Gallstones

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      • Gallstones
        • Prevalence increases with advancing age
        • 10-20% become symptomatic (MCQ)
        • Over 10% of those with stones in the gallbladder have stones in the common bile duct (MCQ)
        • Pathophysiology
          • Three types of stones
            • Cholesterol stones(15%)
            • Mixed stones(80%)(MCQ)
            • Pigment stones(5%)
          • 10% of gallstones are radio-opaque(MCQ)
          • Bile acids act as a detergent keeping cholesterol in solution
          • Bile acids, lecithin and cholesterol result in the formation of micelles
          • Bile is often supersaturated with cholesterol
          • Biliary infection, stasis and changes in gallbladder function can precipitate stone formation
          • Bile is infected in 30% of patients with gallstones
          • Gram-negative organisms are the most common isolated(MCQ)
        • Clinical presentations
          • Acute cholecystitis
          • Empyema of the gallbladder
          • Mucocele of the gallbladder
          • Biliary colic
          • ‘Flatulent dyspepsia’
          • Mirrizi’s syndrome
          • Obstructive jaundice
          • Pancreatitis
          • Acute cholangitis
        • Acute cholecystitis
          • 90% cases result from obstruction tthe cystic duct by a stone
          • Increased pressure within the gallbladder results in an acute inflammatory response
          • Most common organisms are E. coli, Klebsiella and strep. Faecalis (MCQ)
          • Clinical features
            • Constant pain (usually greater than 12 hours duration) in right upper quadrant
            • Fever, tachycardia
            • Tenderness in right upper quadrant
            • Murphy’s sign – guarding in right upper quadrant on deep inspiration (MCQ)
          • Investigation
            • Ultrasound is the initial investigation of choice(MCQ)
            • Diagnostic features on ultrasound include:
              • Presence of gallstones
              • Distended thick-walled gallbladder
              • Pericholecystic fluid
            • Murphy’s sign demonstrated with ultrasound probe
              • If diagnostic doubt a HIDA scan may be useful(MCQ)
              • Will show failure of isotope (hydroxyiminodiacetic acid) uptake by gallbladder
          • Complications of acute cholecystitis(MCQ)
            • Gangrenous cholecystitis
            • Gallbladder perforation
            • Cholecystoenteric fistula
            • Gallstone ileus
          • Management
            • Initial management is usually conservative
            • Patient is fasted, given intravenous fluids and opiate analgesia
            • Intravenous antibiotics (e.g. second generation cephalosporin) should be given to prevent secondary infection
            • 80% patients improve with conservative treatment
            • If fit, should be considered for a laparoscopic cholecystectomy (MCQ)
            • Timing of surgery
              • early surgery (<72 hours) is safe
              • It has a lower conversion rate
              • It avoids the complications of conservative treatment failure
              • If patient unfit for surgery, percutaneous cholecystotomy my be beneficial
              • Particularly useful in acalculus cholecystitis
      • Treatment of gallbladder stones
        • Open cholecystectomy
          • Specific complications
            • Bile duct damage
            • Retained stones
            • Bile leak
          • General complications
            • Wound dehiscence
            • Pulmonary atelectasis
        • ‘mini’ cholecystectomy is done through a 5 cm transverse incision (MCQ)
        • Dissolution therapies
          • High complication rate
          • Poor long-term results
        • Extra-corporeal shock wave lithotripsy
          • Poor stone clearance
        • Laparoscopic Cholecystectomy
          • Shown tbe equally as effective as open cholecystectomy in controlled trials
          • Pre-operative ERCP indicated if: (MCQ)
            • Recent jaundice
            • Abnormal liver function tests
            • Significantly dilated common bile duct
            • Ultrasonic suspicion of bile duct stones
          • Technique
            • CO2 pneumo-peritoneum induced using either Veress needle or open technique(MCQ)
            • Open (Hasson) technique is believed be safer
            • Over half of bowel injuries are caused by Veress needles or trocars
            • Abdominal pressure set to 12-15 mm Hg
            • High intra-abdominal pressure can:
              • Reduce pulmonary compliance
              • Decrease venous return
              • Higher end-tidal CO2 levels
            • Surgery usually performed using four standard ports (2 x10 mm & 2 x 5 mm)
            • Patient positioned with head up tilt and rolled tthe left
            • Calot’s triangle dissected using a retrograde technique(MCQ)
            • Cystic duct and artery identified
            • Ligated with clips or endo-loops
            • About 50% surgeons routinely use intra-operative cholangiography
            • Cholangiography allows: (MCQ)
              • Definition of biliary anatomy
              • Identification of unsuspected CBD stones(~10%patients)
          • Outcome
            • Conversion rates typically about 5%
            • Laparoscopic cholecystectomy associated with:
            • Reduced analgesic requirements
            • Reduced postoperative stay
            • Bile duct injury
              • Occurs in between 0.1% and 0.5% of patients
              • For most injuries hepaticojejunostomy is the treatment of choice (MCQ)
              • Long-term risk include stricture formation and cirrhosis
          • Laparoscopic surgery in acute cholecystitis
              • In those with acute cholecystitis , operation has usually been deferred 6-8 weeks(MCQ)
              • Recently shown that early laparoscopic cholecystectomy is safe
        • Emphysematous Cholecystitis
          • Severe variant of cholecystitis caused by gas-forming bacteria
          • Relatively rare
          • Often results in perforation of the gallbladder
          • high mortality and morbidity
          • Typically affects elderly diabetic men
        • Acalculous Cholecystitis
          • Acute cholecystitis without evidence of gallstones; thought to be due to bil- iary stasis.
          • Ten percent of cases of acute cholecystitis.
          • Risk factors (MCQ)
            • intensive care unit (ICU) patients with multiorgan system failure
            • trauma (especially after major surgery)
            • burns, sepsis
            • TPN
          • Diagnosis
            • Leukocytosis, with or without increased ALP, LFTs, amylase, and total bilirubin
          • Ultrasound:
            • Biliary sludge and inflammation; can also be used to detect complications (e.g., gangrene, empyema, or perforation of the gallbladder)
          • HIDA scan: To confirm diagnosis
          • Treatment
            • Urgent cholecystectomy(MCQ)
            • percutaneous cholecystectomy is an option in p tients with high surgical risk(MCQ)
        • GALLSTONE ILEUS
          • Small bowel obstruction caused by a gallstone
          • the ileocecal valve is the most common site of obstruction. (MCQ)
          • Most often a large stone has eroded a hole through the gallbladder wall to the duodenum, causing a cholecystenteric fistula
          • A gallstone escapes through this hole into the GI tract and eventually gets stuck in the ileum, causing small bowel obstruction.
          • Most common in women over 70.
          • Symptoms of acute cholecystitis followed by signs of small bowel obstruction (nausea, vomiting, abdominal distention, RUQ pain). (MCQ)
          • Diagnosis
            • Abdominal plain films–  pathognomonic features (MCQ)
              • Pneumobilia
              • dilated small bowel
              • a large gallstone in the RLQ
            • Ultrasound: (MCQ)
              • Useful to confirm cholelithiasis; may also identify the fistula
            • Upper and lower GI series: Other diagnostic options that are usually unnecessary
          • Treatment
            • Exploratory laparotomy, removal of the gallstone, and possible small bowel re- section with or without cholecystectomy and fistula repair
            • Typical clinical scenario of Gall stone ileus : (MCQ)
              • A 78- year-old female with a past history of cholelithiasis presents complaining of RUQ pain that radiates to her back, with nausea, vomiting, and abdominal distention. Abdominal plain films
              • show air in the biliary tree and a “‘stepladder” appearance of the small bowel.
              • Think: The history is consistent with both cholelithiasis and small bowel obstruction, and findings on abdominal radiograph are suggestive of gallstone ileus.
        • Clinical Pearls :
          • By definitions: stones in CBD > 2 years after cholecystectomy are primary CBD stones (pigmented, 
related to biliary stasis and infection), rather than cholesterol stones;need sphincterotomy and extraction (MCQ)
          • Three most sensitive signs of cholecystitis: (MCQ)
            • Sonographic Murphy’s sign
            • Wall thickening > 4 mm
            • Pericholecystic fluid
          • Postop lap chole patient not doing well, think: (MCQ)
            •  Viscous injury (e.g. duodenum)
            •  Duct injury
            •  Bile l
            •  Retained CBD stone
            •  Cystic duct stump leak

 

          • Management of gallstone ileus: (MCQ)
            • Remove stone (via enterotomy proximal at site of obstruction)
            • Run entire bowel
            • . In acute setting, especially elderly, reserve cholecystectomy for later (risk of recurrence ≈ 5 – 10%) & repair biliaryenteric fistula
          • Blood supply to supraduodenal bile duct arises from RHA and branches of GDA (retroduodenal artery) and lie longitudinally at the 3 and 9 o’clock positions
          •  Stones associated with ileal disease/resection and TPN use are pigmented stones, not cholesterol stones (are composed of calcium bilirubinate) (MCQ)
          •  Primary common duct stones (those in duct > 2 years after cholecystectomy) are pigmented and related to biliary stasis and infection, not cholesterol(MCQ)
          •  Natural History of Asymptomatic Gallstones:
            • Symptoms develop in about 1 – 3% of patients per year.
            • Hence, observe asymptomatic stones.
          • Complicated gallstone disease develops in about 3 – 5% of symptomatic patients per year.
          • Intraoperative cholangiography is not considered adequate unless the following are visualized: (MCQ)
            • Both right and left hepatic ducts (if notbe concerned about duct transaction)
            • CBD without filling defect
            • Free flow of contrast into duodenum (try glucagon if not seeing)
          • Concentrates bile by active absorption of Na+, Cl‐ (H2O follows)
          • cholecystectomy works by eliminating reservoir forces a more continuous source of bile and eliminates chance for “sludge” and stone formation.
          •  70% of patients with EF < 30% (normal is > 35%) on CCKHIDA benefit from cholecystectomy, although this may still be controversial
          • HIDA scan (most sensitive) (MCQ)
            •  A radionu- cleotide scan in which Technetium-99m labeled iminodiacetic acid is injected intravenously into hepatocytes.
            •  A normal gallbladder would be visualized within 1 hour.
          • Gall stone are often incidental, as most patients are asymptomatic.
          • Abdominal plain films pick up 15% of gallstones.
          • Ultrasound for Gall stones:
            • Procedure of choice;
            • classic findings include an
              • acoustic shadow (“headlight”)
              • gravity-dependent movement of gallstones with patient repositioning
          • Asymptomatic cholelithiasis does not require cholecystectomy unless the patient: (MCQ)
            • Has a porcelain gallbladder (which has an increased incidence of carci- noma)
            • Has sickle cell anemia
            • Hasa stone > 2 to 3 cm
            • Is a pediatric patient
          • Symptomatic cholelithiasis requires cholecystectomy.
          • Medical treatment of cholelithiasis involves chenodeoxycholic acid or ursodeoxycholic acid, drugs that can be used to dissolve cholesterol stones. These are not effective as surgical management.


Gallbladder Surgery for Gallstones
This 3D medical animation shows minimally invasive gallbladder surgery, or cholecystectomy, using a laparoscope to remove gallstones. The animation begins by showing the normal anatomy of the liver and gallbladder.
Gallstone Natural Home Remedy
Gallbladder problems can cause pain and digestive disorder. Naturally treat the symptoms of gallstones and a gallbladder attack using lemon and olive oil. Symptoms, causes and treatments sometimes vary.
Scientific Proof Apple Cider Vinegar Dissolves Liver & Gall Stones
Scientific proof that apple cider vinegar dissolves liver stones & gallstones. This experiment was done with fresh liver & gallbladder stones produced from a liver flush.


What are the symptoms of gallstones?
The majority of people with gallstones have no symptoms at all. This is because the stones generally stay in the gallbladder and cause no problems. Sometimes, however, gallstones may lead to cholecystitis (inflamed gallbladder). Symptoms of gallbladder inflammation include: Pain on the right-hand side of the body, just below the ribs Back pain Pain in the right shoulder Nausea Vomiting Sweating Restlessness

Gallstone, Gallstones and more Gall stones!
Gallstones are hard deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball.
Cholelithiasis
Causes

Gallbladder Surgery (removal of gallstones)
My gallstones pain and remove gallstones from gallbladder
1) Drink 1 glass (250ml) 100% apple juice 4 times a day for 5 days. 1 glass at breakfast, 1 glass at lunch, 1 glass at dinner & 1 glass before going to bed. It softens the gallstones. Eat normally.

Gallstones
These gallstones came out on my 5th liver flush by Hulda Clark on March 20, 2010. There are 2 different shades to indicate different locations in the liver. One huge gallstone 3 inches long and pinecone shaped is my biggest trophy yet
Gallstones
This patient education video explains what causes gallstones and discusses the symptoms, diagnosis, and treatment options.
Watch Inside Of Gall bladder – Stone Removed
Symptomatic gallstone disease needs proper treatment.

With the evolution of treatment, laparoscopic cholecystectomy (Laparoscopic removal of gall bladder) is the gold standard for treatment of gall bladder disease unless any contraindication for surgery.