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Gallstones Types PowerPoint PPT Presentation


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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 - PowerPoint PPT Presentation

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Gallstones Types

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GallstonesTypes

  • Cholesterol stones

  • Pigment stones

    • black stones

    • brown stones


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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


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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


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Brown pigment stones formation

Bilirubin diglucuronide

hydrolysis by -glucuronidase

Unconjugated bilirubin

+Ca ion

Calcium bilirubinate


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Cholesterol gallstonesPathogenesis

  • Supersaturated bile with cholesterol due to enhanced hepatic synthesis

  • Low bile salt pool

  • Poor contractility of gallbladder

  • Excessive bile mucus glycoprotein


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Calcified shadow at right upper abdomen in X-rayDifferential diagnosis


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Cholecystectomy for asymptomatic gallstonesIndication

  • Calcified gallbladder

  • Young patients with sickle cell disease

  • Patients on long-term TPN


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Complications of gallstonesInside the gallbladder

  • Acute cholecystitis

  • Empyema gallbladder

  • Mucocele of gallbladder

  • Carcinoma


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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)


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Mirizzi syndrome

(Cholecystocholedochal fistula)


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Complications of gallstonesIn the common bile duct

  • Obstructive jaundice

  • Acute cholangitis

  • Acute pancreatitis


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Postcholecystectomy syndrome

  • Persistent symptom after cholecystectomy

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


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Postcholecystectomy syndromeInvestigation

  • CBP, RFT, LFT, amylase

  • Upper endoscopy

  • US/CT

  • ERCP

  • HAG SMA


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Acute cholangitisAetiology

  • Stones

  • Malignancy

  • Biliary stricture

  • Anastomotic stricture


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To hepatic vein cholangiovenous reflux

Cholangio-lymphatic reflux

Venous system

Stones obstructing the bile duct


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Acute cholangitisAetiology

  • Predisposing causes

    • obstruction to bile duct

    • bacterial growth in bile


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Acute cholangitis

  • Reynold’s pentad

  • Fever/chill/rigor

  • Right upper quadrant pain

  • Jaundice

  • Hypotension

  • Mental confusion


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Acute cholangitisManagement - initial & conservative

  • Nil by mouth

  • IV fluid

  • Blood tests

  • Blood crossmatch

  • Antibiotic

  • Analgesic

  • Monitoring

    • BP, pulse, temperature, urine output


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Acute cholangitisRationale of conservative treatment

  • 70% will resolve

  • Related to spontaneous stone disimpaction


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Acute cholangitisClinical manifestation of failure of conservative treatment

  •  temperature, pulse

  •  BP

  •  urine output

  •  sensorium

  •  abdominal tenderness, guarding


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Acute cholangitisTreatment for failure of conservatism

  • Invasive monitoring

    • CVP

    • arterial line

    • pulmonary artery wedge pressure

  • Inotrope

  • Mannitol


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Acute cholangitisTreatment for failure of conservatism

  • Biliary decompression and drainage

  • Surgery

    • choledochotomy

    • exploration of CBD

    • T-tube drainage

    • avoid choledochoscopy

    • avoid cholangiography

    • ± cholecystectomy


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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


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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


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Action after T-tube cholangiogram

Residual CBD stone +

Keep T-tube for 2-3 months

Choledochoscopy via fibrous T-tube tract


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T-tube in common bile duct and residual CBD stones

T-tube induces formation of fibrous tissue around it


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Fibrous tract formed around T-tube serves as a

conduit for choledochoscopy


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


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Acute cholangitisTreatment for failure of conservatism

  • Biliary decompression

  • Endoscopy

    • endoscopic retrograde cholangio-pancreatography

    • endoscopic papillotomy

    • basket removal of stone

    • nasobiliary drainage

    • endoprosthesis


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Nasobiliary drainage (NBD)

Nose


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Endoprosthesis


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Acute cholangitisComparison of treatment result


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Acute cholangitisTreatment for failure of conservatism

  • Biliary decompression

  • Radiology percutaneous transhepatic

    biliary drainage (PTBD)


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Percutaneous transhepatic biliary drainage

(External type)


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Percutaneous transhepatic biliary drainage

(External-internal type)


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Acute cholangitis

Strategy of treatment

Conservatism

Failure

Success

Endoscopic drainage

Imaging of bile duct

Radiological drainage

Surgery

Surgical drainage