Cholelithiasis

• Gall stone are most common biliary

pathology.
 ANATOMY
BILIARY SYSTEM
Gall bladder.
cystic duct .
Hepatic duct.
common hepatic duct.
common bile duct.
 Gall bladder
• Pear shaped.
• 7 to 10 cm long.
• Capacity- 30 to 50 ml.
• Can be distended up to 300 ml.
• Located in the inferior surface of the liver.
• Divided in to-Fundus,
• Body
• infundibulum
• neck.(hartmann’s pouch).
• Coating-
1. Serous-derived from peritonoum.
2. Fibromuscular
3. mucous
 Blood supply
• Artery-
 Cystic artery-branch of right
hepatic artery.
• Vein-
hepatic vein

• Lymphatic supply-
 Cystic lymph node
 liver
 FUNCTION OF G.B.
• ABSORBTION AND SECRATION
• MOTOR ACTIVITY.
• NEUROHORMONAL REGULATION



• CONTAIN OF BILE-
1 to 2% bile solt.

1%bile pigment

Cholesterol

Fatty acid

Water-97%.

Secreted at the @ 40 ml /hr.

PH - 8.2 (from liver)

 7.4 to 7.0 (in G.B.)

 Congenital anomalies
• Absence of G.B.
• Duplication
• Bilobed of G.B. with a single a single cystic duct.
• Accessory G.B.
• Floating G.B.
• Left sided G.B.
• Intrahepatic G.B.
• Accessory hepatic duct.
• Two hepatic artery
• Right hepatic artery –tortuous (caterpillar hump /
Moynihan’s hump)
• Double cystic artery.
• Right hepatic artery is adherent to cystic duct.
• Absence of cystic duct.
• Cystic duct may drain in right / left hepatic duct.
 CHOLELITHIASIS(GALLSTON
E)
• GALL STONE ARE COMMON IN POPULATION.
• Women : men - 4:1.
• Rare in first two decades.
• Incidence increases - 21 yr -5th and 6th decade
• COMMON IN 4 “F”s
• Fat, Fertile , Forty, Females.
• Major elements are-
 cholesterol,
 bile pigment
 Calcium,
 iron
 carbonates,
 proteins,
 cellular Debris,
 mucus ,
 carbohydrates.
GALL STONES
 PATHOGENESIS OF STONE
• FOUR FACTORS INVOLVED ARE :
• 1. METABOLIC FACTOR.
• 2. REFLUX FACTOR.
• 3. STASIS FACTOR.
• 4. INFECTIVE FACTOR.
•

• 1.METABOLIC FACTOR:
 Solubility of cholesterol depends on
concentration of conjugated bile salts and
phospholipids in the bile.
 Normal ratio-bile solt : cholesterol-25 : 1.
When his ratio falls up to 13:1 cholesterol

precipitates.
Most of the time cholesterol secretion is
greatly increased without any reduction in
bile solt and phospolipids such as –polya
type partial gastrectomy, infection,
prolonged administration of progesterone.
Bile pigment stone results from
excessive
Haemolysis seen in haemolytic

anaemia septic
Haemolysis and malaria.There is

increased
Breakdown of haemoglobin and excess

of bile
Precipitates to form pigment stone.

2. REFLUX FACTOR: Pancreatic



enzymes are found

3. STASIS FACTOR :
Temporary cessation of bile Flow into the

intestine and stagnation of bile inThe

gallbladder is major factor of gallstone.
It is Associated with interruption of
enterohepatic
circulation,accompanied by decrease in

output
Of bile salts & phospholipids reducing
the solubility
Of cholesterol.


4. INFECTIVE FACTOR: Its major cause of
gallstone
Infection includes organisms such as

E.coli,
Streptococcous etc.

These infection anywhere in the body

reach
Gallbladder via bloodstream or from

bowel
through lymphatics.


 TYPES OF STONES :
1 . PURE STONES. ( 10%)

 CHOLESTEROL STONES.
 PIGMENT STONES.
 CALCIUM CARBONATE STONES.
2 . MIXED AND COMBINED STONES.

(90%)
•
1.PURE STONES :
A . Cholesterol stones

• Most common nearly 70%

• Cholesterol stones is usually solitary with
smooth Surface
• It is oval in shape ,
• light in colour .
• Pure
• Cholesterol stone is pale yellow but often
bile Pigment are deposited within it.
• They are thought To be formed in aseptic
static bile. On section it
• shows radiating lines which cross circular
strata.
B . Pigment stones:
• May be pure or consist
ofCalciumbilirubinate.
• It is black or dark brown in colour.
• Found in gallbladder.
• It is associated with excessive Haemolysis
eg. Sickle cell disease , thalasemia etc
(It is due to ----Haemoglobin >excessive

bilirubin >
>excreated in bile >>pigment stone in

gallbladder.)
• Calcium bilirubinate stones are earthly
brown to
C. CALCIUM CARBONATE STONES:


• Rare type.
• Greyishwhite with smooth surface.
• Alkalinity ofThe bile may favour
precipitation of calcium
• Carbonate with slow build up of stones
.size=2cm
• Sand grain to polyhedral in shape.
2 . MIXED AND COMBINED STONES :
• It has varying proportion of all three stones.
• Combined stones are those in which either
the central core or external
• Layer are pure and remainder of the stone is
a
mixture of constituents .

• Their surfaces are faceted by Mutual

pressure .
• Size vary up to 2 cm diameter.


Cholesterol = yellow.
Bilirubinate = black.

Calcium carbonate = grayish white.

 SIGNS
• PYREXIA
• JAUNDICE
• TENDERNESS-Murphys sign
• LUMP
• BOAS’S SIGN
 SYMPYOMS
• PAIN-
sudden onset, followed by heavy,fatty

meal.
(right upper qudrent,referred to

inferior angle of scapula or Right

shoulder).
• Nausea
• Vomiting
• Belching
• Abdominal distention
 INVESTIGATION
• HAEMATOLOGICAL
 wbc,sr.bilurubin, sr.amylase

• ECG
• X-ray -straight abdomen.
• CT scan
• Ultrasonography
• PTC
• ERCP
• CHOLESCINTIGRAPHY

 EFFECT AND
COMPLICATIONS.
1. IN THE GALLBLADDER :


1 .Asymptomatic gallstone
2.Hydrops of the gallbladder.

3.Flatulent dyspepsia.

4.Gallstone colic.

5.Acute obstructive cholecystitis.

6.Chronic cholecystitis.

7.Carcinoma


2. IN COMMON BILE DUCT:
1.Obstructive jaundice.

2.Liver failure.

3. Cholangitis

4. Acute or recurrent pancreatitis.

3.IN PANCREAS :

1.Acute pancreatities.

2.Acute relapsing pancreatitis.

3.Chronic pancreatitis.

•
4.IN THE INTESTINE:
Gallstone ileus.

SAINT`S TRIAD :

Gallstone , hiatus hernia &

diverticulosis of the colon may exist .The

patient
present with flatulent dyspepsia.

CHOLECYSTIC HEART :

Diseased gallbladder may cause

Diseased cronary blood flow , arrhythmia

or heart
Block . This is known as Cholecystic heart.
ASYMPTOMATIC GALLSTONE:
After a long follow-up

50%cases has turned symptomatic &

serious
Complication have occurred in 20% of

cases;ie
Carcinoma of the gallbladder.

T/t –cholecystectomy.

FLATULENT DYSPEPSIA:

This sym includes feeling of

Fullness after food,belching & heart burn

which
GALLSTONE COLIC:
Small calculi at neck/entry of

cystic duct muscles contraction to expel

it.Occurs
mostly at night.Pain at upper &rt.quadrant of

Abdomen.

ON EXAMINATION:
 Enlarged gallblader on palpation.
SPECIAL INVESTIGATION:

 Straight x-ray show stones In 10% of

cases.
T/t:

cholecystectomy , choledocholithotomy{if stone

Migrated into common bile duct}.

 TREATMENT
• Conservative management:
• NBM
• NASOGASTRIC ASPIRATION for3-5
days.
• I.V. administration should be started
• immediately in the beginning
by 5% dextrose saline & then
changed according to the electrolyte
imbalance .
• Urine output should be monitored.
• Anticholinergic drugs to reduce gastric
&pancreatic secretions.
• Analgesics except Morphine &
Pethidine.
• Antibiotics-
 Stone dissolution:
Ursodeoxycholic acid 8 to


10 mg/kg/day po dissolves
80% of tiny stones < 0.5
cm in diameter . For larger
stones (the majority), the
success rate is much
lower, even with higher
doses of ursodeoxycholic
 CHOLECYSTECTOMY
• INDICATIONS-
1.Chronic cholesystities
2.Trauma to G.B.
3.Empyma
4.Gangrene of G.B.
5.Ca


1.
 contraindication
• Acute cholecystitis.
• Blood coagulopathy
• Incision-
Right subcostal (kocher’s)

1 to 1.5 cm bellow the costal margin in

the epigastrium-run parallel to

subcostal margin ends up to
ant.axillary line.
Right upper paramedian incision
 layers
• Skin
• SC
• Medially-Ant rectus m.,Rectus
m.,post.rectus sheath,peritonium.
• Laterally-ext/int obliqque,
 transverse abdominus
Methods:
ØDUCT-FIRST METHOD:
the cystic duct and artery are dissected first and
•
•

divided,after which gallbladder is removed.This is

•
•

most popular as less chances of injury to the common

•
•
•

bile duct/hepatic artery.

•
•

ØFUNDUS –FIRST METHOD:

•
•
•

Fundus of gallbladder is removed first and then

•
•
•

gradually proceeded toward cystic duct.

•
•
•

Lohey’s method
•
•

Trocar and canula

•
•
•

Ø •
•
•

Ø
 PRE-OPERATIVE:
If pt.have some disturbance of liver


function then give following :

• Glucose drink-150mg orally for 3
days.
• In case where oral intake is not
allowed- 5% glucose I.V.
• Antibiotics

• Oral cholecystography any time

before operation.
 OPERATIVE:
An incision about 6 to 8 inches long is


made in the right chest parallel to

the rib cage or, alternatively, in the
middle of the body from the middle
of the rib cage to near the belly
button.  Once the abdomen is
opened,one wet mob is placed to
displace the duodenum,transverse
colon, s.intestine downwards,another
wet mob is placed to the left of
common bile ductto displac e
stomach to the left.rt. Lobe of liver is
retracted upward by deaver’s
retractor &whole gall
bladder,common bile duct & cystic
The junction of the cystic duct and


cystic artery is displayed by

dissecting the overlying
peritoneum.If the stone is felt at the
cystic duct it is milked towards the
gall bladder.If the stone is impacted
then it is removed through a small
nick on the cystic duct.Thecystic
artery should be explore and
ligated.Then the gall bladder is freed
from the liver and removed out and
stitching is done.
 LAPAROSCOPIC CHOLECYSTECTOMY
The surgeon stands on the pt’s left side with
moniterlevel with pt’s rt.shoulder& makes several
tiny incisions in the abdomen and inserts surgical
instruments and a miniature video camera into
the abdomen. The camera sends a magnified
image from inside the body to a video monitor,
giving the surgeon a closeup view of the organs
and tissues. While watching the monitor, the
surgeon uses the instruments to carefully
separate the gallbladder from the liver, ducts, and
other structures. Then the cystic duct is cut and
the gallbladder removed through one of the small
incisions.
THANK YOU


 ACUTE CHOLECYSTITIS
Inflamation of gallbladder is associated

with calculi[90%].
PATHOGENESIS: FOUR FACTORS –

1.OBSTRUCTION OR STASIS.
2.CHEMICAL IRRITATION.
3.BACTERIAL INFECTION.
4.PANCREATIC REFLUX.
1.OBSTRUCTION OR STASIS: Stones obstruct
the
cystic duct .stone may pass into the common

bile
Duct & GIT.obstruction will cause stasis of bile

leading
to progessive concentration of bile & chemical

Irration of gallbladder.

2.CHEMICAL IRRATION: Erosion of mucosa by

stone .
Bile salts are very toxic to cells & this causes

destruction of cells.Venous & lymphatic stasis

may
also occur.


4. PANCREATIC REFLUX : Injection of
pancreatic
enzyme exercises a definite inflammatory

response.
Active lipases, amylases and proteases have

been
identified in the bile in patients of acute

cholecystitis
PATHOLOGY : Gallbladder enlarged two to

three times
- Bright red or violet to green black in colour
– serosa
conjested covered with fibrinous exudate –

areas of
Gangrene or necrosis – wall of Gallbladder
 Mucosa is hyperaemic & show necrotic
surfaces =
Gangrenous Cholecystitis

Perforation throu site of ischaemic gangrene

give rise
to : a] Biliary peritonitis

 b] Localised pericholecystic abscess or

local
 abscess
 c] cholecystoenteric fistule .
CLINICAL FEATURES :

SYMPTOMS : 1. Past history chronic

cholecystitis
2. Heavy, fatty meal

3. Pain in the right upper quadrant , referred

back to
SIGNS: 1. Pyrexia is a regular feature
2. Jaundice is present in only 10% cases

3. Tenderness in the right upper quadrant

{ rebound
tenderness}

4. Murphy`s sign- acute pain during deep

inspiration
SPECIAL INVESTIGATION : 1. Blood

leucocytosis +
sr.bilirubin , sr.amylase +

2.ECG

3. Straight X-ray –of abdomen

4.Cholecystography
RADIOLOGICAL FINDING
D D : Perforated / penetrating peptic ulcer
.
Acute pancreatitis , gallbladder colic ,

hepatitis .
COMPLICTION : 1. Preforation

 2. Pericholecystic
abscess
 3. Internal fistula .
 Treatment of Acute
Cholecystitis
• Conservative management:

‫ ٭‬NBM & NASOGASTRIC ASPIRATION for3-5
days. I.V. administration should be started
immediately in the beginning by 5% dextrose
saline & then changed according to the
electrolyte imbalance .Urine output should be
monitered.
 *Anticholinergic drugs to reduce gastric
&pancreatic secretions.
 *Analgesics except Morphine & Pethidine.
 *Antibiotics- IInd generation
cephalosporin/chloramphenicol.


• Surgery:
 Cholecystectomy: The operation for removal of
gallbladder.

 Treatment of
Cholelithiasis
• Laparoscopic cholecystectomy for
symptomatic stones.
• For asymptomatic stones sometimes
stone dissolution.
• If gallstone has migrated into the
common bile duct-t/t is
cholecystectomy with
choledocholithotomy.
 Chronic
Cholecystitis
PATHOLOGY:
The external surface becomes opaque

& yellow due to accumulation of

subserous fat.
 Gall bladder



co n tra cte d d ila te d
ro n ic in fla m m a tio n o b stru ctio n
• CLINICAL FEATURES:
 *Intolerance to fatty food
 *belching
 *postcibal epigastric distension
 *nausea & vommiting
 *pain-follows after meals,in the right
quadrant/epigastric region,radiates to the
back to the inferior angle of the right
scapula/inter-scapular region/right
shoulder.
• PHYSICAL SIGNS:
 *Tenderness at right upper
quadrant/epigastric region
 *Murphy’s sign may be positive
INVESTIGATION:
• Examination of blood does not reveal any
picture.
• Oral cholecystography shows non-
visualisation of gallbladder & is quite
diagnostic.
DIFFRENTIAL
• USG-accurate test DIAGNOSIS:
for diagnosis of
gallbladder.
Peptic ulcer,pancreatitis,oesophageal hiatus
hernia,appendicitis,right
 pyelonephritis,myocardial
infarction,pleuritis,arthritic changes of thoracic spine,hepatitis.

TREATMENT:
Cholecystectomy
 CHOLECYSTECTOMY
Methods:
•
•
•

ØDUCT-FIRST METHOD:
•
•
•

The cystic duct and artery are dissected first and

•
•

divided,after which gallbladder is removed.This is

•
•
•

most popular as less chances of injury to the common

•
•
•
bile duct/hepatic artery.
•
•

ØFUNDUS –FIRST METHOD:

•
•
•

Fundus of gallbladder is removed first and then

•
•
•

gradually proceeded toward cystic duct.

•
•

Ø
•
•

Ø
 PRE-OPERATIVE:
If pt.have some disturbance of liver


function then give following :

• Glucose drink-150mg orally for 3
days.
• In case where oral intake is not
allowed- 5% glucose I.V.
• Antibiotics

• Oral cholecystography any time

before operation.
 OPERATIVE:
An incision about 6 to 8 inches long is


made in the right chest parallel to

the rib cage or, alternatively, in the
middle of the body from the middle
of the rib cage to near the belly
button.  Once the abdomen is
opened,one wet mob is placed to
displace the duodenum,transverse
colon, s.intestine downwards,another
wet mob is placed to the left of
common bile ductto displac e
stomach to the left.rt. Lobe of liver is
retracted upward by deaver’s
retractor &whole gall
bladder,common bile duct & cystic
The junction of the cystic duct and


cystic artery is displayed by

dissecting the overlying
peritoneum.If the stone is felt at the
cystic duct it is milked towards the
gall bladder.If the stone is impacted
then it is removed through a small
nick on the cystic duct.Thecystic
artery should be explore and
ligated.Then the gall bladder is freed
from the liver and removed out and
stitching is done.
 LAPAROSCOPIC CHOLECYSTECTOMY
The surgeon stands on the pt’s left side with
moniterlevel with pt’s rt.shoulder& makes several
tiny incisions in the abdomen and inserts surgical
instruments and a miniature video camera into
the abdomen. The camera sends a magnified
image from inside the body to a video monitor,
giving the surgeon a closeup view of the organs
and tissues. While watching the monitor, the
surgeon uses the instruments to carefully
separate the gallbladder from the liver, ducts, and
other structures. Then the cystic duct is cut and
the gallbladder removed through one of the small
incisions.
 Stone dissolution:
Ursodeoxycholic acid 8 to


10 mg/kg/day po dissolves
80% of tiny stones < 0.5
cm in diameter . For larger
stones (the majority), the
success rate is much
lower, even with higher
doses of ursodeoxycholic
 ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
(ERCP)
• The patient swallows an endoscope--a
long, flexible, lighted tube connected to
a computer and TV monitor. The doctor
guides the endoscope through the
stomach and into the small intestine.
The doctor then injects a special dye
that temporarily stains the ducts in the
biliary system. Then the affected bile
duct is located and an instrument on the
endoscope is used to cut the duct. The
stone is captured in a tiny basket and
removed with the endoscope.
ERCP