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

• Reynolds 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