Dr.

SUHAEMI, SpPD, FINASIM

KOLELITIASIS

GALLBLADDER DISORDERS
A. Cholelithiasis and Cholecystitis

1.

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 2. Pathophysiology a.Gallstones form due to 1.Abnormal bile composition 2.Biliary stasis 3.Inflammation of gallbladder

INTRODUCTION

PATHOGENESIS

Normally, bile is sterile due to constant flush, bacteriostatic bile salts, secretory IgA, and biliary mucous; Sphincter of Oddi forms effective barrier to duodenal reflux and ascending infection ERCP or biliary stent insertion can disrupt the Sphincter of Oddi barrier mechanism, causing pathogeneic bacteria to enter the sterile biliary system. Obstruction from stone or tumor increases intrabiliary pressure High pressure diminishes host antibacterial defense- IgA production, bile flow- causing immune dysfunction, increasing small bowel bacterial colonization.
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Bacteria gain access to biliary tree by retrograde ascent Biliary obstruction (stone or stricture) causes bactibilia E Coli (25-50%) Klebsiella (15-20%), Enterobacter (5-10%) High pressure pushes infection into biliary canaliculi, hepatic vein, and perihepatic lymphatics, favoring migration into systemic circulation- bacteremia (20-40%).
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CLINICAL MANIFESTATIONS

RUQ pain (65%) Fever (90%)

May be absent in elderly patients

Jaundice (60%) Hypotension (30%) Altered mental status (10%)

Charcots Triad: Found in 50-70% of patients

Reynolds Pentad:

Additional History Pruitus, acholic stools PMH for gallstones, CBD stones, Recent ERCP, cholangiogram Additional Physical Tachycardia Mild hepatomegaly

ANATOMI

ANATOMI

ANATOMI

COMMON LOCATIONS OF GALLSTONES

GALL STONES

NORMAL GALLBLADDER

Abdominal x-ray film, showing a porcelain gallbladder. This is the term used to describe a gallbladder with a calcified wall.

ABDOMINAL X-RAY DEMONSTRATING STONES IN THE GALLBLADDER

GALLBLADDER, WITH NUMEROUS STONES PRESENT

GALLBLADDER, WITH SLUDGE PRESENT (ARROW)

ACUTE CHOLECYSTITIS NOTICE INCREASED GALLBLADDER WALL THICKNESS

DIAGNOSIS: FIRST-LINE IMAGING

Ultrasonography

Advantage: Sensitive for intrahepatic/extrahepatic/CBD dilatation CBD diameter > 6 mm on US associated with high prevalence of choledocholithaisis Of cholangitis patients, dilated CBD found in 64%, Rapid at bedside Can image aorta, pancreas, liver Identify complications: perforation, empyema, abscess Disadvantage Not useful for choledocholithiasis: Of cholangitis patients, CBD stones observed in 13% 10-20% falsely negative - normal U/S does not r/o cholangitis acute obstruction when there is no time to dilate Small stones in bile duct in 10-20% of cases Advantages CT cholangiograhy enhances CBD stones and increases detection of biliary pathology Sensitivity for CBD stones is 95% Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscess Can visualize other pathologies- cholangitis: diverticuliits, pyelonephritis, mesenteric ischemia, ruptured appendix Disadvantages Sensitivity to contrast Poor imaging of gallstones

CT

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Soto et al. J. Roenterology. 2000

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM (PTC)

PTC is indicated when percutaneous intervention is needed and ERCP either is inappropriate or has failed. Can be used to drain biliary obstructions.

PTC

PTC after injection of dye, showing a large gallstone trapped in the duct.

PTC: The same duct as before, after removal of the stone through the drainage catheter.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct. Biopsies of multiple sites can be taken using this technique. ERCP causes less discomfort than PTC, but acute pancreatitis is a common complication (which is rarely seen in PTC).

ERCP: THE ENDOSCOPE IS INTRODUCED AND IS THREADED AROUND TO THE SPHINCTER OF ODDI. THERE, DYE CAN BE INJECTED INTO THE DUCTS. INSTRUMENTS CAN ALSO BE INSERTED THROUGH THE SCOPE TO REMOVE STONES, INSERT DRAINS, REMOVE TISSUE SAMPLES, OF PERFORM OTHER TREATMENTS.

ERCP SHOWING STONES

ERCP

ERCP(THERAPUTIC)

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)

MRCP is becoming a more viable imaging technique, as MRI technology improves. However, CT and ultrasound are faster, easier, and more readily available, so they are used more frequently than MRCP. MRCP is emerging as a new tool for non-invasive evaluation of the pancreatic and biliary ductal systems. MRCP is gradually replacing PTC and ERCP for diagnostic purposes.

MRCP

MRCP WITH STONES IN THE DUCT

Case 1: Normal MRCP. Note good delineation of normal caliber pancreatic and bile ducts. Fluid in stomach and duodenum also demonstrated.

MANAGEMENT
1-Nonsurgical treatment 2-Surgical treatment Preoperative Intraoperative postoperative

1-NONSURGICAL TREATMENT
Oral dissolution therapy Aim: dissolute small radiolucent stone DX:chenodeoxycholic acid& ursodeoxycholic acid Side effect: diarrhea, pruritus, transient raise in serum transaminases Disadvantage: long term treatment (mnths) high recurrence rate

1-NONSURGICAL TREATMENT

Extracorporal shock wave lithiotrepsy Aim: medium sized radiolucent stone DX:+\- ODT Side effect biliary colic as fragments pass through cystic duct

PEMBEDAHAN
Operation ; 1-gallstone inCBD:ERCP 2-trumatic stricture:bypass via Roux loop of intestinal anastomosed to the proximal dil 3-cholangiocarcinoma:stenting +radiotherapy 4-CA of head of the pancreas or AOV:whipples operation:

WHIPPLE PROCEDURE

POSTOPERATIVE MANAGEMENT
Complication Coagulation disorder Renal failure GIT hemorrhage (stress ulcer) Delayed wound healing