic biliary obstruction

cholangitis

or pancreatitis

Choledocholithiasis


-Clinical features of biliary obstruction caused by CBD stones:

-biliary colic

-jaundice

-lightening of the stools

-darkening of the urine

obstructive jaundice

Choledocholithiasis


-Clinical features of biliary obstruction caused by CBD stones:

-biliary colic

-jaundice

intermittent and transient

with fever

-lightening of the stools

-darkening of the urine

obstructive jaundice

benign obstructive

jaundice

Choledocholithiasis

Serum liver function tests

-bilirubin = elevated

-mainly conjugated bilirubin cholestasis

-alkaline phosphatase = elevated

-transaminases = elevated cholestatic hepatitis

Ultrasonography

-CBD dilation, which can suggest CBD obstruction

-diameter greater than 10 mm

-CBD stones in only 70% of patients

the distal end of the bile duct is obscured

by duodenal or colonic gas

Choledocholithiasis

Magnetic Resonance Imaging

Magnetic resonance cholangiopancreatography (MRCP)

-high sensitivity (90%)

-high specificity (100%)

-advantages:

no need contrast

non-invasive procedure

-disadvantages:

expensive

lack of availability

lack of therapeutic capacity

Choledocholithiasis

Endoscopic Retrograde Cholangiography

= the gold standard for the diagnosis of

CBD stones

-provide also a therapeutic option

Choledocholithiasis

Endoscopic Retrograde Cholangiography

stones in the common bile duct

Choledocholithiasis

Other investigations methods:

•endoscopic ultrasound

•intraoperative ultrasonography

•intraoperative cholangiography

Management of choledocholithiasisEndoscopic

ERC eendoscopic sphinncterotomy and …

Stones removal using a baloon-catheter

Management of choledocholithiasisEndoscopic

ERC eendoscopic sphinncterotomy and …

Stones removal using a basket-catheter (Dormia)

Management of choledocholithiasis

Transcystic stones removal using a Dormia-baket

Laparoscopic

- 2 techniques: transcystic or through a choledochotomy

Management of choledocholithiasis

CBD stones removal trhough a choledochotomy

Laparoscopic

- 2 techniques: transcystic or through a choledochotomy

Management of choledocholithiasisOpen Common Bile Duct Exploration

(instead of) Conclusion

Biliary surgery always makes me

hungry!

Calculous biliary disease.ppt

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