1. GALL STONE DISEASES AND CHOLECYSTITIS

2. DEFINITIONS • Gall stone diseases = all diseases associated with biliary tree stone • Cholecystitis = A clinical diagnosis, Inflammation of the gall bladder: calculous and non calculous. • Cholelithiasis = presence of stone in the Gall bladder: most common biliary pathology

3. INCIDENCE • Common in Western countries • 10% of white population • 20 – 30% of autopsies • Increasing in Africa • The five ‘F’ epidemiology • Females • Fifty years old • Fertile • Fat • Flatulent dyspepsia

4. AETIOLOGY • Three factors interplay • Metabolic • Infection • Bile stasis

6. METABOLIC FACTORS Cholesterol solubilized by bile salt and phospholipids Bile Salt: Cholesterol ratio 30:1 and 20:1 Critical ratio =13:1 Factors that reduce bile salt concentration Avitaminosis A Excessive absorption in GB

8. INFECTIONS • Organisms commonly identified in gall stones: • Streptococcus • Coli forms • Salmonella

9. Bile stasis • Strictures • Worms • tumours

10. OTHERS • Genetics • Ethnicity • NIDDM • Ileal disease/Resections • Cystic fibrosis • OCP use

11. PATHOGENESIS • INITIATION • Increased cholesterol precipitation • Increased mucus secretion • GROWTH

12. CHOLESTEROL PRECIPITAION • Disordered composition of bile – abnormal micelle formation • Lithogenic bile: has more DIOH bile acids = larger micelles = less solubilizing for cholesterol • Reduced total bile salt pool • Reduced liver synthesis • Increased intestinal degradation

13. CHOLESTEROL PRECIPITAION • Water absorption in Gall bladder = increased concentration of cholesterol • Increased activity of B-glucuronidase in lithogenic bile = increased conjugation of bile = increased demand for bile salt

14. CHOLESTEROL PRECIPITAION • Increased phosphorylase A = reduced lecithin = reduced cholesterol solubilizing • Causes are: • E-coli • pancreatic reflux

15. Mucus factor • Increased mucus secretion = • Increased viscosity of bile • Accretion of cholesterol, calcium bilirubinate & bile salt = • Spherule formation • Mucus holds the spherule down in the GB

16. GROWTH PHASE • Bile constituents deposit on spherules • 2o infection act to increase the size • Mucus secretion increases • Stasis, infection

17. TYPES OF GALL STONES • Composition of gall stones • Cholesterol stones = 6% • Pigment stones • Haemoglobinopathies • Ca++ bilirubinate mostly • Mixed stones: most common • Cholesterol predominate • Ca++ bilirubinate • Caco3, capo4, ca++palmitate, proteins

21. EFFECT OF GALL STONES • In the Gall bladder • Silent stones • Chronic cholecystitis • Acute cholecystitis • Gangrene • Perforation • Empyema • Mucocele of the gall bladder • Carcinoma of the gall bladder

22. EFFECT OF GALL STONES • In the Bile duct • Obstructive jaundice • Cholangitis • Acute pancreatitis • In the Intestine • Gall stone illus

23. CHRONIC CALCULOUS CHOLECYSTITIS • Characterised by thick walled gall bladder • Often an incidental finding • Symptomatic ones due to • Inflammation of the wall • Obstruction of the duct • Organisms involved

24. CHRONIC CHOLECYSTITIS: CLINICAL FEATURES • Pain • Dyspepsia • Tenderness • Differentials: • Saints triad • Peptic ulcer • pancreatitis

25. CHRONIC CHOLECYSTITIS: DIAGNOSTIC TOOLS • Ultrasound scan • Thick walled gall bladder • Presence of stones • Oral cholecystography

28. CHRONIC CHOLECYSTITIS: TREATMENT • Adjuncts • Analgesics • Antiemetics • Low fat diet • Cholecystectomy • Stone dissolution • Lithotripsy (ECSWL) • Percutaneous stone removal

29. ACUTE CALCULOUS CHOLECYSTITIS • Gall bladder acutely inflamed • Chemical • Bacterial • Agents • Impacted stones = 70% • Tumours = 21%

31. ACUTE CHOLECYSTITIS: BACTERIOLOGY • Positive culture of bile = 35% • Positive culture of wall = 65% • Chemical inflammation = 30% • Involved organisms • E. coli • Klebisiella • Strep. Faecalis • Salmonella • Staph. Aureus • Cl. welchi

32. ACUTE CHOLECYSTITIS: SEQUELAE • Resolution • Empyema • Perforation • Local abscess • Peritonitis • Males • 0.5%

33. ACUTE CHELECYSTITIS: CLINICALS • Acute pain • nausea / vomiting • Fever • Tenderness • Murphy’s sign • Mass • Boa’s sign

34. ACUTE CHOLECYSYTITIS: DIAGNOSTIC TOOLS • Ultrasound scan • Stone presence • Tenderness • Inflammatory oedema • Cholecyntigraphy (HIDA scan)

36. ACUTE CHOLECYSYTITIS: DIFFERENTIALS • Acute appendicitis • Perforated peptic ulcer • Acute pancreatitis • Pyelonephritis • MI • pneumonia

37. ACUTE CHOLECYSTITIS: TREATMENT • Initial Management: • NPO • IV fluids • NG tube drainage • Analgesics • Antibiotics

38. ACUTE CHOLECYSTITIS: TREATMENT • Definitive treatment: • Cholecysytectomy • Open cholecystectomy • Laparoscopic Cholecystectomy

39. BILE DUCT STONES • Occur in 5- 16% of patients with gall stone • Can be intra or extra hepatic • 1o stone dev. in bile duct • Stasis • 2o stones from gall bladder • 80% have infected bile

40. BILE DUCT STONES: SEQUELAE • Asymptomatic • Symptomatic • Bile duct obstruction • Obstructive jaundice • Cholangitis • Acute pancreatitis

41. BILE DUCT STONES: CLINICAL FEATURES • Non • Jaundice • Pancreatitis pain • Charcot’s triad • Pain • Intermittent jaundice • Intermittent fever

42. BILE DUCT STONES: CLINICAL FEATURES • Differential diagnosis • Other causes of Obstructive jaundice • Courvoisier’s law • Non Obstructive Jaundice

43. BILE DUCT STONES: DIAGNOSTIC TOOLS • LFT: • Mostly conjugated hyperbilirubinaemia • Increased ALP • Minimal increase in transaminases • Ultrasound scan: • GB stone • Dilated Bile duct • Normal pancreas

44. BILE DUCT STONES: DIAGNOSTIC TOOLS • Endoscopic Retrograde Cholangio-pancreaticography (ERCP) • Percutaneous Transhepatic Cholangiography (PTC)

45. BILE DUCT STONES: COMPLICATIONS • Biliary cirrhosis • Acute (toxic) surpurativecholangitis • (Renauld’s pentad) • Charcots triad + Shock, CNS depression

46. BILE DUCT STONES:TREATMENT • Support the liver • High glucose intake • Correct clotting profile: Vit. K • Blood culture and antibiotics • Prevent Renal failure: proper hydration

47. BILE DUCT STONES:TREATMENT • Stone removal • ERCP + Papillotomy • Operative removal • Oral dissolution with Bile salts • Lithotripsy • ECSWL • Intra-corporal • Percutaneous stone removal • Via T-tube tract • Dissolution with MTBE, Mono-octanion

48. THANK YOU