Gallstones 2024 PDF

Gallstones Mohammad Jundy Anatomy: Gallbladder function (physiology): Gallbladder: - Storage of bile (Capa...

Gallstones Mohammad Jundy Anatomy: Gallbladder function (physiology): Gallbladder: - Storage of bile (Capacity =25-30 ml): - Pear-shaped muscular tube ➔ Bile is secreted via liver & stored in GB. - Parts: fundus, body, Neck, cystic duct. ➔ CCK (Cholecystokinin) stimulates GB contraction & bile secretion into - Found in RUQ. 2nd part of doudenom. - below liver visceral surface (under segment IVB) - Concentration of bile (reabsorbs water & electorates) - Possible Hartmann’s pouch (Infundibulum): - Bile composition: ➔ A dilation in GB neck before cystic duct. ➔ water (97%), conjugated bilirubin, bile salts ➔ If found, MC site for stone to lodge. ➔ phospholipids and fatty acids. - Arterial Blood supply: - Bile salts & phospholipids: digest and absorps lipids. ➔ Cystic artery (from right hepatic artery) - Histology: Enterohepatic circulation: ➔ Simple columnar epithelium. - 95% of bile salts are reabsorbed in terminal ileum. Bile acids / salts are derived from cholesterol ➔ microvilli Secreting mucin + no musclaris mucos - Resection of terminal ileum (chron’s disease): ➔ No bile salts reabsorption: gallstone formation. Biliary tree: ➔ Malabsorption of fat & fat-soluble vitamins: steatorrhea. - Intrahepatic ducts give Right & left hepatic ducts then ➔ fat soluble vitamins (A.K.E.D): vit K deficiency (bleeding tendency) - Right & left hepatic ducts form Common hepatic duct. - Cystic duct + Common hepatic duct = Common bile duct. Gallbladder stones (Cholelithiasis): - Common bile duct: - MC biliary pathology (around 6% of population) ➔ Travel in the hepatoduodenal ligament. Risk factors: (5 F’s) ➔ CBD + major pancreatic duct: form a tract that ends - Fat (obese), Forty (middle age), Fertile (multipara), with ampulla of vater (a dilation in 2nd part of duodenum) - Female (F>M 3: 1): ↑ estrogen → ↓ contractility of GB ➔ Major duodenal papilla (surrounded by sphincter of Oddi) - Fair (more in Caucasian (white) > Africa and Asia) - Family history Calot triangle (Hepatocystic triangle): (3C) - Formed by: Common hepatic duct, Cystic duct,Cystic artery. Etiology: - Surgical importance in cholecystectomy Cholesterol and mixed stones - Disturbance in bile salts to cholesterol ratio: Portal triad: (hepatic pedicle) ➔ Normal ratio: 25:1 - 1) Hepatic artery 2) CBD 3) Portal vein (most Posterior) ➔ If ratio changed to 13:1 >> lithogenic bile. (form stones) ➔ Causes: ▪ ↑ cholesterol: fatty diet, obesity & DM. ▪ ↓ bile salts: ✓ Terminal ileum resection / cystic fibrosis (↓ absorption) ✓ Liver cirrhosis (↓ formation) ▪ Overabsorption of water (concentrated bile)  Gallstones Mohammad Jundy - Stasis of bile: - Complications in bile duct: ➔ Female hormones (estrogen, OCP): spasm of sphincter A) Obstructive jaundice: of Oddi ▪ Stone obstructs biliary flow >> backflow of bile. ➔ Outflow obstruction. ▪ Have 2 mechanisms: 1) Stone pass GB & lodge in CBD (MC) or further down. Pigmented stones etiology: 2) Mirizzi syndrome: (rare) - Increased (↑) unconjugated bilirubin: ✓ Stone impacted in GB (cystic duct/neck) ➔ Hemolysis: black stone. (SCD, hereditary spherocytosis) ✓ Compress common hepatic duct > jaundice. ➔ Infection: brown color. (bacteria convert C-BR to UCB) B) Ascending cholangitis: Pure Cholesterol Mixed Pigmented ▪ Most serious, very deadly (sepsis) Incidence 20% (MC IN USA) Most common (75%) 5% ▪ Stone cause flow obstruction > stasis > bacterial growth Structure Cholesterol (mainly) Cholesterol Calcium bilirubinate + Ca carbonate + Ca bilirubinate ▪ Bacteria migrates from duodenum & go proximal to Etiology 1-Disturbance in bile salts to cholesterol ratio ↑ unconjugated obstruction 2- Bile stasis bilirubin level: ▪ MC bacteria: E. coli 1) Hemolysis ▪ Charcot triad of cholangitis: 2) Infection 1) Fever 2) jaundice 3) RUQ pain Number Single or multiple (MC) multiple Multiple Color yellow Yellowish brown Black →hemolysis ▪ Reynold pentad: Charcot + shock signs Brown→infection 4) altered mental status cut section Radiating Laminated Amorphous 5) hypotension (shock) (light & dark zones) Shape Oval Faceted Irregular C) Acute pancreatitis: X-ray - Radiolucent (MC) Higher probability to be radio-opaque (low amount of Ca 2+) (depend on calcium level) ▪ Stone lodge in ampulla of vater (distal to major pancreatic duct) - Radiopaque (10-20%) ▪ Obstruction & reflux of pancreatic secretions > acute pancreatitis (autolysis) If Stone in CBD, No pancreatitis D) Gallstone ileus: ▪ Mechanical obstruction, not ileus (misnomer) ▪ GB perforation: formation of fistula with ileum ▪ Cholecysto-enteric fistula: stone pass until reaching Complications of gallstones: iliocecal valve > intestinal obstruction. - Silent stones: (MC) ▪ Rigler triad: (GPS) ➔ Asymptomatic, observe pt. ✓ Pneumobilia (air inside biliary tract) - Complications in GB: ✓ SBO (small bowel obstruction) ➔ Biliary colic ✓ Ectopic radiolucent Gallstone ➔ Acute cholecystitis ➔ Chronic cholecystitis (predispose to CA)  Gallstones Mohammad Jundy Summary of complications: (ORAL) Pathogenesis: - Acute cholecystitis. - Calcular acute cholecystitis (95%) *Stone* - Ascending cholangitis ➔ GB obstruction via stone > Chemical irritation to mucosa > - Acute pancreatitis. inflammation > mucos secretion > edema/distention > mucocele - Intestinal obstruction. ➔ Stasis > ↑ bacteria > infection> pus > empyema. ➔ ↑ intraluminal pressure > Compress B.V > ischemia > gangrene Biliary colic: ➔ Perforation > Peritonitis - Transient obstruction of GB, by a stone in cystic duct or ➔ Summary: (ORAL) hartmann’s pouch. ▪ obstruction & mucocele. - The stone is inside GB and just lying in resting state ▪ infection & empyema. - Postprandial: After food (esp. fatty food) ▪ Gangrene & weak wall. ➔ Secretion of CCK > move bile > stone lodge & obstructs. ▪ perforation & peritonitis. ➔ GB try to overcome obstruction: spasm of GB wall. ➔ Cause colicky pain (repetitive cycle) - Acalcular acute cholecystitis (95%) *no stone* - After that stone may pass or return to GB ➔ More dangerous, occur in ill pt. ➔ Causes: C/P: (SOCRATES) A) Acute ill Pt.: (shock, trauma, burn) - Site: upper abdomen (max. at RUQ) ▪ Blood shift to vital organs > GB ischemia > infection - Onset: not a true colic (misnomer) A) Chronic ill Pt.: ➔ periods of Sudden pain > ↑ in intensity > plateau > ▪ TPN (total parenteral nutrition) > No GB stimulation > stasis >etc. intensity (but never disappears during pain period) - Character: gripping C/P: - Radiation: epigastric area (visceral) or - Severe and localized RUQ pain (somatic - parietal) band like in upper abdomen (T8-T9) - Radiation: epigastric area. - Referred: right upper shoulder & tip of right scapula. - Referred: right upper shoulder & tip of right scapula. ➔ Caused by diaphragm irritation: Phrenic nerve. - Ass. Sx: nausea, vomiting, diaphoresis. - Ass. Sx: nausea, vomiting, diaphoresis. - Timing: > 6 hours - Timing: < 6 hours. - Exaggerated by deep breathing or movement (Pt. lying still on bed) - Exacerbating factors: post prandial, especially fatty meal. - Reliving: Strong analgesia. Physical examination: - Severity: moderate-severe. - Vital signs: ➔ High grade fever > 38, tachycardia, ↑RR (rapid shallow breathing) Acute cholecystitis: - Abdominal exam: - Inflammation of GB, MC due to obstruction ➔ RUQ tenderness, guarding + rigidity (peritonitis) - Organisms: ➔ palpable mass (mucocele or empyema) ➔ Bacteria migrates from doudenom (bile is sterile) ➔ Murphy sign. ➔ E. coli (Most common) ➔ Auscultation: normal unless peritonitis ➔ DM Pt.: suspectable to clostridium (gas forming bacteria)  Gallstones Mohammad Jundy Murphy sign: - X-ray: (rarely used) - sudden cessation of inspiration upon deep ➔ not useful. (radiopaque stones in 10-20% of cases) palpation in RUQ due to pain. ➔ Detect porcelain gallbladder - Pain: GB go down & contact examiner hand. - HIDA scan: ➔ Most sensitive (but rarely used): show non-filling of GB DDX (differential diagnosis): Obstructive jaundice cases: - Perforated peptic ulcer (serious, rule it out) - MRCP (magnetic resonance cholangiopancreatography): - Inferior MI (serious, rule it out by ECG if suspected) ➔ Noninvasive, diagnostic only - Lower lobe pneumonia (R.t lobe) ➔ for CBD stone/biliary stones (obstructive jaundice) - Acute pancreatitis - ERCP (endoscopic retrograde cholangiopancreatography): - Acute pyelonephritis ➔ Invasive - Renal stone (nephrolithiasis ) ➔ Both diagnostic & therapeutic (esp. CBD stone) - High appendicitis (retroperitoneal appendix) ➔ Complications: acute pancreatitis, - Cholangitis (have jaundice, Charcot triad) infection, bleeding, perforation. - Other DDx: gastritis, hepatitis, liver abscess, cancers. - Other invasive procedures (rarely used): (MINI-OSCE) ➔ PTC (percutaneous transhepatic cholangiography) Investigations: ➔ Intra-Operative cholangiogram Labs (CBC, LFT, KFT, Amylase & lipase) - CBC: Leukocytosis Treatment: Abx=mainly 3rd G - LFT: - < 3 days: cephalosporins ➔ AST & ALT: Possible mild elevation. (liver damage marker) ➔ Conservative (NPO, IV fluids, etc.) (g- bacteria (e.coli)) ➔ GGT & ALP: (in bile) ➔ Early Cholecystectomy ▪ Possible mild elevation. - > 3 days: ▪ if highly elevated = biliary obstruction (e.g CBD) ➔ Conservative (NPO, etc..) + lithotripsy. ➔ Seum total and direct bilirubin: ➔ 90% subside within few days: ▪ If Total > 2.5 mg / dl = jaundice. ▪ discharge & delayed (elective) Cholecystectomy. ▪ Direct bilirubin: if high ↑ (obstructive jaundice) ➔ 10% (failure of conservative Tt): ✓ biliary obstruction (CBD) (do MRCP/ERCP) ▪ Cholecystostomy (drainage of GB) > elective Cholecystectomy. - KFT: AKI (dehydration) - Emergency cholecystectomy: - Amylase and lipase. (rule acute pancreatitis) ➔ when pyrexia & tachycardia Don’t resolve in first few hours and Pt. develops rigors. Imaging: ➔ indicate empyema, high risk of perforation. - Ultrasound: - Cholecystectomy: ➔ Study of choice. (initial) ➔ Remove GB + cystic duct + cystic artery with ligation. ➔ Findings: gallstone, enlarged wall thickness > 4 mm, ➔ laparoscopy (preferred) pericholecystic fluid, sonographic murphy sign, ➔ Open cholecystectomy (Kocher incision) Double wall sign. - Biliary obstruction: (CBD stone or below) - CT scan (undiagnostic U/S) ➔ DO ERCP & remove stone.  Gallstones Mohammad Jundy Chronic cholecystitis: - CBD stone: choledocholithiasis. Pathology: - Small stones in GB is more scary than large. - GB stone > repeated attacks of biliary colic/acute cholecystitis ➔ Pass to CBD. (obstructive jaundice/cholangitis) - chronic inflammation in the GB (wall thickening & fibrosis) C/P: - Biliary sludge: a nidus for gallstones (‫)زي حثل القهوة‬ - Recurrent episodes similar to acute cholecystitis - Cholesterol stones steps: ➔ But less severe and self-limiting ➔ Supersaturation (1st) > Stasis > crystallization > stone formation - Fatty dyspepsia. DDx: - peptic ulcer - Hiatal hernia - chronic pancreatitis - IBS - Obstructive jaundice history ‫اول ما تشوف واحد‬ Tt: ➔ Itchiness (bile salts deposition on skin) ‫عنده صفار اسأله‬ - Elective laparoscopic cholecystectomy ‫تغي ف‬ ‫ف حكة ؟ ف ر‬ ➔ Dark urine, Pale stool. ‫الياز؟‬ ‫لون البول او ر‬ Complications ➔ pale stools: no Stercobilinogen - Porcelain gallbladder ➔ Dark urine: ↑ conjugated bilirubin ➔ Calcification of GB wall due to chronic inflammation. ➔ Jaundice first location = sclera (due to elastic fibers) ➔ Appear on x-ray. ➔ Other locations: hand creases, under the tounge. - Gallbladder cancer. - LFT: Post Cholecystectomy complications: ➔ Normal total bilirubin 2.5 mg/dl - Bile leakage: (may lead to peritonitis) ➔ Direct bilirubin < 30% of total. - Bile duct strictures: ➔ ALT & AST: markers of hepatocellular damage. ➔ Most dangerous complication. ➔ GGT & ALP: markers of biliary obstruction. ➔ scarring and fibrosis of ducts. ➔ LFT Only calculate total and direct (indirect calculated manually) ➔ high risk of cholangitis, obstructive jaundice ➔ Secondary biliary cirrhosis and liver failure. - Hemolysis dark urine: ↑ urobilinogen - Post cholecystectomy syndrome: - Elective Cholecystectomy usually done 2 -3 months after. ➔ symptoms remain even after surgery ? - A pt. with CBD stone & done ERCP when to do cholecystectomy: ➔ maybe: leakage, incomplete GB removal, CBD stone ➔ The next day (at same admission) Notes: - ORAL Q: difference bt radiated & referred pain )‫(ابحث عنه بالنت او اسألن اذا ما عرفت‬ - cases: ➔ if jaundice is present: ERCP or MRCP ➔ or dialated CBD on U/S: ERCP or MRCP - CBD normal diameter = 5-6 mm. (increase 1mm/10 years in > 40 y/o) ➔ In general, above 6 = dialated. (indicate stone passage)