CALCULOUS BILIARY DISEASE Fabian Ovidiu

Biliary physiology
Cystic duct

The bile ducts, gallbladder and sphincter of Oddi act in concert to modify, store, and regulate the flow of bile

Common hepatic duct

Common bile duct

Choledocus

Gallbladder Sphincter of Oddi

Biliary physiology
The functions of the gallbladder: -to concentrate -to store the bile Bile is concentrated 5-fold to 10-fold by the absorption of water and electrolytes a marked change in bile composition The concentration of bile may affect the solubilities of two important components: - cholesterol and - calcium the gallbladder bile becomes concentrated -several changes occur in the capacity of bile to solubilize cholesterol.

Biliary physiology
The major organic solutes in bile are: - bilirubin

- bile salts
- phospholipids - cholesterol Cholesterol = highly nonpolar

= insoluble in water

Biliary physiology
Cholesterol is maintained in solution in some complex biochemical structures:
The hidrophobic molecules of cholesterol are surounded by hidrophilic molecules

micelles

vesicles

Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and phospholipid

Gallstones formation
Supersaturated bile: - the capability of these micelles and vesicles to solubilise the cholesterol is exceded the precipitation (cristalisation) of the cholesterol occur Pronucleating factors -mucin glycoproteins -immunoglobulins

-transferrin
accelerate the precipitation of cholesterol in bile

Gallstones formation

Sludge = a mixture of cholesterol crystals, calcium bilirubinate granules, and a mucin gel matrix

The cristals of cholesterol growth, include glicroproteins from mucin gel and calcium bilirubinate

gallstones

Gallstones formation

Gallstone types
gallstones cholesterol gallstones The pathogenesis of cholesterol gallstones involves four factors: -cholesterol supersaturation in bile -crystal nucleation pigment gallstones Black pigment stones = associated with -hemolytic conditions or -cirrhosis unconjugated bilirubin increased Brown pigment stones -earthy in texture -some bacteria produces enzymatic hydrolysis of soluble conjugated bilirubin free bilirubin it precipitates with calcium

-gallbladder dysmotility
-gallbladder absorption

Gallstone types

cholesterol gallstones

Gallstone types

black gallstones

Gallstone types

brown gallstones

Gallstone types

cholesterol and pigment gallstones

Natural history of gallstones

asimptomatic gallstones
-discovered at the time of laparotomy or during abdominal imaging for nonbiliary disease -the vast majority of patients with gallstones are asymptomatic

gallstones

during years

biliary colic acute cholecystitis

simptomatic gallstones complications

choledocholithiasis gallstone pancreatitis gallstone ileus gallbladder carcinoma

Natural history of gallstones

Simptomatic gallstones
1.Pain -tipical pain: biliary colic -atipical pain

2.Other simptoms: -nausea -vomiting

obstruction of the cystic duct results in a progressive increase in tension in the gallbladder wall, leading to constant pain in the majority of patients

-bloating
-belching

Biliary colic
The pain: -in the right upper quadrant and/or epigastrium -frequently radiates to the back and right scapula -the intensity of the pain = severe -occurs following fatty meals (50% of patients) -the duration of pain: 1 to 5 hours (tipically) rarely persist for more than 24 hours if > 24 hours suggests an acute cholecystitis) rarely shorter than 1 hour

-the episodes of biliary colic = less frequent than one per week.

Atipical pain
Atypical pain is common -some patients do not relate their pain to meals or time of day -not all attacks are necessarily severe -the pain is continuous rather than episodic -the pain located predominantly in the back or the left upper or right lower quadrant -the less typical the pain search for another cause,
renal colic, peptic ulcer, hiatal hernia, abdominal wall hernia, liver disease, disease of the small bowell, disease of the large bowell

even in the presence of stones

Treatment of atypical biliary colic is appropriate when other causes of pain have been eliminated.

Diagnostic imaging
Abdominal X-ray -only 15% of gallstones contain sufficient calcium to appear on X-ray Ultrasound -noninvasive, inexpensive, and widely available -identifies gallstones and bile duct dilation -gallstones create echoes and are free-floating -the ultrasound waves cannot penetrate the stones shadowing gallstones shadowing sludge

Diagnostic imaging
Cholescintigraphy -Tc99m labeled iminodiacetic acid - injected intravenously -the radionuclide is excreted into the bile

-delayed filling of the gallbladder and CBD

or absent filling of the duodenum suggests an obstruction at CBD

Diagnostic imaging
Computerized Tomography

multiple distinct large stones

ayering of small stones and sludge

In fact the role of CT scanning is limited to the diagnosis of complications of gallstone disease such as acute cholecystitis (gallbladder wall thickening, pericholecystic fluid), choledocholithiasis (intrahepatic and extrahepatic bile duct dilation), pancreatitis (pancreatic edema and inflammation) and gallbladder cancer

Treatment
Nonoperative Therapy The nonsurgical options for the treatment of gallstone disease include: -oral dissolution therapy with the bile acids (ursodeoxycholic acid and chenodeoxycholic acid)

-contact dissolution therapy with organic solvents (methyl tertbutyl ether)

-extracorporeal shock wave biliary lithotripsy. These treatments are rarely used today.

Treatment
Nonoperative Therapy The nonsurgical options for the treatment of gallstone disease include: -oral dissolution therapy with the bile acids (ursodeoxycholic acid and chenodeoxycholic acid) cholesterol gallstones

-contact dissolution therapy with organic solvents (methyl tert-butyl ether) cannulation of the gallbladder with direct infusion of the agent -only cholesterol gallstones
-extracorporeal shock wave biliary lithotripsy -0.5 to 2 cm diameter gallstone -risk of choledocholitiasis These treatments are rarely used today.

Treatment operative therapy

Laparoscopic cholecistectomy -pneumoperitoneum -trocar placement

Treatment operative therapy

Laparoscopic cholecistectomy the Calot triangle (on its area pass the cystic artery)

The peritoneum overlying the cystic duct gallbladder junction is opened

Treatment operative therapy

Laparoscopic cholecistectomy

The cystic duct is isolated

The cystic duct is clipped proximal and distal and divided with the hook scissors

Treatment operative therapy

Laparoscopic cholecistectomy

The cystic artery is dissected, clipped and divided

The gallbladder is dissected from the liver by scoring the serosa with electrocautery

Treatment operative therapy

Open cholecistectomy
-upper midline or right subcostal incision -identification and division of the cystic duct and artery -removal of cholecist from the gallbladder bed

If the anatomy cannot be clearly identified, the gallbladder should be dissected from the fundus downward towards the gallbladder neck, making the ductal and vascular anatomy easier to identify.

Chronic calculous cholecystitis

Pathogenesis -gallstones lead to recurrent episodes of cystic duct obstruction recurrent inflammatory proces -over time scarring and a nonfunctioning gallbladder -histopathologically: subepithelial and subserosal fibrosis and a mononuclear cell infiltrate Clinical Presentation: -pain (biliary colic or atypical pain), nausea and vomiting -physical examination: is usually completely normal during biliary colic, mild right upper quadrant tenderness may be present -laboratory values bilirubin transaminases alkaline phosphatase are also usually normal

Chronic calculous cholecystitis

Diagnosis -requires two findings abdominal pain consistent the presence of gallstones -usualy documented by ultrasonography.

Management -the treatment of choice: elective laparoscopic cholecystectomy -conversion to an open cholecystectomy is necessary in less than 5%

Acute calculous cholecystitis

Pathophysiology -the most common complication of gallstones (20% to 30% of patients with symptomatic disease) -results from a stone impaction at the gallbladder-cystic duct junction -as in biliary colic -primarily: inflammation (without bacteria) -secondary: bacterial infection Escherichia coli = the most common organism

Acute calculous cholecystitis

Pathophysiology
Gallstones Cystic duct obstruction Pain (biliary colic) Inflammation

acute calculous cholecystitis

Obstruction is relieved (90%)

Obstruction not relieved (10%) Inflammation and edema Vascular compromise

Minimal histological changes (scarring and fibrosis) Cronic cholecystitis

Ischemia, necrosis, perforation

Acute calculous cholecystitis

Clinical Presentation -right upper quadrant pain similar to that of biliary colic -the pain is usually unremitting may last several days -often associated with nausea, emesis, anorexia, and fever On physical examination: -low-grade fever -localized right upper quadrant tenderness and guarding which distinguishes the episode from simple biliary colic -Murphy's sign inspiratory arrest during deep palpation of the right upper quadrant =the classic physical finding of acute cholecystitis -a palpable right upper quadrant mass is appreciated in one third of patients omentum that has migrated to the area around the gallbladder -mild jaundice may be

Acute calculous cholecystitis

Clinical Presentation Laboratory evaluation can show -a mild leukocytosis (white blood cell count [WBC] 12,000 to 15,000 cells/mm3) -mild elevations in serum bilirubin (<4 mg/dL) alkaline phosphatase the transaminases amylase may also be seen with acute cholecystitis

Acute calculous cholecystitis

Diagnosis Ultrasound = the most useful examination when a cholecystitis is suspected - first: establish the presence or absence of gallstones

-additional findings suggestive of acute cholecystitis: thickening of the gallbladder wall (>4 mm) pericholecystic fluid focal tenderness directly over the gallbladder (sonographic Murphy's sign)
CT is less sensitive for these conditions than ultrasonography may show -gallbladder wall thickening -pericholecystic fluid and edema -gallstones -air in the gallbladder or gallbladder wall (emphysematous cholecystitis)

Acute calculous cholecystitis

Management -preoperative: nothing by mouth intravenous hydration nasogastric tube if there is persistent nausea and vomiting or abdominal distention broad-spectrum antibiotics maintained into the immediate postoperative period parenteral analgesia: nonsteroidal analgesics no narcotics! (increase biliary pressure) The treatment of choice for acute cholecystitis is cholecystectomy.

Acute calculous cholecystitis

Management The treatment of choice for acute cholecystitis is cholecystectomy. Open cholecystectomy has been the standard treatment for many years Laparoscopic cholecystectomy can be performed safely in the setting of acute cholecystitis The timing of cholecystectomy -delayed cholecystectomy in the past -patients were initially managed nonoperatively -elective cholecystectomy - 6 weeks later after the acute inflammation had resolved -early laparoscopic cholecystectomy (within 3 days of symptom onset) -within 24 to 72 hours of diagnosis -conversion to an open procedure should be considered if dissection is difficult

Acute calculous cholecystitis

Management In certain high-risk patients whose medical conditions precludes cholecystectomy, a cholecystostomy can be performed for acute cholecystitis.

After the acute episode resolves, the patient can undergo cholecystectomy.

Complications of acute cholecystitis

Several complications of acute cholecystitis are recognized in clinical practice: -empyema of the gallbladder -emphysematous cholecystitis -perforation -cholecystenteric fistula

Complications of acute cholecystitis

Gallbladder empyema = an advanced stage of cholecystitis - bacterial invasion of the gallbladder pus in the lumen Clinical presentation: -severe right upper quadrant pain -high-grade fever -significant leukocytosis cardiovascular collapse may be seen Treatment: -broad-spectrum antibiotics (including anaerobic coverage) -emergent cholecystectomy or cholecystostomy

Complications of acute cholecystitis

Emphysematous cholecystitis -develops more commonly in males and patients with diabetes mellitus -severe right upper quadrant pain -eneralized sepsis Abdominal films or CT scans may demonstrate air within the gallbladder wall or lumen

Treatement: -prompt antibiotic therapy -emergency cholecystectomy

Complications of acute cholecystitis

Gangrene/Perforation -gangrene occurs when the wall becomes ischemic and leads to perforation -gallbladder perforation: -localized or -free

-localized perforation generally pericholecystic abscess -free perforation spilling of bile into the peritoneal cavity generalized peritonitis

Complications of acute cholecystitis

Cholecystoenteric fistula -seldom the gallbladder will perforate into duodenum or hepatic flexure of the colon
If a large gallstone passes a mechanical bowel obstruction may result = gallstone ileus The site of obstruction is in the narrowest part of the small intestine (ileum) or large intestine (sigmoid colon). Patients with gallstone ileus present with signs and symptoms of intestinal obstruction.

Acute cholangitis
= a bacterial infection of the biliary ductal system -it varies in severity from mild and self-limited to severe and life threatening The clinical triad: fever jaundice pain = Charcots triad

Acute cholangitis
Pathophysiology -cholangitis results from a combination of two factors: -significant bacterial concentrations in the bile E. coli
Klebsiella pneumonia the enterococci Bacteroides fragilis.

-biliary obstruction
choledocholithiasis benign strictures biliary enteric anastomotic strictures

Acute cholangitis
Clinical Presentation -a wide spectrum of disease self-limited illness and never seek attention severe illness (toxic cholangitis) jaundice fever abdominal pain mental obtundation hypotension Fever is the most common presenting symptom and is often accompanied by shivers. Jaundice is a frequent physical finding but may be absent. Pain is also commonly present but is often mild. = Reynolds' pentad

Acute cholangitis
Diagnosis -clinical diagnosis -laboratory tests can support evidence of biliary obstruction. leukocytosis
hyperbilirubinemia elevations of alkaline phosphatase elevations of transaminases

-CT, ultrasound, and MRI scanning evidence of biliary ductal dilation and occasionally CBD stones

Acute cholangitis
Management -the initial treatment: antibiotics
toxic cholangitis:

-intensive care unit monitoring -vasopressors to support blood pressure -emergency biliary decompression endoscopically or via the percutaneous transhepatic route

Acute cholangitis
Management Endoscopic biliary drainage -endoscopic sphincterotomy and stone extraction

-or simply placement of an endoscopic biliary stent in the hemodynamically unstable patient Laparoscopic cholecystectomy after 6 to 12 weeks.

Acute cholangitis
Management Another option: percutaneous transhepatic biliary decompression

Laparoscopic cholecystectomy after 6 to 12 weeks.

Sphincter of Oddi dysfunction

= a structural or functional abnormality involving the sphincter -fibrosis of the sphincter due to gallstone migration -operative or endoscopic trauma -pancreatitis -other nonspecific inflammatory elevated sphincter pressures.

-suspected in patients with typical episodic biliary-type pain without an obvious organic cause
Treatement: -endoscopic sphincterotomy -transduodenal sphincteroplasty with transampullary septotomy

Sphincter of Oddi dysfunction

endoscopic sphincterotomy

Sphincter of Oddi dysfunction

transduodenal sphincteroplasty

Sphincter of Oddi dysfunction

transduodenal sphincteroplasty with transampullary septotomy

Choledocholithiasis
Classification and Etiology CBD stones can be classified as - primary develop de novo within the bile ducts occur in patients with bile stasis ( brown pigment stones) -benign biliary strictures -sclerosing cholangitis -choledochal cyst disease -sphincter of Oddi dysfunction - secondary develop in the gallbladder and subsequently fall into the composition similar to gallbladder stones

Choledocholithiasis
Clinical Presentation -common duct stones are often asymptomatic -symptomatic choledocholithiasis biliary colic extrahepatic biliary obstruction cholangitis or pancreatitis

Choledocholithiasis
Clinical Presentation -Clinical features of biliary obstruction caused by CBD stones: -biliary colic -jaundice obstructive jaundice

-lightening of the stools -darkening of the urine

Choledocholithiasis
Clinical Presentation -Clinical features of biliary obstruction caused by CBD stones: -biliary colic -jaundice intermittent and transient with fever -lightening of the stools -darkening of the urine benign obstructive jaundice obstructive jaundice

Choledocholithiasis
Serum liver function tests -bilirubin = elevated -mainly conjugated bilirubin -alkaline phosphatase = elevated -transaminases = elevated cholestatic hepatitis Ultrasonography -CBD dilation, which can suggest CBD obstruction -diameter greater than 10 mm -CBD stones in only 70% of patients the distal end of the bile duct is obscured by duodenal or colonic gas cholestasis

Choledocholithiasis
Magnetic Resonance Imaging Magnetic resonance cholangiopancreatography (MRCP) -high sensitivity (90%) -high specificity (100%) -advantages: no need contrast non-invasive procedure -disadvantages:
expensive lack of availability lack of therapeutic capacity

Choledocholithiasis
Endoscopic Retrograde Cholangiography = the gold standard for the diagnosis of

CBD stones
-provide also a therapeutic option

Choledocholithiasis
Endoscopic Retrograde Cholangiography

stones in the common bile duct

Choledocholithiasis
Other investigations methods: endoscopic ultrasound

intraoperative ultrasonography intraoperative cholangiography

Management of choledocholithiasis
Endoscopic ERC eendoscopic sphinncterotomy and

Stones removal using a baloon-catheter

Management of choledocholithiasis
Endoscopic ERC eendoscopic sphinncterotomy and

Stones removal using a basket-catheter (Dormia)

Management of choledocholithiasis
Laparoscopic - 2 techniques: transcystic or through a choledochotomy

Transcystic stones removal using a Dormia-baket

Management of choledocholithiasis
Laparoscopic - 2 techniques: transcystic or through a choledochotomy

CBD stones removal trhough a choledochotomy

Management of choledocholithiasis
Open Common Bile Duct Exploration

Management of choledocholithiasis
Open Common Bile Duct Exploration

Management of choledocholithiasis
Open Common Bile Duct Exploration

(instead of) Conclusion

Biliary surgery always makes me hungry!