Gallstones types l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 48

Gallstones Types PowerPoint PPT Presentation


  • 639 Views
  • Updated On :
  • Presentation posted in: General

Gallstones Types. Cholesterol stones Pigment stones black stones brown stones. Factors associated with black pigment stones formation. Chronic liver disease (increased frequency with severity) Ileal resection Chronic haemolysis sickle cell anaemia hereditary spherocytosis

Download Presentation

Gallstones Types

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


GallstonesTypes

  • Cholesterol stones

  • Pigment stones

    • black stones

    • brown stones


Factors associated with black pigment stones formation

  • Chronic liver disease (increased frequency with severity)

  • Ileal resection

  • Chronic haemolysis

    • sickle cell anaemia

    • hereditary spherocytosis

    • thalassemia major

  • Total parenteral nutrition

  • Vagotomy


Reasons for gallstone formation in cirrhosis

  • Cirrhotic liver unable to convert all unconjugated bilirubin into bilirubin mono- and di-glucuronides

  • Small fraction of unconjugated bilirubin spills into bile

  • Unconjugated bilirubin precipitated with calcium


Brown pigment stones formation

Bilirubin diglucuronide

hydrolysis by -glucuronidase

Unconjugated bilirubin

+Ca ion

Calcium bilirubinate


Cholesterol gallstonesPathogenesis

  • Supersaturated bile with cholesterol due to enhanced hepatic synthesis

  • Low bile salt pool

  • Poor contractility of gallbladder

  • Excessive bile mucus glycoprotein


Calcified shadow at right upper abdomen in X-rayDifferential diagnosis


Cholecystectomy for asymptomatic gallstonesIndication

  • Calcified gallbladder

  • Young patients with sickle cell disease

  • Patients on long-term TPN


Complications of gallstonesInside the gallbladder

  • Acute cholecystitis

  • Empyema gallbladder

  • Mucocele of gallbladder

  • Carcinoma


Complications of gallstonesOutside the gallbladder

  • Perforation into peritoneal cavity

  •  peritonitis or abscess

  • Perforation into duodenum, colon

  •  gallstone ileus

  • Perforation into liver bed

  •  liver abscess

  • Perforation into CBD

  •  bile duct obstruction (Mirizzi syndrome)


Mirizzi syndrome

(Cholecystocholedochal fistula)


Complications of gallstonesIn the common bile duct

  • Obstructive jaundice

  • Acute cholangitis

  • Acute pancreatitis


Postcholecystectomy syndrome

  • Persistent symptom after cholecystectomy

  • Due to technical complication of cholecystectomy and/or missed pathology which is the real cause of original symptom


Postcholecystectomy syndromeInvestigation

  • CBP, RFT, LFT, amylase

  • Upper endoscopy

  • US/CT

  • ERCP

  • HAG SMA


Acute cholangitisAetiology

  • Stones

  • Malignancy

  • Biliary stricture

  • Anastomotic stricture


To hepatic vein cholangiovenous reflux

Cholangio-lymphatic reflux

Venous system

Stones obstructing the bile duct


Acute cholangitisAetiology

  • Predisposing causes

    • obstruction to bile duct

    • bacterial growth in bile


Acute cholangitis

  • Reynold’s pentad

  • Fever/chill/rigor

  • Right upper quadrant pain

  • Jaundice

  • Hypotension

  • Mental confusion


Acute cholangitisManagement - initial & conservative

  • Nil by mouth

  • IV fluid

  • Blood tests

  • Blood crossmatch

  • Antibiotic

  • Analgesic

  • Monitoring

    • BP, pulse, temperature, urine output


Acute cholangitisRationale of conservative treatment

  • 70% will resolve

  • Related to spontaneous stone disimpaction


Acute cholangitisClinical manifestation of failure of conservative treatment

  •  temperature, pulse

  •  BP

  •  urine output

  •  sensorium

  •  abdominal tenderness, guarding


Acute cholangitisTreatment for failure of conservatism

  • Invasive monitoring

    • CVP

    • arterial line

    • pulmonary artery wedge pressure

  • Inotrope

  • Mannitol


Acute cholangitisTreatment for failure of conservatism

  • Biliary decompression and drainage

  • Surgery

    • choledochotomy

    • exploration of CBD

    • T-tube drainage

    • avoid choledochoscopy

    • avoid cholangiography

    • ± cholecystectomy


Function of T-tube after exploration of common bile duct

  • Serves to allow infected bile draining into the external environment and prevent elevation of intraductal pressure (and bile leakage through the suture line or holes) if there is oedema of lower end of CBD or residual CBD stones

  • For postoperative cholangiogram on day 7-10


Action after T-tube cholangiogram

No residual CBD stone

Spigot T-tube

Fever +

Fever -

Release spigot

Keep T-tube spigot for 6 weeks

Re-do cholangiogram for possible CBD stone

Remove T-tube


Action after T-tube cholangiogram

Residual CBD stone +

Keep T-tube for 2-3 months

Choledochoscopy via fibrous T-tube tract


T-tube in common bile duct and residual CBD stones

T-tube induces formation of fibrous tissue around it


Fibrous tract formed around T-tube serves as a

conduit for choledochoscopy


Insertion of choledochoscope into the common bile duct through T-tube tract for extraction of residual CBD stones


Acute cholangitisTreatment for failure of conservatism

  • Biliary decompression

  • Endoscopy

    • endoscopic retrograde cholangio-pancreatography

    • endoscopic papillotomy

    • basket removal of stone

    • nasobiliary drainage

    • endoprosthesis


Nasobiliary drainage (NBD)

Nose


Endoprosthesis


Acute cholangitisComparison of treatment result


Acute cholangitisTreatment for failure of conservatism

  • Biliary decompression

  • Radiology percutaneous transhepatic

    biliary drainage (PTBD)


Percutaneous transhepatic biliary drainage

(External type)


Percutaneous transhepatic biliary drainage

(External-internal type)


Acute cholangitis

Strategy of treatment

Conservatism

Failure

Success

Endoscopic drainage

Imaging of bile duct

Radiological drainage

Surgery

Surgical drainage


  • Login