Pre-hepatic

Hepatic

Post hepatic ( surgical/obstructive )

Causes:

Lumen

Wall

Outside wall

Investigations:

Laboratory tests

Imaging investigations

Special tests

Laboratory Tests:

Liver biochemical tests: bilirubin alk phosphatase GGT AST ALT Serology Autoantibody screen Tumour markers Coagulation screen

Imaging investigations:

Ultrasound EUS CT scan ERCP MRCP PTC

Types of Gallstone:

Cholesterol

Mixed

Pigment

Appearance of gallstones

Appearance of gallstones

Pathogenesis of Gallstones: Lithogenic Bile

Stasis

Nucleating Factors

Lithogenic Bile: Cholesterol Synthesis in Liver Cholesterol/Bile Salt ratio 7 alpha hydoxylase HMG co-enzyme reductase

Components of bile

Stasis:

Vagotomy

Pregnancy

Nucleating Factors:

Mucus Glycoproteins

Desquamated Epithelia

Foreign Bodies

Cholesterol gallstone pathogenesis

Clinical Presentations: Silent 70% Mechanical Impaction Cystic Duct Biliary Colic CBD Jaundice Cholangitis Inflammation Acute Cholecystitis Chronic Cholecystitis Acute Pancreatitis Ulceration/Fistula Formation Carcinoma

Investigation of Gallstones:

Ultrasound Oral Cholecystogram Cholangiography Endoscopic Retrograde Peroperative MRCP HIDA Scan

Gallstones and biliary sludge

Several noninvasive imaging modalities currently available

Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography

Per-operative cholangiopancreatography

Management:

Asymptomatic

Symptomatic

Endoscopic view of sphincterotomy and basket extraction (a)

Endoscopic view of sphincterotomy and basket extraction (b)

Endoscopic view of sphincterotomy and basket extraction (c)

Balloon dilation of the papilla and stone extraction (d)

Operating room setup for laparoscopic cholecystectomy

Laparoscopic cholecystectomies and pneumoperitoneum

4 laparoscopic ports during laparoscopic cholecystectomy