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Gallstone Disease

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Gallstone Disease Objectives Basic biliary anatomy and physiology Pathophysiology of gallstone disease Clinical manifestations of gallstone disease Complications of ... – PowerPoint PPT presentation

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Title: Gallstone Disease


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

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Gallstones
  • Common (20 population)
  • Cholesterol stones in West
  • Female proponderance (3/1)
  • Risk factors
  • Obesity
  • Oestrogen
  • Hypercholesterolaemia
  • Increasing age
  • 5 Fs

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
  • RUQaround to back
  • Constant
  • Associated nausea and vomiting
  • May last several hours to days
  • Recurrent attacks common

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

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

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Murphys 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

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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)
  • LFTs (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-amoxiclavgentamicinpiperacillin)
  • 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)

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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

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

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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
ERCPEndoscopic 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

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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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