INDEX

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 Cholelithiasis
Anatomy of Gall bladder
Gallbladder is a pear-or globular-shaped organ present in the right
hypochondrium on the inferior surface of the liver, situated in the
gallbladder fossa. It is about 8-12 cm long
 Fundus: It is the dilated portion of the gallbladder adherent to
undersurface of liver from which it can be separated easily.
 Neck: The narrow angulated distal portion of the neck is called
Hartmann’s pouch-common site where stones occur and tend to
stay for a long time (also called infundibulum of gallbladder).
 Gallbladder drains into the common bile duct (CBD) through
cystic duct, which is 3 cm long. It is lined by cuboidal
epithelium. There are prominent mucosal folds within the cystic
duct due to the presence of prominent circular muscle fibres
underneath. Its lumen is usually 1-3 mm in diameter.
Contraction of gallbladder produces a functional valve called
valve of Heister which prevents the migration of stone into the
CBD. The wall of cystic duct is surrounded by a sphincter
structure called sphincter of Lutkens. A spiral fold keeps cystic
duct open for drainage of bile.

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Page 3 of 26
Cholecystohepatic Triangle or Calot’s Triangle Boundaries
 Lateral: Cystic duct and gallbladder
 Medial: Common hepatic duct
 Above: Inferior surface of right lobe of the liver.
Calot’s triangle is dissected free of all tissue except for the cystic duct
and artery, and the base of the liver bed is exposed the critical view of
safety-Strasberg et al.
Blood supply of gall bladder
Cystic artery, a branch of right hepatic artery, arises behind the
common bile duct. Soon, it branches out over the surface of
gallbladder. Cystic artery is an end artery . Multiple small veins from
the surface of gallbladder join the liver surface. There is also a cystic
vein, from the neck of gallbladder draining into portal vein directly.
This explains early spread of gallbladder malignancy to the liver.
Lymphatics

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  Subserosal and submucosal lymph nodes drain into cystic lymph
node of Lund and from here they drain into nodes in the hilum
of liver and coeliac nodes.
 Subserosal lymphatic vessels of gallbladder are also connected
to subcapsular lymph channels of liver, which accounts for
frequent spread of carcinoma gallbladder to the liver.
Anatomy of the Bile Ducts
 Common hepatic duct (CHD) is formed by the union of right
and left hepatic ducts. It is 3 cm long, receives cystic duct and
continues as common bile duct (CBD).
 Common bile duct is about 8 cm long. It has four parts:
Supraduodenal, retroduodenal, infraduodenal and intraduodenal.
Along with pancreatic duct, it forms ampulla of Vater.
Controlled by sphincter of Oddi, it ends by an opening into the
second part of duodenum .

Physiology of gall bladder

Functions of the Gallbladder
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  Reservoir for bile:
Bile excreted by the liver is stored in the gallbladder as total of
about 500 to 1000 ml per day. At fasting, the tone of sphincter of
Oddi is high. Food contents in the duodenum stimulates release
of cholecystokinin, which causes gallbladder to contract.
 Concentration:
Bile is 98% water. Due to active absorption of water, sodium
chloride and bicarbo- nate, bile gets concentrated 5-10 times.
Thus, a relative increase in bile salts, bile pigments, cholesterol
and calcium occurs.
 Mucus secretion:
It secretes about 20 ml mucus per day. Obstruction to the cystic
duct causes mucocele of the gallbladder.

Bile
 Secreted from hepatocytes. Is more than 7.0
 pH 20 – 1000ml / d * ay 98% is water.

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  Concentrated in gallbladder because of absorption of water.
Capacity of gallbladder is 40-50 ml.
 Fatty food stimulation releases cholecystokinin, which
stimulates gallbladder to contract and at the same time, sphincter
of Oddi to relax.
 It also has inorganic ions (more than plasma) and hence, severe
electrolyte imbalance is seen in biliary fistula.
 Cholesterol, synthesised in the liver, gives rise to bile acids-
cholic and chenodeoxycholic acids. They are metabolised in the
colon to deoxycholic acid and lithocholic acids.
 Main function of bile acids in the bile is to maintain cholesterol
in solution.

CHOLELITHIASIS ( Gall stones )

Calculus or stone formation in gall bladder is known as cholelithiasis.
Incidences

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The incidence of gallstones increases with age, and women are
affected approximately three times more often than men. The
prevalence of gallstone disease among women who are younger than
50 years of age is 5% to 15%; in older women, it is approximately
25%. It is rare in first two decades.
This condition is more common in 5 F’s – Fatty, Fertile (multiparity),
Forty, Flatulent and Females.
Composition of gall stones
Major elements in gallstone are cholesterol, bile pigment and calcium,
it also include iron, carbonates, phosphorus, protein, cellular debris,
mucus and carbohydrate.
Aetiology
1. Metabolic Causes
 Cholesterol is produced from the liver, which gives rise to
bile acids. Cholesterol is insoluble and it must be
transported within the bile salt micelles and phospholipid
(lecithin) vesicles. Normal ratio of bile acids: cholesterol is
25:1.
 This ratio is necessary to maintain the cholesterol in liquid
form by forming micelles. When the ratio drops down to
13:1 (which is called critical ratio), cholesterol crystals
will nucleate and stones will form.
 Obesity, high calorie diet and medications which increase
cholesterol secretion can result in stone formation.
2. Infection
 It is the most common cause responsible for a gallstone in
80% of patients. Sources of infection are tonsils, tooth,
bowel, etc.
 Organisms such as E. Coli, Proteus, anaerobic organisms,
streptococci, etc. Reach the gallbladder wall through the

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 bloodstream and form a focus/nidus around which
cholesterol and bile salts get precipitated.
 Over a period of many years, this results in a mixed stone.
They are usually multiple and occur in infected bile.
3. Bile stasis and decreased Bile Acid Pool
 Pregnancy, oestrogens, following vagotomy and prolonged
total parenteral nutrition are associated with bile stasis.
 They are prone to mixed stones as a result of bile stasis.
4. Haemolytic Anaemia
 Examples: Hereditary spherocytosis, sickle cell anaemia.
 Bilirubin production is increased because of increased
breakdown of RBCs. Since the production is more, they
cannot conjugate with glucuronic acid, which is produced
at normal levels.
 Such unconjugated bilirubin combines with calcium and is
excreted in the biliary tree resulting in calcium bilirubinate
stones (pigment stones) not only in the gallbladder but also
in the entire ductal system.
5. Saint's Triad
Gallstones can occur along with two other conditions:
 Diverticulosis of colon
 Hiatus hernia
6. Parasitic Infestation
 In Oriental countries, Clonorchis sinensis (Chinese liver
fluke) infestations can cause stone in the biliary tree.
 Ascaris lumbricoides in the biliary tree may produce
stones the common bile duct.
7. Due to Abnormal mucus
It is produced in congenital cystic fibrosis. Gallstones occur in
these children due to impairment of bile flow.
8. Risk factors of Gall Stones

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  Female sex
 Obesity
 Maturity onset diabetes
 Age > 40 years

Types of Gall Stones

A. Cholesterol
 Constitutes about 10% of the gallstones.
 Occur in patients withIncreased cholesterol levels.
 Fatty women are commonly affected.
 It is single, solitary, occurs in aseptic bile Sometimes they
can be multiple. Precipitation of cholesterol gives rise to
stone.
 Such stones can be silent for many years. They are
radiolucent.
 Pigment can also get precipitated along with cholestero
Formation of cholesterol Stones

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 B. Brown pigment stones
 Rare in gallbladder, occurs in bile duct.
 Composed of calcium bilirubinate, calcium palmitate and
calcium stearate + cholesterol.
 Occur due to bile stasis caused by foreign bodies,
endoprosthesis, Clonorchis sinensis and Ascaris
lumbricoides.
C. Mixed stones
 They constitute about 80% of gallstones.
 They contain alternating layers of cholesterol and pigment
with epithelial debris or vegetations, from infective
organisms.

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  They are multiple, small, faceted by mutual pressure.
D. Pigmented Stones
 They are found in 5 to 10% of patients.
 They are calcium bilirubinate stones.
 Commonly occur due to haemolysis. Hence, they are
black, multiple, small, irregular concretions or sludge
particles.
 For reasons not clear, cirrhotic patients have increased
incidence of black pigment stones.
 Bacteria also have a major role to play in the formation of
pigment stones. Patients with pigment stones have more
sepsis than patients with cholesterol stones.

Clinical features
Clinical presentation of these patients vary from dyspepsia to severe
forms such as pancreatitis and perforation of the gallbladder.
Complications are Classified as in the gallbladder, in the CBD and in
the intestines.
IN THE GALLBLADDER
 Asymptomatic gallstones: Silent asymptomatic stones occurs
in 10% of males and 20% of females. The dangerous and
gravest complication of asymptomatic gallstone is carcinoma of
gall bladder.
Treatment : Considering of dreadful compli- cations the
treatment is cholecystectomy (removal of gall bladder).

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  Biliary colic: The pain occurs with periodi-city, severe pain
within hours after meal (commonest presentation). Biliary colic
is spasmodic pain often severe, in right epigas- trium radiating
to inferior angle of right scapula. It is often triggered by a
fatty/heavy meal. It is aggravated by supine position and while
sleeping at night. Fever and increased WBC count may be
observed.

Colic is a form of pain that starts and stops abruptly. It occurs

due to muscular contractions of a hollow tube (colon, ureter, gall
bladder, etc.) in an attempt to relieve an obstruction forcefully
 Cholecystitis: This is inflammation of gall bladder.
 Empyema gall bladder: Pus filled gall bladder It may be a
sequel of acute cholecystitis or the result of a mucocele
becoming infected. The treatment is drainage and, later, chole
cystectomy.
 Perforation : It may cause biliary peritonitis or pericholecystitic
abscess.
 Mucocele of gall bladder: Usually cholesterol type of gall
stone may block the cystic dust. The bile is absorbed and gall
bladder becomes filled and distended with mucous. It is called
mucocele. Treatment is cholecystectomy to avoid complications
like infection, perfora- tion etc.
 Carcinoma gall bladder: It may occur due to continuously
irritation by stone.
IN THE CBD
 Secondary CBD stones (occurs in 10% of gallstones).
 Cholangitis: Inflammation of bile duct.
 Pancreatitis: It occurs due to reflux of bile in pancreas.
 Mirizzi syndrome: In Mirizzi syndrome, gall- stone impacts in
the gall bladder wall and compresses it causing pressure
necrosis which further gets adherent to CBD wall. It eventually
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 causes compression and later occasionally leads into
cholecystochole- dochal fistula (fistula between gall bladder and
bile duct).
IN THE INTESTINE
 Cholecystoduodenal fistula : It may cause gall stone ileus and
so intestinal obstruction.
 Flatulent dyspepsia: It is discomfort in the abdomen, belching,
heartburn, fat intole rance, and sensation of fullness in the
abdomen usually observed in fatty, fertile, flatulent females.

IN THE BILE DUCT

 Obstructive jaundice
 Cholangitis
 White bile
 Acute pancreatitis

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Complications of the Gall bladder
Silent Stones
 This is usually a single, silent, cholesterol is symptomless. Stone
which
 Accidentally may be by an ultrasound or plain X-ray abdomen
(since calcium content is low It is in a cholesterol stone, it is
very rarely visible in a plain X-ray). Stone rarely causes
 This obstructive jaundice. Hence, it is left alone without
treatment.
Flatulent Dyspepsia
If an obese woman (fatty, fertile, flatulent, female in complains of
gaseous ity food and discomfort in the abdomen, hence to and
belching, she probably has gallstones Tourn patients benefit from
cholecystectomy.
Gallstone Colic
 It usually occurs at night wherein a stone tends to block the
cystic duct or neck of gallbladder in the supine position.

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  It is a severe colicky upper abdominal pain felt in the right
hypochondrium, may shoot to the back or between shoulder
blades. The pain is continuous and lasts for a few hours. Pain
may radiate to chest also
- The pain is due to spasm of gallbladder.
- It is associated with vomiting due to reflex pylorospasm,
restlessness and sweating.
- There is tenderness in the right hypochondrium.
 Pain may last for a few minutes to a few

Differential diagnoses include:

 Chronic duodenal ulcer

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  Reflux oesophagitis (some causes can present as
 Precordial chest pain)
 Pancreatitis
 Myocardial infarction

Investigations
 Complete blood test: It shows increased WBC counts.
 X – ray abdomen: A plain radiograph of the gall Nadder show
radio-opaque gallstones in 10% alpatients with gallstones. The
center of a stone may contain radiolucent gas in a triradiate or
biradiate fissure and this gives rise to characteristic dark shapes
on a radio- graph, the ‘Mercedes-Benz’ or ‘seagull’ sign. Plain
X-ray should be differentiated from kidney stones. In lateral
view X-ray, gallstone will be in front of the vertebra whereas
kidney one overlaps the vertebra.
 Oral cholecystography: Although this was the standard method
of investigating the gall bladder for many years, it has now been
outdated by ultrasonography. A biliary contrast medium based
on tri-iodobenzoic acid, which is primarily excreted by the
liver , is taken by mouth. It is absorbed into the portal venous
system, transported across liver cells into bile and concentrated
in the gall bladder, where it becomes visible on a radiograph.
Patients are then given a fatty meal; a normal gall bladder
contracts. Failure of the gall bladder to opacity is evidence of
gall bladder disease, provided that the contrast material has been
absorbed and the patient is not jaundiced.
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  Intravenous cholecystography: The contrast medium is given
through intravenous route and then multiple radiographs are
taken to visualize the gall bladder.
 Ultrasonography: Trans-abdominal ultrasono- graphy is the
initial imaging modality of choice as it is accurate, readily
available, inexpensive and quick to perform. However, it is
operator dependent and may be suboptimal due to excessive
body fat and intraluminal bowel gas. It can demonstrate biliary
calculi, the size of the gall bladder, the thickness of the gall
bladder wall, the presence of inflammation around the gall
bladder, the size of the common bile duct and, occasionally, the
presence of stones within the biliary tree. It may even show a
carcinoma of the pancreas occluding the common bile duct.

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  Computerized tomography (CT scan): This imaging modality
allows visualization of the liver, bile ducts, gall bladder and
pancreas, but the efficacy is not better than ultra- sonography
and it is expensive also.
 Radioisotope scanning (Cholescintigraphy) :Technetium-99m
(99mTc)-labelled deriva- tives of iminodiacetic acid are (when
injected intravenously) selectively taken up by the
retroendothelial cells of the liver and excreted into bile. This
allows visualization of the biliary tree and gall bladder.
 MRCP (Magnetic resonance cholangiopancreato- graphy):
Magnetic resonance cholangiopanc- reatography (MRCP) is an
imaging technique based on the principles of nuclear magnetic
resonance used to image the gall bladder and biliary system. It is
non-invasive and can provide either cross-sectional or projection
images. Contrast is not required and excellent images can be
obtained of the biliary tree that demonstrate ductal obstruc-tion,
strictures or other intraductal abnormalities.
 ERCP (Endoscopic retrograde cholangio-
pancreatography):
This technique remains widely used. Using a side-viewing
endoscope, the ampulla of Vater can be identified and
cannulated. Injection of water-solub contrast directly into the
bile duct provides excellent images of the ductal anatomy and
can identify causes of obstruction such as stones or malignant
strictures.
Therapeutic interventions such as stone removal or stent
placement to relieve the obstruction can be performed through
ERCP. Thus, ERCP is a both therapeutic and diagnostic
technique.
 PTC (Percutaneous transhepatic cholangiography) :
This is an invasive technique in which the bile ducts are
cannulated directly (percutaneous or through skin). Under
radiological control (either ultrasound or CT), a bile duct is
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 cannulated. Successful entry is confirmed by contrast injection
or aspiration of bile. Water-soluble contrast medium is injected
to demonstrate the biliary system. Multiple images can be taken
to demonstrate areas of strictures or obstruction.

Management
Nutritional And Support therapy –
 The diet immediately after an episode is usually limited to low-
fat liquids.
 Include powdered supplements ↑ protein & carbohydrate into
skim milk.
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  Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-
gas-forming veg, bread, coffee or tea may be added as tolerated.
 Avoid eggs, cream, pork, fried foods, cheese, gas- forming
vegetables & alcohol.
 Fatty foods may bring on an episode.
 Dietary management may be the major mode of therapy in
patients who have had only dietary intolerance to fatty foods &
vague G.I. symptoms
Pharmacologic Therapy –
 Ursodeoxycholic acid (UDCA), chenodeoxycholic Acid
(chenodiol or CDCA).
 Acts by inhibiting the synthesis & secretion of cholesterol,
thereby desaturating bile.
 Existing stones can be reduced in size, small ones dissolved &
new stones prevented from forming.
 6 to 12 months of therapy are required.
 The effective dose of medication depends on body weight.
 This method of treatment is generally indicated for patients who
refuse surgery or for whom surgery is considered too risky.
 Patients with significant, frequent symptoms, cystic duct
occlusion, or pigment stones are not candidates for this therapy.
 Symptomatic patients with acceptable operative risk are more
appropriate for laparoscopic or open cholecystectomy.
Non Surgical removal of Gall Stones –
1) Dissolving Gall Stones
 By infusion of a solvent (mono-octanoin or methyl tertiary
butyl ether [MTBE]) into the gallbladder.
 Can be infused through a tube or catheter inserted
percutaneously directly into the gallbladder; a tube or
drain inserted through a T-tube tract to dissolve stones not

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 removed at the time of surgery; an ERCP endoscope; or a
transnasal biliary catheter.
 In the latter procedure, the catheter is introduc through the
mouth & inserted into the CBD. The upper end of the tube
is then rerouted from the mouth to the nose & left in place.
 This enables the patient to eat & drink normally while
passage of stones is monitored or chemical solvents are
infused to dissolve the stones.
 This method of dissolution of stones is not widely used in
patients with gallstone disease.
 Method used when the size of stone not more than 20 mm
in diameter.
2) Stone Removal by instrumentation
 used to remove stones that were not removed at the time of
cholecystectomy or have become lodged in the CBD.
 A catheter & instrument with a basket attached are
threaded through the T-tube tract or fistula formed at the
time of T-tube insertion; the basket is used to retrieve &
remove the stones lodged in the common bile duct.
 A second procedure involves the use of the ERCP
endoscope.After the endoscope is inserted, a cutting
instrument is passed through the endoscope into the
ampulla of Vater of CBD.
 Another instrument with a small basket or ballo its tip may
be inserted through the endoscope to retrieve the stones.
 The patient is closely observed for bleeding, perforation &
the development of pancreatitis or sepsis.
 The ERCP procedure is particularly useful in the diagnosis
& treatment of patients who have symptoms after biliary
tract surgery, for patients with intact gallbladders, & for
patients in whom surgery is particularly hazardous.
3) Extracorporeal Shock wave Lithotripsy
 Used for nonsurgical fragmentation of gallstones.
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  Derived from lithos, meaning stone & tripsis, meaning
rubbing or friction.
 Uses repeated shock waves directed at the gallstones in the
gallbladder or CBD to fragment the stones.
 The energy is transmitted to the body through a fluid-filled
bag, or it may be transmitted while the patient is immersed
in a water bath.
 Converging shock waves are directed to the stones to be
fragmented.
 After the stones are gradually broken up, the stone
fragments pass from the gallbladder or CBD
spontaneously are removed by endoscopy, or dissolved
with oral bile acid or solvent.
 Requires no incision & no hospitalization, patients are
usually treated as OPD, but several sessions are generally
necessary.
4) Intracorporeal Lithotripsy
 Fragmented by means of laser pulse technology.
 A laser pulse is directed under fluoroscopic guidance with
the use of devices that can distinguish between stones &
tissue.
 Produces rapid expansion & disintegration of plasma on
the stone surface, resulting in a mechanical shock wave.
 Electro-hydraulic lithotripsy uses a probe with two
electrodes that deliver electric sparks in rapid pulses,
creating expansion of the liquid environment surrounding
the gallstones.
 This results in pressure waves that cause stone fragment.
 Can be employed percutaneously with the use of a basket
or balloon catheter system or by direct visualization
through an endoscope.
 Repeated procedures may be necessary due to stone size,
local anatomy, bleeding, or technical difficulty.
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  A nasobiliary tube can be inserted to allow for biliary
decompression & prevent stone impaction in the CBD
This approach allows time for improvement in the
patient’s clinical condition until gallstones are cleared
endoscopically, percutaneously, or surgically.
Surgical Management
1) Laproscopic Cholecystectomy
 If the CBD is thought to be obstructed by a gallstone, an
ERCP with sphincterotomy may be performed
 Performed through a small incision or puncture made
through the abdominal wall in the umbilicus.
2) Cholecystectomy
 Gallbladder is removed through an abdominal incision
(usually right subcostal) after the cystic duct & artery are
ligated.
 Performed for acute & chronic cholecystitis.
 Drain may be placed close to the gallbladder bed &
brought out through a puncture wound if there is a bile
leak.
 Drain type is chosen based on the physician’s preference.
3) Small incision cholecystectomy
 Gallbladder is removed through a small incision.
 If needed, the surgical incision is extended to
 Remove large gallbladder stones.
 Drains may or may not be used.
 The cost savings resulting from the shorter hospital stay
have been identified as a major reason for pursuing this
type of procedure.
 The procedure is controversial because it limits exposure
to all the involved biliary structures.

4) Choledochostomy
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  An incision into the common duct, usually for removal of
stones.
 After the stones have been evacuated, a tube usually is
inserted into the duct for drainage of bile until edema
subsides.
 This tube is connected to gravity drainage tubing, the
patient is monitored closely.
 A laproscopic cholecystectomy is planned for a future date
after acute inflammation has resolved.
5) Surgical Cholecystostomy
 Performed when the patient’s condition prevents more
extensive surgery or when an acute inflammatory reaction
is severe.
 The gallbladder is surgically opened, the stones & the bile
or the purulent drainage are removed & a drainage tube is
secured with a purse-string suture.
 The drainage tube is connected to a drainage system to
prevent bile from leaking around the tube or escaping into
the peritoneal cavity.

6) Percutaneous cholecystectomy

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  Used in the treatment & diagnosis of acute cholecystitis in
patients who are poor risks for any surgical procedure or
for general anesthesia.
 Under local anesthesia, a fine needle is inserted through
the abdominal wall & liver edge into the gallbladder under
the guidance of ultrasound or computed tomography.
 Bile is aspirated to ensure adequate placement of the
needle & a catheter is inserted into the gallbladder to
decompress the biliary tract.

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