WILLIAM L.

OLALIA, MD, FPCS

Associate Professor III, Department of Surgery
UST Faculty of Medicine & Surgery
 Anatomy & Physiology
 Gallstone formation
– Types of stones
 Diagnostic Studies
 Gallstone Disease
– Natural history
– Complications
 Acute/chronic cholecystitis
 Choledocholithiasis
 Cholangitis
 Biliary pancreatitis
 Operative interventions
 Anatomy

 Gallbladder
 Bile ducts
 Arteries

N.B. Anatomical variations common

Anatomy
 Anatomy

 Gall Bladder
– pear-shaped sac in the fossa of the
liver
– 7-10 cms long
– 30-50 ml average capacity
– divides the liver into right and left
lobes
 Anatomy

 Blood supply of the gall bladder

cystic artery – a branch of the right
hepatic artery in 90% of cases
 Anatomy
 The bile ducts
Extrahepatic ducts
right and left hepatic ducts
common hepatic duct
cystic duct
common bile duct
* The arterial supply to the bile ducts is from
the Gastroduodenal and Right Hepatic
Arteries
 Anatomy
 Common hepatic duct
- 1 to 4 cms length
- approx. 4 mm diameter
N.B.: the common hepatic duct is
joined at an acute angle by the cystic
duct to form the common bile duct
 Anatomy

 Cystic duct
– variable length
– contains spiral valves of Heister
 Anatomy

 Common bile duct is about 7- 11 cm in

length and 5 to 10 mm in diameter
 Ampulla of Vater- opening of the
common bile duct into the duodenum
 Sphincter of Oddi- surrounds the
common bile at the ampulla of vater
it controls bile flow
Anatomy
 Anatomy

Gallbladder stomach

CBD

DUODENUM pancreas

jejunum
 Physiology
Bile formation and Composition
 500- 1000 mL of bile/day
 mainly composed of water, electrolytes, bile
salts, proteins, lipids, and bile pigments
 Enterohepatic circulation (95% of bile acid
pool)
 Digestion and absorption of fats in the
intestines
 Physiology

 Gallbladder function
– Concentrate & store hepatic bile
– Deliver bile into the duodenum in
response to a meal
 Gallstone Disease
 One of the most common problems of the
GIT (11-36%)
 Predisposing factors:
– age, gender, ethnic background
– obesity, pregnancy, diet
– terminal ileal resection, gastric surgery,
hemolytic disorders
* Females are three times more likely to
develop gallstones
* 4F’s (fat, female, fetus, family history)
 Gallstone formation

 Dependent on the concentrations of :

– Bile salts
– Cholesterol
– Lecithin
 Gallstones form as a result of solid
settling out of solution
 Gallstone formation

 Two major types

– Cholesterol stones (80% of cases)
– Pigment stones (15-20%)
 Black pigment stones (hemolytic
disorders)
 Brown pigment stones (bacterial
infection, parasites)
 Gallstone Formation
 Cholesterol stones
– usually multiple, variable size, hard and
faceted or irregular, mulberry- shaped
and soft.
– supersaturation of bile with cholesterol
 common primary event in the formation of
cholesterol stones
 caused by cholesterol hypersecretion
Cholesterol Stones
 Gallstone Formation

 Pigmented stones
- small, brittle, black and sometimes
spiculated
- formed by supersaturation of calcium
bilirubinate, carbonate and
phosphate
- secondary to hemolytic disorders
Pigmented Stones
 Gallstone Disease
Natural History
 Most patients with gallstones will
remain asymptomatic
 About 3% become symptomatic per
year
 3 to 5% of symptomatic patients
develop complications
 Few patients develop complications
without previous biliary symptoms
 Diagnostic Studies
 Ultrasound of
LGBPS
 Sensitivity and
specificity of over
90%
 Posterior acoustic
Posterior
shadowing Acoustic
shadow
 Diagnostic Studies

 Oral cholecystography
– stones noted on film as filling
defects
– seldom utilized nowadays
 Diagnostic Studies

 Biliary Radionuclide Scanning (HIDA

Scan)
– acute cholecystitis
– biliary leak after biliary surgery
– non-visualized gall bladder with filling
of the common duct and duodenum
– Specificity and Sensitivity is 95%
 Diagnostic Studies
 Endoscopic Retrograde
Cholangiography
- both diagnostic and
therapeutic
- invasive
- direct visualization of
the ampullary region &
distal CBD
- success rate 90%
 Diagnostic Studies

 Endoscopic Retrograde
Cholangiography
 Success rate 90%
 Complications:
- occur in 5% of cases
- pancreatitis
- cholangitis
 Diagnostic Studies
 Computed Tomography
( CT Scan)
- defines the course and
status of the extra-
hepatic biliary tree and
adjacent structures
- test of choice in cholecystitis
evaluating patients
with suspected
malignancy of biliary
tree and pancreas
 Diagnostic Studies
 Percutaneous
Transhepatic
Cholangiography
– Intrahepatic bile duct
is accessed
percutaneously with a
needle under
fluoroscopy
– It defines the biliary
tree proximal to the
affected segment
 Diagnostic Studies
 Magnetic Resonance
Cholangiopancrea- Pancreatic
CBD
tography duct

– Offers a single non

invasive test for the
diagnosis of biliary
tract and pancreatic
disease
– Sensitivity is 95%
– Specificity is 89%
 Gallstone Disease
Complications
 Acute /chronic cholecystitis
 Choledocholithiasis
 Cholangitis
 Gallstone pancreatitis
 Biliary-enteric fistulae (gallstone ileus)
 Gallbladder carcinoma
 Symptomatic Gallstones

 Acute Cholecystitis
– secondary to gallstones in 90-95%
– initiated by obstruction of the cystic
duct by a stone
– Distention  inflammation/edema
 secondary bacterial infection
– Thickened gall bladder wall,
pericholecystic fluid on ultrasound
Symptomatic Gallstones
 Acute Cholecystitis
– may progress to acute gangrenous
cholecystitis, empyema, or
emphysematous cholecystitis
– Positive Murphy’s sign
– Mild to moderate leukocytosis (12-
15,000 wbc)
Symptomatic Gallstones

 Acute Cholecystitis
Diagnosis:
- Clinical profile
- Ultrasonography
- Biliary radio nuclide scanning
(HIDA)
 Symptomatic Gallstones

 Acute Cholecystitis
Treatment:
- Fluid resuscitation
- Antibiotics VS gram (-) aerobes and
anaerobes
- Analgesics
- Cholecystectomy is the definitive treatment
- Early cholecystectomy preferred over
interval/delayed cholecystectomy
 Symptomatic gallstones

- gallbladder
wall becomes
grossly
thickened and
reddish with
subserosal
hemorrhages
 Symptomatic Gallstones

 Chronic Cholecystitis
– recurrent episodes of pain
– pain due to stone obstructing the cystic duct
– pain in the epigastrium or RUQ area
radiating to the back
– pain associated with fatty/ heavy meal
– pathologic changes do not correlate well with
symptoms
– hydrops of the gallbladder
 Symptomatic Gallstones

 Chronic Cholecystitis

Diagnosis:
same as acute cholecystitis
Symptomatic Gallstones
 Chronic Cholecystitis
Treatment:
- elective open or laparoscopic
cholecystectomy (relief in about 90%)
- dietary advice while waiting for surgery
- diabetic patients should have prompt
cholcystectomy
Symptomatic Gallstones
 Choledocholithiasis
– Found in 6 to 12% with gallbladder stones
– 20-25% of patients > 60 years old with
symptomatic gallstones
– Majority are secondary stones
– Primary CBD stones more common among
asians
Symptomatic Gallstones
 Choledocholithiasis
Clinical Profile:
– Maybe silent or asymptomatic
– Biliary colic just like in gallbladder stones
– Symptoms maybe intermittent (ball valve
mechanisms)
  bilirubin, alkaline phosphatase & transaminases
– Impacted stone  progressive jaundice
– Small stone may pass thru the ampulla spontaneously
Symptomatic Gallstones
 Choledocholithiasis

Diagnosis:
– Ultrasonography: stones in the gallbladder, dilated
CBD (> 8mm)
– Biliary colic, jaundice, gallbladder stones on
ultrasound
– Magnetic Resonance Cholangiography (MRC) 95% &
89% sensitivity and specificity
– ERCP – gold standard in diagnosing CBD stones with
therapeutic options
Symptomatic Gallstones
 Choledocholithiasis
Treatment:
Plan A
pre-op endoscopic cholangiography

sphincterotomy + stone removal

laparoscopic cholecystectomy
 Symptomatic Gallstones
 Choledocholithiasis

Treatment:
Plan B
open cholecystectomy
intraoperative cholangiogram

open common bile duct exploration

t-tube placement
 Symptomatic Gallstones
 Acute Cholangitis
– Ascending bacterial infection from bile duct
obstruction
– Stones, strictures, parasites, instrumentation
– Fever, abdominal pain & jaundice (Charcot’s
triad)
– May lead to septicemia and disorientation
(Reynolds pentad)
– Leukocytosis, increased bilirubin and alkaline
phosphatase
 Symptomatic Gallstones
 Acute Cholangitis
Treatment:
– Fluid resuscitation, IV antibiotics
– ERCP/PTC diagnostic/therapeutic
– About 15% will require emergency biliary
decompression
 ERCP
 PTC
 T-tube choledochostomy/cholecystostomy
– Definitive treatment done later
 Symptomatic Gallstones
 Biliary Pancreatitis
– Another complication of CBD stone
– Obstruction of the pancreatic duct by an
impacted stone
– Temporary obstruction by a stone passing
thru the ampulla
– Ultrasound of biliary tree essential in
patients with pancreatitis
Symptomatic Gallstones
 Biliary Pancreatitis

Treatment:
– Severe pancreatitis: ERCP with sphincterotomy &
stone extraction
– Cholecystectomy (open or laparoscopic later /same
admission)
– Mild pancreatitis: elective cholecystectomy
N.B. possibility of spontaneous passage of
stone thru ampulla
 Operative Interventions

Cholecystostomy
– decompresses and drains the distended,
inflamed, hydropic, or purulent gall
bladder
– applicable to patients not fit to undergo
abdominal operation
– done either by open or percutaneous
ultrasound or CT guided
 Operative Interventions

Cholecystectomy
ISSUE: OPEN vs. LAPAROSCOPIC
CHOLECYSTECTOMY
Parameters:
 Operative Interventions
Cholecystectomy
OPEN
vs.
LAPAROSCOPICCHOLECYSTECTOMY
Parameters:
– Patient’s choice
– Technical expertise
– Patient’s condition
– Cost
– Length of hospital stay
– Complications
 Open cholecystectomy
 Safe and effective
treatment of acute
and chronic
cholecystitis
 Carl Langenbuch
performed the first
cholecystectomy in
1882
Laparoscopic cholecystectomy

 Introduced by Philippe Mouret in 1987

 Pneumoperitoneum is introduced to
the abdominal cavity using carbon
dioxide
 Surgery is video assisted using trocars
and special instruments
 Laparoscopic cholecystectomy

 The mortality rate of for laparoscopic

cholecystectomy is 0.1%
 Conversion to open cholecystectomy is
5%