Gallstones Types

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Gallstones Types

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1. Gallstones Types Cholesterol stones Pigment stones black stones brown stones

3. 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

4. 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

5. Brown pigment stones formation

6. Cholesterol gallstones Pathogenesis Supersaturated bile with cholesterol due to enhanced hepatic synthesis Low bile salt pool Poor contractility of gallbladder Excessive bile mucus glycoprotein

11. Calcified shadow at right upper abdomen in X-ray Differential diagnosis

12. Cholecystectomy for asymptomatic gallstones Indication Calcified gallbladder Young patients with sickle cell disease Patients on long-term TPN

13. Complications of gallstones Inside the gallbladder Acute cholecystitis Empyema gallbladder Mucocele of gallbladder Carcinoma

14. Complications of gallstones Outside 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)

16. Complications of gallstones In the common bile duct Obstructive jaundice Acute cholangitis Acute pancreatitis

17. Postcholecystectomy syndrome Persistent symptom after cholecystectomy Due to technical complication of cholecystectomy and/or missed pathology which is the real cause of original symptom

18. Postcholecystectomy syndrome Investigation CBP, RFT, LFT, amylase Upper endoscopy US/CT ERCP HAG SMA

19. Acute cholangitis Aetiology Stones Malignancy Biliary stricture Anastomotic stricture

21. Acute cholangitis Aetiology Predisposing causes obstruction to bile duct bacterial growth in bile

22. Acute cholangitis Reynold?s pentad Fever/chill/rigor Right upper quadrant pain Jaundice Hypotension Mental confusion

23. Acute cholangitis Management - initial & conservative Nil by mouth IV fluid Blood tests Blood crossmatch Antibiotic Analgesic Monitoring BP, pulse, temperature, urine output

24. Acute cholangitis Rationale of conservative treatment 70% will resolve Related to spontaneous stone disimpaction

25. Acute cholangitis Clinical manifestation of failure of conservative treatment ? temperature, pulse ? BP ? urine output ? sensorium ? abdominal tenderness, guarding

26. Acute cholangitis Treatment for failure of conservatism Invasive monitoring CVP arterial line pulmonary artery wedge pressure Inotrope Mannitol

27. Acute cholangitis Treatment for failure of conservatism Biliary decompression and drainage Surgery choledochotomy exploration of CBD T-tube drainage avoid choledochoscopy avoid cholangiography ? cholecystectomy

28. 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

34. Acute cholangitis Treatment for failure of conservatism Biliary decompression Endoscopy endoscopic retrograde cholangio-pancreatography endoscopic papillotomy basket removal of stone nasobiliary drainage endoprosthesis

40. Acute cholangitis Comparison of treatment result

41. Acute cholangitis Treatment for failure of conservatism Biliary decompression Radiology percutaneous transhepatic biliary drainage (PTBD)


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