Gallstones

Gallstone disease and complications Kaya Saribeyoglu, MD Istanbul University, Cerrahpasa Medical Faculty Department of General Surgery

Gallstone Pathogenesis • Bile = bile salts (acids), phospholipids, cholesterol, conjugated bilirubin, water, ions • Pathogenesis involves 3 stages: 1. cholesterol supersaturation in bile 2. crystal nucleation 3. stone growth

Bile salts Cholic acid Deoxycholic acid Cheno deoxycholic acid Sodium taurocholic acid Sodium glycocolic acid

Gallstones Clinical Presentation – RUQ (or epigastric) pain (colicky, referring to back) – Jaundice – Intestinal obstruction - Fever - Nausea - Vomiting

Gallstones Complications – Inflammation of the gallbladder (cholecystitis), – Inflammation of the bile duct (cholangitis) – Inflammation of the pancreas (biliary pancreatitis) – Obstruction of the intestine (gallstone ileus) – Obstructive jaundice – Malignancies

• • • •

Symptomatic cholelithiasis

Biliary colic Pain: 1-5 hrs, rarely > 24hrs Ultrasound reveals gallstones Treatment: Laparoscopic cholecystectomy

Chronic calculous cholecystitis • Recurrent inflammatory process • Overtime, leads to scarring/wall thickening of the gallbladder • Treatment: laparoscopic cholecystectomy

Acute calculous cholecystitis

• Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema • May be associated with empyema, gangrene, rupture of the GB • Pain usually + >24hrs • Palpable/tender or even visible RUQ mass • US: Thickened wall (DD!!: CHI, hypoalbuminemia) • Nuclear HIDA : nonfilling of GB • Treatment: Cholecystectomy (early or

Acute acalculous cholecystitis • 5-10% • Critically ill patients or prolonged TPN • Complications: gangrene, empyema, perforation • Decreased enteral stimulation = low cholecystokinin = gallbladder stasis • Emergent cholecystectomy • Or cholecystostomy and delayed cholecystectomy

Choledocholithiasis • Gallstones within common bile duct (or common hepatic duct • DD: cholelithiasis, hepatitis, sclerosing cholangitis, cholangiocarcinoma

Choledocholithiasis Management • ERCP • Laparoscopic procedures – Trancystic exploration – Laparoscopic choledochotomy

• Open procedures

Surgeon

Endoscopist Radiologist

Choledocholithiasis Management ERCP • Success rate for the clearance of choledocholithiasis is 70-90%

ERCP Overall complication rate: 5% to 10% Mortality: 0.02% to 0.5% Freeman et al. N Engl J Med 1996 Cotton PB et al. Gastrointest Endosc 1991

ERCP Risks Early: Perforation, bleeding, infection, pancreatitis Late: Papillary stenosis, stricture due to cautery, cholangitis, biliary malignancy due to enterobiliary reflux

ERCP Risk of malignancy transformation ERCP: 27 708 ES: 11,617 1976 - 2003 The risk of malignancy in the bile ducts, liver, or pancreas is elevated after ERCP in benign disease. However, endoscopic sphincterotomy does not seem to affect this risk. Luo et al. Clin Gastroenterol Hepatol 2008

Difficult bile duct stones at ERCP • • • • • • • • •

Stones >15 mm, Intrahepatic stones Multiple stones Impacted stones Stone proximal to a biliary stricture Tortuous bile duct Duodenal diverticulum Prior Billroth II Prior surgical duodenotomy

Management of preoperatively “suspected” CBD stones • Jaundice • Elevated cholestatic liver function tests • History of pancreatitis • Dilated biliary system on radiographic imaging Negative ERCP: 40-70% !! Kroh M. Surg Clin North Am 2008

Reducing negative ERCP • • • •

EUS MRCP Intraoperative cholangiography Laparoscopic US

Endoscopic Ultrasound Meta-analysis including 27 papers Sensitivity: 0.94; speficifity: 0.95 EUS should be used to select patients for a therapeutic ERCP and to minimize the risk of complications associated with unnecessary diagnostic ERCP Tse et al. Gastrointest Endosc 2008

MRCP Detection of CBD stones before LC Sensitivity: 90% Speficifity: 96% Boraschi et al. Acta Radiologica 2002

IOC Routine IOC or Selective IOC for CBD stones There would be only 1.5%of the patients having missed CBD stones if selective IOC was to be performed Singh et al. Aust NZ Surg 2000

Laparoscopic US Less invasive, quick, no radiation, Identification of CBD stones Sensitivity 92%, Specificity 100% Could replace IOC

Management of diagnosed CBD stones PREOPERATIVE PERIOD No particular difficulty /contraindication ERCP Difficulties Failed attempts Contraindications

Surgery

Management of diagnosed CBD stones DIAGNOSIS OF CBD STONES DURING OP • Experience of the surgeon • Number, size, type of the CBD stones

Management of diagnosed CBD stones DIAGNOSIS OF CBD STONES DURING OP Options • Laparoscopic trancystic CBD exploration • Laparoscopic choledochotomy • Open CBD exploration • Postoperative ERCP

Laparoscopic trancystic CBD exploration • CBD is left intact • Successful CBD clearance in 60-70% • Usually requires specific instruments • Requires experience • Not appropriate in multiple large stones, small caliber CD, impacted stones etc.

Laparoscopic Choledochotomy • Effective exploration • Enables bilioenteric drainage / decompression • Residual stones may be removed via Ttube tract (4 - 6w later) • Compications of T-tube or bilioenteric anastomosis • Requires advanced laparoscopic skills

Open CBD exploration • • • • • •

Unsuccessful transcystic CBD expl Unsuccessful laparoscopic choledochotomy Multiple (>10) stones Large stones Impacted stones Failed or unavailable ERCP

Management of diagnosed CBD stones POSTOPERATIVE PERIOD No particular difficulty /contraindication ERCP Difficulties Failed attempts Contraindications

Surgery

Stone removal from T-tube tract

Laparoscopic bile duct exploration

Cholangitis • Infection of the bile ducts (CBD obstruction due to stones, strictures, tumors, bilioenteric anastomoses ascariasis etc.) • Charcot’s triad 70% +: fever, RUQ pain, jaundice • May lead to life-threatening sepsis and septic shock (Reynolds’ pentad= Charcot’s triad + hypotension and altered mental status) Treatment • Broad-spectrum antibiotherapy • Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC) • Surgery

Gallstone pancreatitis • Acute pancreatitis is related to galltones in most cases in Turkey • Pathophysiology – Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone

Tretament: • Resuscitation • ERC:P stone extraction/sphincterotomy • Cholecystectomy during hospital stay

The End