Kholesistitis & kholelithiasis
dr Putra Hendra SpPD
Gallbladder Disorders
Cholelithiasis and Cholecystitis
Definitions
a. Cholelithiasis: formation of stones (calculi)
within the gallbladder or biliary duct system
b. Cholecystitis: inflammation of gall bladder
c. Cholangitis: inflammation of the biliary ducts
Gall Stones
I’ll leave you with these.
Eww!
Common locations of gallstones
Epidemiology
Fat, Fair, Female, Fertile, Fourty
inaccurate, but reminder of the
typical patient
F:M = 2:1
10% of British women in their 40s
have gallstones
Genetic predisposition – ask about
family history
Those who are most at risk.
These are all adjectives to describe the person most at
risk of developing symptomatic gallstones.
FAIR FAT FORTY FEMALE
Gallstones
Types of gallstone
Cholesterolstones (20%)
Pigment stones (5%)
Mixed (75%)
Pathophysiology
1. Abnormal bile composition
2.Biliary stasis
3.Inflammation of gallbladder
Pathogenesis
Composition of bile:
Bilirubin (by-product of haem degradation)
Cholesterol (kept soluble by bile salts and lecithin)
Bile salts/acids (cholic acid/chenodeoxycholic
acid): mostly reabsorbed in terminal ileum(entero-
hepatic circulation).
Lecithin (increases solubility of cholesterol)
Inorganic salts (sodium bicarbonate to keep bile
alkaline to neutralise gastric acid in duodenum)
Water (makes up 97% of bile)
b. Most gallstones are composed primarily of bile
(80%); remainder are composed of a mixture of
bile components
c. Excess cholesterol in bile is associated with
obesity, high-cholesterol diet and drugs that lower
cholesterol levels
d. If stones from gallbladder lodge in the cystic
duct
1. There can be reflux of bile into the gallbladder
and liver
2. Gallbladder has increased pressure leading to
ischemia and inflammation
3. Severe ischemia can lead to necrosis of the gall
bladder
4. If the common bile duct is obstructed,
pancreatitis can develop
Obstructive Jaundice
Pemeriksaan:
USG
Will confirm gallstones in the gallbladder
CBD dilatation i.e. >8mm (not always!)
May visualise stone in CBD (most often does not)
MRCP
In cases where suspect stone in CBD but USg indeterminate
E.g.1 obstructive LFTs but USS shows no biliary dilatation
and no stone in CBD
E.g. 2 normal LFTS but USS shows biliary dilatation
ERCP
If confirmed stone in CBD on USS or MRCP proceed to ERCP
which will confirm this (diagnostic) and allow extraction of
stones and sphincterotomy (therepeutic)
Diagnostics.
Fecal studies.
Serum bilirubin tests.
Ultrasound of the
gallbladder.
Signs and Symptoms
Abdominal pain
nausea./vomiting
Fatty stools
Anxiety, chills, fever
Weakness
Weight loss
Jaundice
Plural effusion
Multi system failure
Coagulation defects
Shock
Elevated: serum amylase, lipase, glucose & urine amylase,
bilirubin, WBC
Manifestations of
cholelithiasis
a. Many persons are asymptomatic
b. Early symptoms are epigastic fullness
after meals or mild distress after eating a
fatty meal
c. Biliary colic (if stone is blocking cystic
or common bile duct): steady pain in
epigastric or RUQ of abdomen lasting up to
5 hours with nausea and vomiting
d. Jaundice may occur if there is
obstruction of common bile duct
Signs and Symptoms.
Low grade fever.
Elevated leukocyte count.
Mild jaundice.
Stools that contain fat – steatorrhea.
Clay colored stools caused by a lack of
bile in the intestinal tract.
Urine may be dark amber- to tea-colored.
Diagnostic Tests
a. Serum bilirubin: conjugated bilirubin is elevated
with bile duct obstruction
b. CBC reveals elevation in the WBC as with infection
and inflammation
c. Serum amylase and lipase are elevated, if
obstruction of the common bile duct has caused
pancreatitis
d. USG: identifies presence of gallstones
e. Other tests may include flat plate of the abdomen,
oral cholecytogram, gall bladder scan
Pathophysiologic classification of Jaundice
Hemolytic Jaundice
Hepatic Jaundice
Obstructive
Jaundice(Cholestasis)
Congenital Jaundice
prehepatik
hepatik
posthepatik
Mechanism of Physiologic Jaundice
Increased rbc’s
Shortened rbc lifespan
Immature hepatic
uptake &
conjugation
Increased enterohepatic
Circulation
Hemolytic Jaundice
Pathogenesis
Overproduction
Hemolysis (intra and extra vascular)
inherited or genetic disorders
acquired immune hemolytic anemia
(Autoimmune hemolytic anemia)
nonimmune hemolytic anemia
(paroxysmal nocturna Hemoglobinruia)
Ineffective erythropoiesis
Overproduction may overload the liver with UB
Hemolytic Jaundice
Symptoms
weakness, Dark urine, anemia,
Icterus, splenomegaly
Lab
UB bilirubinuria (-)
fecal and urine urobilinogen
hemolytic anemia
hemoglobinuria (in acute intravascular
hemolysis)
Reticulocyte counts
Hemolytic Jaundice
(pre-hepatic)
urinary changes:
bilirubin: absent
urobilinogen: increased or
normal
faecal changes:
stercobilinogen: normal
Obstructive Jaundice
Pathogenesis
it is due to intra- and extra hepatic
obstruction of bile ducts
intrahepatic Jaundice: Hepatitis,
PBC, Drugs
Extra Hepatic Biliary Obstruction:
Stones, Stricture, Inflammation,
Tumors, (Ampulla of Vater)
Etiology of Obstructive Jaundice
Intrahepatic
Liver cell Damage/Blockage of Bile
Canaliculi
Drugs or chemical toxins
Dubin-Johnson syndrome
Estrogens or Pregnancy
Hepatitis-viral,chemical
Infiltrative tumors
Intrahepatic biliary hypoplasia or atresia
Primary biliary cirrhosis
Etiology of Obstructive Jaundice
Extrahepatik
Obstructive of bile Ducts
Compression obstruction from tumors
Congenital choledochal cyst
Extrahepatic biliary atresia
Intraluminal gallstones
Stenosis-postoperative or inflammary
Tatalaksana batu empedu
Medication: (Melarutkan batu)
ursodiol
Mahal
Lama
Kambuh bila obat berhenti
Tindakan mengeluarkan batu:
Pain & Drugs: Biliary Tract
Morphine used to be contraindicated. It is now
known that all opiates create spasm of the
Sphincter of Oddi
Antacids: reduce gastric acid & associated pain.
Histamine blockers: reduce gastric acid
secretion, which stimulates pancreatic enzymes.
Anticholenergics: reduce spasm of sphincter of
ODDI
Tindakan mengeluarkan batu
@ Shock wave lithotripsy
@ endoscopic sphincterotomy
@ Placement of aT-tube
@ Cholendoscopic:
Endoscopic Retrograde Cholangiopancreatography (ERCP)
@ Operasi:
# Teretutup:
laparoscopic cholecystectomy :
Treatment of choice: Minimally invasive procedur
with low risk of complications
# Terbuka
Surgical laparotomy (incision inside the abdomen)
to remove gall bladder
Medical Management.
If stones are present in the
common bile duct, an
endoscopic sphincterotomy
must be performed to remove
them BEFORE a
cholecystectomy is done.
A number of various
instruments are inserted
through the endoscope in
order to "cut" or stretch the
sphincter.
Once this is done, additional
instruments are passed that
enable the removal of stones
and the stretching of
narrowed regions of the
ducts.
Drains (stents) can also be
used to prevent a narrowed
area from rapidly returning to
its previously narrowed state.
Biliary lithotripsy
Medical Management.
Lithotripsy If the attack of
for patients with only cholelithiasis is mild –
a FEW stones. bed rest is prescribed.
patient is placed on
NPO to allow GI tract
and gallbladder to
rest.
an NG tube is placed
on low suction.
fluids are given IV in
order to replace lost
fluids from NG tube
suction.
What is a “T” Tube?
Comes right out of bile duct
Sutured in place on skin
1st 24-48 hours
200-500 ml of drainage
Potential Complications:
Dislodgement
Infection
T-tube placement in the common bile duct
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Figure 46-2: Cholendoscopic Removal of
Gallstones
B Menu F
Retrieving the CBD Stones
Indication To Surgical Treatment
• All forms of acute calculous
cholecystitis
• Destructive and complicated forms of
noncalculous cholecystitis
• Acute catarrhal cholecystitis
• Conservative treatment of which was
uneffective
Methods of Operative Treatment
• Cholecystectomy from the neck
(retrograde)
• Cholecystectomy from the bottom
(antegrade)
• Laparoscopic cholecystectomy
Lap Cholecystectomy
Watch for
indications of:
Infection
Hemorrhage
Damage to
adjacent organs
Lap Cholecystectomy
Medical Management.
Cholecystectomy
or
Laparoscopic Cholecystectomy
– removal of the gallbladder.
This is the treatment of choice.
The gallbladder along with the cystic
duct, vein and artery are ligated.
Complications of Gallstones
Biliary Colic
Acute Cholecystitis
Gallbladder Empyema
Gallbladder gangrene
Gallbladder perforation
Obstructive Jaundice
Ascending Cholangitis
Pancreatitis
Gallstone Ileus (rare)
Complications
Gallstone ileus
Pathogenesis:
Gallstone causing small bowel obstruction (usually obstructs in
terminal ileum)
Gallstone enters small bowel via cholecysto-duodenal fistula (not
via CBD)
AXR – dilated small bowel loops
May see stone if radio-opaque
Treatment
NBM
Fluid resuscitation + catheter
NG tube
Analgesia
Surgery (will not settle with conservative management) –
enterotomy + removal of stone
Diagnosis of gallstone ileus usually made at the time of surgery.
Sequence of
pathological
processes
localising a
perforation of the
gallbladder
What is Acute Cholecystitis?
Sudden inflammation of the
gallbladder
accumulation of bile and increased
pressure.
The combination of concentrated bile and
pressure building up irritate the wall of
the gallbladder causing it to swell.
Severe inflammation of the gallbladder
blood flow cell death.
By definition,
cholecystitis is an
inflammation of the
gallbladder wall and
nearby abdominal
lining.
Abdominal wall
Gallbladder
Normal Gall Bladder Inflammed Gall Bladder
Acute Cholecystitis Causes
Over 90% of
acute cholecystitis
cases are caused
by obstruction of
the cystic duct by
gallstones in the
gall bladder
Numerous other pathologies may also be
causes such as an infection, trauma and
tumors of the gallbladder.
Acute Cholecystitis
Pathogenesis:
Due to obstruction of cystic duct by gallstone:
Cystic duct blockage by gallstone
Obstruction to secretion of bile from
gallbladder
Bile becomes concentrated
Chemical inflammation initially
Secondarily infected by organisms released
by liver into bile stream
Tumor. A tumor may prevent bile from draining
out of your gallbladder properly, causing bile
buildup that can lead to cholecystitis.
Signs and Symptoms
Pain in the right upper quadrant
Tenderness over your abdomen
when it's touched
An increase in pain when taking
in a deep breath
Pain that radiates from to your
right shoulder or back
Nausea
Vomiting
Fever
Diffuse
DD Causes abdominal pain Acute pancreatitis
DKA
Gastroenteritis
Intestinal obstruction
RUQ/LUQ Peritonitis
Acute pancreatitis Mesenteric ischaemia
Lower lobe pneumonia
Myocardial ischaemia
RUQ LUQ
Cholecystitis Gastritis
Biliary colic Splenic rupture/abscess
Hepatitis
Hepatic abscess
RLQ LLQ
Appendicitis Sigmoid diverticulitis
Caecal diverticulitis
Meckel’s diverticulitis
RLQ/LLQ
IBD
Renal stones
Cystitis
Endometriosis
Ruptured ectopic pregnancy
Incarcerated hernias
Psoas abscess
Symptoms and clinical signs
Murphy's symptoms is a delay of breathing during
palpation of gall-bladder on inhalation.
Kehr's symptom is strengthening of pain at
pressure on the area of gall-bladder, especially on deep
inhalation.
Ortner's symptom — painfulness at the easy
pushing on right costal arc by the edge of palm.
Mussy's symptom — painfulness at palpation
between the legs (above a collar-bone) of right nodding
muscle.
Blumberg's signs are the increases of painfulness
at the rapid taking away of fingers by which a front
abdominal wall is pressed on. This symptom is not
pathognomic for cholecystitis but matters very much in
diagnostics of peritonitis.
Tokyo Guidelines for acute cholecystitis
(TG 07)
• Mild - RUQ pain w/murphy’s signs and USG
findings (40-70%)
• Moderate - acute cholecystitis w/ WBC >18K;
>72hrs of symptoms; palpable tender mass
(25%-60%)
• Severe - acute cholecystitis with organ
dysfunction/s
CT Scans
Normal size
gallbladder
Patient X, Gallbladder
diagnosed with
Cholecystitis
Tatalaksana
Rawat inap
Analgetik
Diet cair
IVF
Antibiotics
95% sembuh
Bila tifdak sembuh CT scan
Empyema percutaneous drainage
Gangrene/perforation with generalised
peritonitis emergency surgery
Non-operative management of
cholecystitis
Antibiotics covering gram – bacilli and
anaerobic organisms
Gall bladder drainage procedures
Percutaneous vs Endoscopic transpapillary
approach
Complications of cholecystitis
a. Chronic cholecystitis occurs after
repeated attacks of acute cholecystitis;
often asymptomatic
b. Empyema: collection of infected fluid
within gallbladder
c. Gangrene of gall bladder with
perforation leading to peritonitis, abscess
formation
d. Pancreatitis
e. liver damage
f. intestinal obstruction
