Complications of Cholelithiasis

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Transcript of Complications of Cholelithiasis

COMPLICATIONS OF CHOLELITHIASISComplications:Gallstones that do not cause symptoms rarely lead to problems. Death, even from gallstones with symptoms, is very rare. Serious complications are also rare. If they do occur, complications usually develop from stones in the bile duct, or after surgery. Gallstones, however, can cause obstruction at any point along the ducts that carry bile. In such cases, symptoms can develop.y

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In most cases of obstruction, the stones block the cystic duct, which leads from the gallbladder to the common bile duct. This can cause pain (biliary colic), infection and inflammation (acute cholecystitis), or both. About 10% of patients with symptomatic gallstones also have stones that pass into and obstruct the common bile duct (choledocholithiasis).

Infections The most serious complication of acute cholecystitis is infection, which develops in about 20% of cases. It is extremely dangerous and life threatening if it spreads to other parts of the body (a condition called septicemia), and surgery is often required. Symptoms include fever, rapid heartbeat, fast breathing, and confusion. Among the conditions that can lead to septicemia are the following:y

Gangrene or Abscesses. If acute cholecystitis is untreated and becomes very severe, inflammation can cause abscesses.

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Inflammation can also cause necrosis (destruction of tissue in the gallbladder), which leads to gangrene. The highest risk is in men over 50 who have a history of heart disease and high levels of infection. Perforated Gallbladder. An estimated 10% of acute cholecystitis cases result in a perforated gallbladder, which is a life-threatening condition. In general, this occurs in people who wait too long to seek help, or in people who do not respond to treatment. Perforation of the gallbladder is most common in people with diabetes. The risk for perforation increases with a condition called emphysematous cholecystitis, in which gas forms in the gallbladder. Once the gallbladder has been perforated, pain may temporarily decrease. This is a dangerous and misleading event, however, because peritonitis (widespread abdominal infection) develops afterward. Empyema. Pus in the gallbladder (empyema) occurs in 2 - 3% of patients with acute cholecystitis. Patients usually experience severe abdominal pain for more than 7 days. The physical exam often fails to reveal the cause. The condition can be life-threatening, particularly if the infection spreads to other parts of the body. Fistula. In some cases, the inflamed gallbladder adheres to and perforates nearby organs, such as the small intestine. In such cases a fistula (channel) between the organs develops. Sometimes, in these cases, gallstones can actually pass into the small intestine, which can be very serious and requires immediate surgery. Gallstone Ileus. A gallstone blocking the intestine is known as gallstone ileus. It primarily occurs in patients over age 65, and can sometimes be fatal. Depending on where the stone is located, surgery to remove the stone may be required.

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Infection in the Common Bile Duct (Cholangitis). Infection in the common bile duct from obstruction is common and serious. If antibiotics are administered immediately, the infection clears up in 75% of patients. If cholangitis does not improve, the infection may spread and become lifethreatening. Either surgery or a procedure known as endoscopic sphincterotomy is required to open and drain the ducts. Those at highest risk for a poor outlook also have one or more of the following conditions: o Kidney failure o Liver abscess o Cirrhosis o Over 50 years old Pancreatitis. Common bile duct stones are responsible for most cases of pancreatitis (inflammation of the pancreas), a condition that can be life threatening. The pancreatic duct, which carries digestive enzymes, joins the common bile duct right before it enters the intestine. It is therefore not unusual for stones that pass through or lodge in the lower portion of the common bile duct to obstruct the pancreatic duct.

Other Complications Gallbladder Cancer: Gallstones are present in about 80% of people with gallbladder cancer. There is a strong association between gallbladder cancer and cholelithiasis, chronic cholecystitis, and inflammation. Symptoms of gallbladder cancer usually do not appear until the disease has reached an advanced stage and may include weight loss, anemia, recurrent vomiting, and a lump in the abdomen. Research shows that survival rates for gallbladder cancer are on the rise, although the death rate remains high because many people

are diagnosed when the cancer is already at a late stage. When the cancer is caught at an early stage and has not spread beyond the mucosa (inner lining), removing the gallbladder (resection) can cure many people with the disease. If the cancer has spread beyond the gallbladder, other treatments may be required. This cancer is very rare, even among people with gallstones. Certain conditions in the gallbladder, however, contribute to a higher-than-average risk for this cancer. Gallbladder Polyps. Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 - 15 mm have a lower risk, but they should still discuss gallbladder removal with their doctor. Primary Sclerosing Cholangitis. Primary sclerosing cholangitis is a rare disease that causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7 - 12% for gallbladder cancer. The cause is unknown, although it tends to strike younger men with ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of being cancerous. Anomalous Junction of the Pancreatic and Biliary Ducts. With this rare condition, which is present at birth (congenital), the junction of the common bile duct and main pancreatic duct is located outside the wall of the small intestine and forms a long channel between the two ducts. This problem poses a very high risk of cancer in the biliary tract. Porcelain Gallbladders. Gallbladders are referred to as porcelain when their walls have become so calcified (covered in calcium deposits) that they look like porcelain on an x-ray. Porcelain

gallbladders have been associated with a very high risk of cancer, although recent evidence suggests that the risk is lower than was previously thought. This condition may develop from a chronic inflammatory reaction that may actually be responsible for the cancer risk. The cancer risk appears to depend on the presence of specific factors, such as partial calcification involving the inner lining of the gallbladder.

obstruction of the neck of the gall-bladder or the cystic duct cause destructive inflammation to develop due to stagnated bile, activation of infection and vascular disorders. When infection is spread in the abdominal cavity, peritonitis develops. Conservative therapy may cause unblocking of the gall-bladder. A stone moves into the cavity of the gall-bladder (rarely into choledoch), the contents of the gall-bladder spill through choledoch into the duodenum, and the attack subsides. Hydrops of the gall-bladder develops in the presence of obstruction with low virulent infection and high immune defense system. The attack subsides, a patient feels better. A painless and tensed gall-bladder is palpable at the right subcostal region. Acute cholecystitis may be accompanied by jaundice, caused by different factors. Prolonged history of the disease with multiple attacks leads to hepatic parenchyma being changed dystrophy,

hepatitis, biliary cirrhosis. A new attack of the disease causes exacerbation process in the liver presented as parenchymatous jaundice, which does not take a long course and can be easily treated conservatively. Progressive acute cholecystitis may lead to infiltrate formation with compression of extrahepatic biliary ducts with the resultant mechanical jaundice. Subsiding of the inflammatory process in the gall-bladder and the resolution of infiltrate will arrest jaundice. The most common cause of jaundice is calculous cholecystitis associated with choledocholithiasis. Stones of the bile-excreting ducts are usually of cystic origin. Obturative major duodenal papilla with an opening 3 mm in diameter leads to bile hypertension and mechanical jaundice. The consolidation of the head of the pancreas in cholecystopancreatitis causes constriction of the terminal choledoch in the site, where the duct crosses the parenchyma of the pancreas. The exacerbation of pancreatitis may lead to impaired bile outflow and the onset of jaundice. Intensive supporting care will abort the attack of cholecystopancreatitis, and jaundice passes.

Another possible cause of jaundice is stenosis of major duodenal papilla, which may be caused by: frequent spasms of papilla with blood supply disturbances and connective tissue development; migration of calculus through papilla with microtraumas of the mucous membrane. Isolated stenosis, however, can rarely cause jaundice. Stenotic rigid papilla becomes a place, where migrating calculi harbor; and a stone impacted at papilla will cause jaundice. It is necessary to note, that gallstones can be relatively rare formed in the bile-excretory passages. It occurs when there is an affected bile outflow due to stenosis of the distal choledoch. Above the area of stenosis, a biliary ointment is being formed. This is an amorphous soft shapeless lump that grows into a soft crumble calculus. Mechanical jaundice may be caused only by a total obstruction of choledoch or major duodenal papilla. When there are floating calculi, jaundice is intermittent, what is ass