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 Surgery
Contraindications
 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 T-
tube 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 Surgery
Contraindications

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