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Aregawi kassa, MD
MU-CHS
Jan 16/2012G.C
Mx of cholelithiasis and
17/01/2012 G.C complications 1
Anatomy
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Anatomy
In the inferior
surface of the liver
Pear shaped
7-10cm long
30-50ml capacity
Has four parts;
Fundus, Body,
Infundibulum and
neck
Calots triangle
bounded medially
by CHD, superiorly
the liver surface
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Anatomy
Vascular supply
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Anatomy
Lymphatic drainage
Innervations
Vagus motor supply
Sympathetic nerves that pass through the celiac and
splanchnic nerves then into the spinal cord
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Anatomy- Anomalies ? ~40%
inadvertent biliary tract injury
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Gallstone Pathogenesis
Bile = water, bile salts, phospholipids, cholesterol
Also bilirubin which is conjugated before excretion
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Pathophysiology
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Pathophysiology
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Types of stones
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Differential Diagnosis of RUQ pain
Biliary disease
Acute cholecystitis, chronic cholecystitis, CBD stone,
cholangitis
Hepatitis
Definition
On and off postprandial epigastric/RUQ pain due to
transient cystic duct obstruction by stone, no fever/WBC,
normal LFT
The pain occurs due to a stone obstructing the cystic
duct, causing wall tension; pain resolves when stone
passes
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Spectrum of Gallstone Disease
Cholelithiasis Symptomatic
cholelithiasis can be a
herald to:
an attack of acute
cholecystitis
Asymptomatic Symptomatic or ongoing chronic
cholelithiasis cholelithiasis cholecystitis
May also resolve
Chronic Acute
calculous calculous Mx of cholelithiasis and
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Frequency
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Morbidity/Mortality
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Race
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Sex
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Age
It is uncommon in children.
If they do, its more likely that they have congenital
biliary anomalies, or hemolytic pigment stones.
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Risk factors
3 clinical stages:
Asymptomatic - Most (~80%)
Symptomatic, and
With complications (cholecystitis, cholangitis,
CBD stones).
A history of epigastric pain with radiation to shoulder
may suggest it.
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History
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Physical
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Workup
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Workup
In retrospective study,
60% of patients with cholecytitis had a WBC > 11,000.
WBC greater than 15,000 may indicate perforation or
gangrene.
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Imaging Studies
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CT Scan
For complications,
Ductal dilatation,
Surrounding organs.
Misses 20% of GS.
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Denotes the GB
wall thickening
denotes the fluid
around the GB
GB also appears
distended
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Plain FilmsX-rays:
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Imaging
Ultrasound
95% sensitive for stones,
80% specific for cholecystitis.
It is 98% sensitive and specific for simple stones.
Wall thickening (2-4mm)
Distension
Pericholecystic fluid, sonographic Murphys.
Dilated CBD (7-8mm).
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Ultrasound
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Imaging
Hida scan documents
cystic duct patency.
GB should be visualized
in 30 min.
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Imaging-ERCP
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Acute calculous cholecystitis
Defnition
Acute GB inflammation due to cystic duct obstruction.
Persistent RUQ pain +/- fever, WBC, LFT, +Murphys
= inspiratory arrest
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Lap cholecystectomy very effective
with few complications (4%).
5% convert to open.
In acute setting up to 50% open.
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Acute acalculous cholecystitis
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Caused by gallbladder stasis from lack of enteral
stimulation by cholecystokinin
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Chronic cholecystitis
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Complications of acute cholecystitis
Empyema of Pus-filled GB due to bacterial proliferation
gallbladder in obstructed GB. Usually more toxic, high
fever
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Cholangitis
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Tx: NPO, aggressive IV Fluids, broad spectrum IV
Antibiotics
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Gallstone pancreatitis
Pathophysiology
Reflux of bile into pancreatic duct and/or obstruction
of ampulla by stone
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Tx: ABC, resuscitate, NPO/IVF, pain meds
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Prognosis
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Laparoscopic Cholecystectomy
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Laparoscopic Cholecystectomy
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Laparascopic cholecystectomy
Advantages Disadvantages
Less pain Lack of depth perception
Small incisions View controlled by camera
Better cosmesis operator
Short hospitalization Difficult to control hemorrage
Eariler return to full CO2 insufflation
activity complications
Decreased total costs
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Postoperative complications
1. Bleeding inadvertent vascular injury
liver cirrhosis
portal HTN
Rx apply pressure with hot packs 5 min
identify bleeder and ligate
- Hogarth Pringle maneuver
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Postoperative complications
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Causes inexperience
- aberrant anatomy
-inflammation
-bleeding
-injudious use of cautery
-large stone in Hartmans pouch
-wrong direction of traction of gall
bladder
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Classifications or grading
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Strasberg classification-
class A-injury to small ducts
class B-injury to the sectoral duct with
stricture
class c-injury to sectoral duct with leak
class d-lateral injury to extrahepatic
duct
classes E1-5 (Bismuth)
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Bile duct injury cont
Presentations Diagnosis
-obstructive jaundice -CBC
-evidence of bile leak -LFT
-cholangitis -serum Albumin and
coagulation profile
-Abd u/s
-MRCP,PTC
-ERCP ,
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Operative treatment Bile duct injury
Immediate repair
simple ligation of ducts
-closure over a T-tube
-end to end anastomosis with a T tube
-Roux-en-Y anastomosis with transhepatic bilary
stents
Elective repair
-hepaticojejunostomy with Roux-en y limb
usually after 2 months
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Postoperative complications cont
3. Retained stone
In 1% of cholecystectomies
Rx Dormia extraction
Endoscopic sphinicterotomy and extraction
T-tube flashing
Reoperation
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Postoperative complications cont
4. Post cholecystectomy syndrome.
Persistent or recurrent signs and symptoms after
cholecystectomy excluding early post op. complications
10% of patients
common in middle aged
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DDx of Post cholecystectomy syndrome cont
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Post cholecystectomy syndrome cont
1. Hx & P/E.
2. Lab. CBC, serum amylase, LFT, PT.
3. Imaging. CXR , US , CT , PTC MRCP
Upper GI & SB follow through ,
Ba enema
Endoscopy. ERCP , Total colonoscopy
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Post cholecystectomy syndrome cont
Mx. 1. Medical.
2. Surgical.
3. Psychiatric consultation
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Safety
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Thank u
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