Gallbladder disease presents in various syndromes:

1. Asymptomatic gallstones (80%)

2. Biliary colic: Symptomatic cholelithiasis
3. Acute cholecystitis
4. Chronic cholecystitis
5. Choledocholithiasis
6. Ascending cholangitis
7. Gallbladder muocele
8. Empyema of gallbladder
9. Biliary pancreatitis
10. Cholangiohepatitis
11. Gallstone perforation
12. Mirizzi's Syndrome
13. Gallstone ileus
14. Acalculous cholecystitis
15. Biliary cysts
16. Sclerosing cholangitis
17. Cancer of bile ducts & gallbladder
What are the different types of gallstone?
• Cholesterol
• Mixed
• Pigmented

Risk factors for developing mixed/cholesterol gallstones:

• Female gender
• Pregnancy
• OCP use (excess E2 -> higher cholesterol in bile and decreased GB motility)
• Obesity - decreases bile salts
• High fat diet - increases bile cholesterol
• Crohn's disease and terminal ileal resection - loss of bile salts
• Rapid weight loss/bypass surgery
• Hyperlipidemia
• Vagotomy - vagus n. causes GB to contract, vagotomy causes GB not to contract, sludge collects
to form stones
• Somatostatinoma - causes gallstone

How do cholesterol gallstones form? (70-80% of gallstone)

These form when the concentration of cholesterol in bile exceeds its solubility causing precipitation
of cholesterol crystals.

How do pigmented gallstones form? (20-30% of gallstone)

Pigmented gallstones are either black or brown and the dark coloration is d/t the presence of
calcium bilirubinate within stones. RBC breakdown causes the amount of unconjugated bilirubin to
increase -> formation of black stones.

Risk factors: hemolytic anemia (SCD), hereditary spherocytosis, alcoholic cirrhosis

What are the complications of gallstones?

In the gallbladder and cystic duct:
1. Biliary colic
2. Acute/chronic Cholecystitis
3. Mucocele
4. Empyema of gallbladder
5. Mirrizzi's syndrome
6. Carcinoma
In the bile ducts:
1. Obstructive jaundice
2. Cholangitis
3. Pancreatitis
In the gut:
1. Gallstone ileus
Asymptomatic Gallstones
• occurs in 80-95% of patients
• expectant management and close follow-up
• counsel patient about sx - biliary colic, acute cholecystitis, obstructive jaundice.
• there is no benefit for cholecystectomy for asymptomatic gallstones

What are the indications for surgery in an asymptomatic patient with gallstones?
1. Patient with a GB mass suggestive of malignancy/patients at high risk of malignancy (GB polyp/
porcelain GB) -> prophylactic surgery
2. Immunocompromised patients
3. Patients with chronic hemolytic disease (SCD, thalassemia)

Biliary Colic/Symptomatic Cholelithiasis

• Clinical presentation: (6)
◦A patient with biliary colic presents with right hypochondriac/epigastric pain that is constant
but may wax and wane in intensity resolving within minutes to 4hrs. It is associated with
nausea and vomiting and is usually postprandial after fatty meals. On physical examination,
the patient is systemically well.
◦History
‣ constant RUQ/epigastric pain which may wax and wane in intensity but resolves within
minutes to 3-4h. NB - biliary colic is not true colic. A colicky type of pain is a pain that
comes and goes. Biliary colic does not come and go. It may fluctuate over time in
intensity, but it does not disappear. It is constant.
‣ radiates to the right subscapular region (GB and scapula share same cutaneous
dermatome from C3-C4 spinal nerves. GB distention/inflammation triggers scapular
pain via the phrenic nerve)
‣ associated with nausea and vomiting, bloating, abdominal distension
‣ usually postprandial after fatty meals
◦Exam
‣ pt. is systemically well
• Patho: transient gallstone obstruction of the cystic duct without infection. Occurs when the
gallbladder contracts (CCK) but its outflow is obstructed.
• Labs: LFTs are normal

• Chronic cholecystitis characterised by recurrent attacks of pain (Schwartz)

• Mx: analgesia, outpatient management with eventual elective cholecystectomy
Acute Cholecystitis
• Sustained obstruction (impaction) of the cystic duct most often by a gallstone. This leads to
inflammation and edema of gallbladder wall d/t irritation by concentrated bile (chemical
cholecystitis). This eventually leads to stasis, bacterial overgrowth and invasion of the GB wall.
Can progress to ischemia -> necrosis -> perforation.
• Presentation
◦Severe, persistent RUQ/epigastric pain (>6h) associated with fever and positive Murphy's
sign.
◦Hx
◦persistent (>6h), severe RUQ/epigastric pain that progressively intensifies
◦radiates to inferior angle of scapula
◦associated with: fever, nausea, vomiting
◦Px
◦Vitals: fever, tachycardia (systemic sx indicates more severe biliary disease such as acute
cholecystitis/acute cholangitis)
◦RHC tenderness with guarding
◦Murphy's sign positive: arrest of inspiration following RUQ palpation. Why do you get it? It
represents focal peritonitis of the anterior abdominal wall parietal peritoneum d/t
inflammation of the adjacent GB.
◦Boas's sign: hyperaesthesia (increases/altered sensitivity) just below the right scapula d/t
irritation of phrenic nerve (C3, 4 and 5). Sensitivity of sign <7%
• Investigations
◦Labs
‣ CBC: elevated WBCC
◦Diagnostic: USS findings of cholecystitis can give 5 pieces of info:
‣ cholelithiasis revealed as echogenic foci with posterior acoustic shadowing
‣ thickened wall of the gallbladder (> 4mm)
‣ pericholecystic fluid (edema of GB wall)
• these 2 findings are diagnostic for acute cholecystitis
‣ sonographic Murphy's sign (most sensitive)
‣ diameter of the CBD (if > 6mm is suggestive of obstruction from either a gallstone or
tumor). Normal CBD ranges from < 4mm until age 40 then additional 1mm for every 10
years over age 40.
◦HIDA scan if USS nondiagnostic
• DDx: acute appendicitis, perforated duodenal ulcer, acute pancreatitis, right sided basal
pneumonia and coronary thrombosis
• Management: How do you treat cholecystitis?
◦Management would begin with hospital admission and resuscitation
◦NPO
◦IV fluids
◦IV abx - ceftriaxone and metronidazole. alternatives: piperacillin/tazobactam
◦Analgesia
◦Definitive tx: (1) Urgent (within 48h) laparoscopic cholecystectomy
‣ advantages include minimal scarring of the abdominal wall
 ◦(2) Open surgery: GB perforation
◦(3) Delayed cholecystectomy (after 6 weeks) performed if: pt is too sick to tolerate surgery
◦What do you do for a patient that you can't do surgery on?
‣ (4) Percutaneous cholecystostomy - drainage via T-tube. Indicated if pt. is elderly or high
risk/unsuitable for surgery and is the preferred tx for acalculous cholecystitis.
• Complications of acute cholecystitis
◦Empyema of gallbladder
◦Gangrene and perforation
◦Cholecystenteric fistula
◦Gallstone ileus
◦Hydrops

Chronic Cholecystitis
• Recurrent bouts of symptomatic cholelithiasis -> chronic inflammation of the GB with fibrotic
changes seen on histologic examination.
• Patho: repeated episodes of inflammation -> chronic fibrosis and thickening of the gallbladder
wall.
• Presentation
◦recurrent bouts of abdominal pain (d/t mild cholecystitis)
◦discomfort after fatty meals

Choledocholithiasis
• CBD obstruction by gallstone
• Presentation
◦may be asymptomatic
◦attacks of biliary colic (lasting hrs-days) accompanied by obstructive jaundice (scleral icterus,
pruritis, clay-coloured stools and dark urine)
• Investigations
• Labs
◦CBC - WBC for infx
◦Amylase - pancreatitis
◦LFTs
◦Total Bilirubin >2.5 mg/dL - clinical jaundice; first site - under tongue and sclerae
◦Obstructive jaundice -> direct (conjugated) hyperbilirubinemia.
• Imaging
◦USS: gallstones in GB, gallstones in CBD, dilated CBD (normal: <8-9mm. > 10mm is
abnormal) Is USS useful? Not reliable as CBD is retroduodenal
◦If you do CT how often will you see gallstone? - 10%
◦MRCP
• Management
◦ERCP with stone removal
◦Papillotomy
◦Open/laparoscopic cholecystectomy with CBD exploration
◦Transcystic duct removal
• Complications: secondary biliary cirrhosis, liver failure
Ascending Cholangitis
• Ascending bacterial infection of the biliary system associated with CBD obstruction
• Patho: obstruction of the CBD leading to ascending infection of the biliary tract. MCC is
choledocholithiasis. Other causes: bile duct strictures, parasites, instrumentation of the biliary
system (ERCP) and indwelling biliary stents.
• Common causative agents:
◦Klebsiella, E. coli, Enterobacter, Enterococcus
• Presentation
◦Persistent RUQ pain, fever, jaundice (Charcot's triad; only in 50-70% of pts)
◦Reynold's pentad: Charcot's triad + AMS + hypotension / cholangitis with septic shock
◦Look for evidence of SIRS
• Labs
◦CBC
◦LFTs:
‣ Hepatic injury -> increase AST and ALT out of proportion to ALP rise. This indicate viral
hepatitis, liver ischemia or toxic insult.
‣ Posthepatic obstruction -> there is increased ALP out of proportion to transaminases.
This indicates choledocholithiasis or cholangitis. Concomitant and proportionate rise in
GGT is more specific to liver disease as ALP increases with other diseases such as bone
pathology.
• Diagnosis: Tokyo guidlines. Patient has evidence of:
◦systemic inflammation (fever +/- leukocytosis)
◦cholestasis (jaundice +/- abnormal liver enzymes)
◦biliary obstruction (dilated bile ducts on USS)
• Management
◦resuscitation: aggressive IV fluids, blood for culture, catheterise and monitor urine output
◦broad spectrum abx: IV ceftriaxone and metronidazole; imipenem if pt. in shock
◦urgent biliary decompression via ERCP
◦PTC if ERCP fails
◦definitive tx
‣ open cholecystectomy with CBD exploration, lap chole.
◦urgent biliary drainage via endoscopic sphincterotomy

Courvoisier's Law: If in the presence of jaundice the GB is palpable, then the jaundice is unlikely to
be due to stone.
 ‣ AST, ALT
‣ AP
‣ GGT
• Symptomatic cholelithiasis: normal LFTs
• Acute cholecystitis: mild elevations in LFTs
• Choledocholithiasis: significantly elevated AP and GGT in proportion to AST and
ALT suggest cholestasis/biliary obstruction
• Hepatocellular damage: marked elevations in AST/ALT out of proportion to AP and
GGT
◦Amylase, lipase -> to r/o gallstone pancreatitis
• Imaging
◦USS: features (5)
◦AXR - only visible 10% of time; only pigmented stones seen.
◦UGI endoscopy
• MRCP (magnetic resonance cholangiopancreatography)
◦allows visualisation of the biliary tree
◦preferred if pt does not require therapeutic intervention that ERCP provides
◦noninvasive; no risk of complications assoc. w/ ERCP
• ERCP (endoscopic retrograde cholangiopancreatography)
◦endoscopic intubation of bile ducts through ampulla of Vater
◦allows visualisation of the ducts and contained stones
◦therapeutic:
‣ allows extraction using balloon cather/Dormia basket
‣ sphincterotomy
‣ stenting
◦complications
‣ pancreatitis
‣ cholangitis
‣ hemorrhage
‣ perforation into bile duct, duodenum
• What is the difference between MRCP and ERCP?
◦ERCP is diagnostic and therapeutic whereas MRCP is only diagnostic.
• Which should you start with if you suspect choledocholithiasis?
◦Tokyo Guidelines
◦Go straight to ERCP in: (1) if pt. has cholangitis (charcot's triad), (2) if pt. has very obvious
obstructive jaundice TB > 4 and (3) if you do an USS and you can clearly see that there is a
stone in the CBD.
• If the pt. has gallstone pancreatitis, should you do an ERCP?
◦No, because the obstruction is transient. It can also worsen? pancreatitis by taking bacteria
from the oral mucosa and pushing it into the mucosa.
• Cholescintigraphy (HIDA scan)
◦done if gallstones are not seen on an USS and biliary disease is suspected
◦radiolabeled hepatic iminodiacetic acid is given IV and then imaging is performed. This
compound is absorbed by hepatocytes and then excreted into bile and seen within 30-60
min in the gallbladder, bile ducts and small bowel in a normal patient.
Mirizzi's Syndrome
• gallstone impacted in Hartmann's pouch/cystic duct causing external compression of the CHD
resulting in obstructive jaundice. Bailey def: stone ulcerating through the neck of the GB into the
common hepatic duct
• stages

Gallstone Pancreatitis
• transient obstruction of the distal CBD (and pancreatic duct)

Gallstone Ileus
• Rigler's triad
• Tx: correct the underlying cause and remove gallstone
• Enterolithotomy
• Should you also do a cholecystectomy?

Bouveret Syndrome
Gastric outlet obstruction 2/2 impaction of a gallstone in the pylorus or proximal duodenum. Rare

Acalculous cholecystitis
• occurs in: critically ill ICU patients, sepsis, burns, patients on TPN
• 2/2 biliary stasis and GB ischemia in the presence of severe systemic illness
• poor nutrition -> biliary stasis; dehydration and hypotensions -> viscous bile formation and GB
iscemia -> bile may get infected -> cholecystitis
• associated with typhoid fever and gas gangrene
• tx - emergent cholecystectomy

Work-up
• Labs
◦CBC
◦LFTs
‣ Total and direct bilirubin
What are the disadvantages of laparoscopic surgery?
1. steep learning curve
2. inadvertent damage to surrounding structures as a result of lmited field e.g. visceral injury

OSCE questions
This is an USS showing the gallbladder suggestive of acute cholecystitis
1. USS findings of acute cholecystitis
2. Difference in presentations
A. How does the pt with acute cholecystitis present compared to the patient with simple
cholelithiasis - hx and px
3. Difference between pain of biliary colic and acute cholecystitis
4. What does pain refering to the back/inferior scapula indicate? What nerve is involved?
5. What is the most common type of GB stone? - mixed cholesterol stones
6. What are the complications of gallstones?
7. Can a stone in the gallbladder cause obstructive jaundice?
A. Yes, only in the presence of Mirizzi syndrome
8. How often can an XRAY see a gallstone?
9. Can you get cholecystitis without a stone?
10. How do you treat cholecystitis?
11. When is a delayed cholecystectomy required?
12. What do you do for a patient that you can't do surgery on?
13. If the patient has yellowing of the eyes, where could it be that the stone is? - CBD
14. What bilirubin level do you get jaundice at?
15. In obstructive jaundice, is there direct/indirect hyperbilirubinemia?
16.
Laporoscopic Cholecystectomy

Definition
Removal of the gallbladder using the laparoscopic technique

Indications

Contraindications

What is the significance of Calot's triangle?

Calot's triangle is bordered superiorly by the inferior surface of the liver, laterally by the cystic duct
and medially by the common hepatic duct.
It contains the cystic artery and cystic lymph node.
It is significant because it is important to identify and diessect out the triangle in order to visualise
the cystic duct and artery so that both structures can be clipped and divided safely.

Procedure
◦Patient placed in reverse trendelenberg position (body flat but head 15-30 degrees higher
◦Identification and safe dissection of Calot's triangle

Complications of Lap. Chole.

Inraoperative
• Hemorrhage, infection, pain
• CBD injury (biloma, cystic duct stump leak) - CBD is mistaken for cystic duct and thus
inadvertently divided
◦manifestation: postop abdominal pain, bloating, anorexia and elevated LFTs.
◦management: depend on severity of injury. T-tube placement. Roux-en-Y
hepaticojujenostomy. ERCP and stenting of the sphincter of oddi
• Bowel injury requiring laparotomy
• Possibility of conversion to an open procedure

Notes
Porcelain (calcified) bladder poses an increased risk of malignancy -> cholecystectomy

What are the advantages of laparoscopic surgery?

1. less traumatic for patients
2. reduced adhesion formation
3. reduced postop pain
4. faster postop recovery
5. improved cosmesis
6. shorter stay in hospital and quicker return to normal daily life