The gallbladder, gallstones, and beyond….
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Transcript of The gallbladder, gallstones, and beyond….
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The gallbladder, gallstones, and beyond….
Leslie Kobayashi, MDJanuary 31, 2012
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Anatomy
Liver Bile ducts Pancreas Duodenum Transverse colon
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Anatomy
FundusBodyInfundibulum/NeckCystic duct
Spiral Valves of Heister
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Anatomy
Triangle of calot Borders: CHD, cystic duct, liver
edge Contents: Cystic artery, node of
Calot
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Ductal Anatomy
Right and Left Hepatic ductsCommon Hepatic ductCystic ductCommon bile duct
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Aberrant anatomy
Vascular
Normally (>90%) cystic a. arises from RHA
Replaced right hepatic a.
Replaced left hepatic a.
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Bile
500-1500mL produced daily Composition: water, electrolytes, bile salts,
proteins, lipids
Ductal epithelium products▪ Alkaline phosphatase▪ HCO3
Hepatocyte products▪ Bile in conjugated soluble form synthesized
from cholesterol▪ Primarily cholate and chenodeoxycholate
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Bile
95% of bile re-absorbed into the liver via portal vein (enterohepatic circulation) 85-90% in terminal ileum via active transport 10-15% deconjugated in colon, absorbed
passively 5% excreted in stool Cycles 6-10x daily
80% of bile stored in GB in fasting state
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GB
Function store and concentrate bile
Absorption: NaCL, H2O occurs rapidly Secretion: mucus, H+
GB average capacity 30-50mL
Can increase to 300mL with obstruction
Normal ejection 50-70% in 30-40min
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Significance
Do gallbladder problems create a significant healthcare burden?
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YES!
Health burden
6.2 Billion$ in US 1.8 million ambulatory care visits Increased 20% since 1980’s Cholecystectomy most common
elective abdominal procedure in the US▪ 750,000 annually
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Why does that happen?
Stones
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Types of stones
Cholesterol stones (75%) Female fat fertile
Black stones (20%) Hemolytic diseases (Sickle cell disease) Cirrhosis
Brown stones (5%) Infection PSC
*primarily form in the ducts
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Cholesterol stones
Low calcium, radiolucent
Created when fractional cholesterol content of bile increased, and with incomplete emptying of GB
Associated with obesity, rapid weight loss, Native American/Hispanic heritage, ↑TG’s, ↓HDL, Spinal cord injury
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Cholesterol stones
Hormonal influence
Estrogen increases lithogenicity of bile▪ Increased risk for females▪ Increased risk in obesity
Progesterone increases SM relaxation and bile stasis, decrease bile salt secretion▪ Increased risk in pregnancy
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Cholesterol stones
Increase risk of stone formation TPN Octreotide Ceftriaxone
Decrease risk of stone formation Statins ?ursodiol
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Pigmented stones
Often radiopaque due to calcium bilirubinate, calcium fatty acid soaps and inorganic calcium salts
Two types Black Brown
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Pigmented stones
Black Form in GB Bile sterile Associated with age, hemolytic DO’s,
alcoholism, cirrhosis, Gilbert’s syndrome, Cystic fibrosis, pancreatitis and TPN
Cholecystectomy curative
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Pigmented stones
Brown Form in ducts as well as GB Always infected 1O with enteric
organisms, often associated with cholangitis
Associated with parasitic infection (liver fluke)
Associated with IBD, duodenal diverticulae
Will often recur after LC/OC
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Stones: Where do they go?
And what do they do?
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Stones
Asymptomatic Symptomatic
Uncomplicated
Complicated
No obstructio
n
+ Infection/inflammation
+ Obstructio
n
CBD
- Infection
+infection
Ampulla
GSP
Choledocho Cholangitis
Biliary colic
Cholecystitis
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In the gallbladder
Incidence: 10-30% of the population Asymptomatic (80%) Symptomatic (1-3% per year)
No inflammation: Biliary colic +inflammation: acute cholecystitis +obstruction : choledocholithiasis, GSP +obstruction+inflammation: cholangitis
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Biliary colic
History Transient abdominal pain Occurs after fatty meals
Exam Benign
Labs Normal
Ultrasound GS
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Hyperechoic masses, dependent in location
Acoustic shadowing
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Cholecystitis
History Prolonged pain Fevers Nausea/emesis
Exam Fever,
tachycardia RUQ TTP,
Murphy’s sign
Labs Leukocytosis Mild ↑ LFT’s
Imaging
Ultrasound HIDA
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Cholecystitis
Gallstones Obstruction of gallbladder
Obstruction causes inflammation Inflamed wall is thickened Edema or emphysema of GBW
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Cholecystitis
Inflammation may or may not be associated with infection
50-70% of bile cultures are positive
E. coli, Klebsiella, Streptococcus, Enterobacter
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Ultrasound
95% sensitivity/specificity
Signs of cholecystitis Gallstones GBW >3mm Pericholecystic fluid GBW striations or air within GBW Sonographic Murphy’s sign
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GS with GBW thickening
Normal GBW <3mm
Pericholecystic fluid
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HIDA
Cholescintigraphy: Injection of Tc99 labeled hydroxyl iminodiacetic acid
HIDA→hepatocytes→secreted into bile
Normal visualization of GB, CBD and SB within 30-60 min
+scan if no visualization of GB within 1hr and +uptake in CBD or SB
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HIDA
Rim sign*Sphincter, ↙CBD
Normal HIDA
Positive HIDA
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HIDA
False positives common in fasting patients Up to 40-60% in critically ill
Can decrease false+ rate with morphine
↑sphincter of Oddi pressure causing preferential filling of the GB
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Cholecystitis: Complications
↑Tension in GBW =↓perfusion →Necrosis of GBW
Gangrenous/emphysematous cholecystitis▪ 1% of cases, 3:1 M>F▪ Conversion rate 30-50%
GB Perforation▪ Assoc with ↑mortality (~20%)▪ Gallstone ileus
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Gallstone ileus
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Complications
Cystic duct obstruction→ Hydrops
Bile is absorbed but GB mucosa continues to secrete mucus
GB tense, filled with mucinous fluid
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Complications
Mirrizi’s syndrome
Impacted stone in infundibulum or CD →External compression of the CBD
0.7-1.4% of patients Assc with ↑risk of CBD injury, GB cancer
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What if the stones escape the GB?
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Stones in the CBD
Stone in CBD
No obstruction
Symptomatic
Asymptomatic
+ obstruction
No infection
+Infection
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Choledocholithiasis
History: jaundice, icterus, pruritis, dark urine, steatorrhea, acholic stools, bleeding
Exam: jaundice, icterus, RUQ pain, Murphy’s sign
Labs Elevated LFT’s, INR Elevated bilirubin highest PPV 25-50% May be normal in up to 30% of patients
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Choledocholithiasis
Imaging Dilated CBD on UTZ
▪ CBD <5mm risk of stone ~1%▪ CBD >5mm risk of stone 58%
MRCP Sensitivity 95% Specificity 89%
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CBD dilation
Stones within the bile duct
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Cholangitis
History/Exam: similar to choledocholithiasis with sepsis, septic shock
Labs/Imaging: similar to choledocholithiasis with leukocytosis, bactermia, ±MSOF
Charcot’s triad
Reynolds pentad
RUQ pain, fevers, jaundice
Triad + ΔMS, shock
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Beyond the CBD
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Gallstone pancreatitis
History: epigastric pain, nausea/emesis
Exam: RUQ/epigastric TTP, SIRS Labs: amylase/lipase ↑3x nl,
±↑LFT’s, leukocytosis Imaging: ±CBD dilation, pancreatic
edema, necrosis, fluid collection
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Ranson’s criteria-Alcoholic
First 24hours: Glucose >200 Age >55 LDH>350 AST>250 WBC>16k
48 hours Ca <8 Hct↓>10 PaO2 <60 BUN↑>5 Base Deficit >4 Sequestration >6L
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Ranson’s criteria-Non-Alcoholic
First 24hours: Glucose >220 Age >70 LDH>400 AST>440 WBC>18k
48 hours Ca <8 Hct↓>10 PaO2 <60 BUN↑>2 Base Deficit >5 Sequestration >6L
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Ranson’s criteria
Each category 0 or 1Add up total pointsMortality
0-2 <5% 3-4 15% 5-6 40% 7-8 ~100%
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Treatments
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Treatment
Medical
Surgical
Lap Open CBDE
ERCP sphincterotom
y, stent
Percutaneous Cholecystosto
my tube
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Treating the gallbladder
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Gallstone “Cleanse”
PreparationEat a diet high in alkaline-forming foods and low in fats for at least 3-5 days before the cleanse.Help to gently prepare the liver by having a glass of fresh apple juice every day for 1 week prior to the cleanse. Apple juice helps to dissolve the stones
Ingredients
•Epsom salts (Magnesium Sulfate): 4 tablespoons•Olive oil: 1/2 cup or 125 ml•Fresh pink grapefruit: squeeze 1/2 cup (125 ml) juice•Or use 7-8 fresh lemons/limes: squeezed into 1/2 cup juice•1 liter jar with lid
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Medical
Or you could try:
IVF hydrationAntibioticsBowel rest
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Medical
Ursodiol: used as Mechanism: supplemental bile acid
decreases lithogenicity of bile, dissolve existing stones
Indications: bridge to LC/OC, too sick for OR, cirrhotics, PSC, TPN
Efficacy: may ↓LFT’s in PSC/cirrhotics, may ↓stones/sludge on UTZ, does not ↓symptoms, prevent need for OR, stones recur after cessation of medication
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Medical
Diet: Cholesterol/Fatty acids
Carbohydrates
Legumes
Unsaturated fats
Coffee, FiberVitamin C, Alcohol
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Treatment
Failure of medical management in acute cholecystitis 32%
Recurrence rate of GSP 29-63% Surgical management results in
reduced HLOS
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Treatment
Timing of surgery for acute cholecystitis Within 48hrs vs >72hrs no difference in
conversion rates, OR time, LOS Comparing first hospitalization (<7d) vs
delayed (>6wks)▪ 17.5% rqr emergent cholecystectomy for
recurrent/unresolving sx’s▪ No difference in conversion rates or CBD
injury
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Treatment
Timing of surgery for GSP Early operation safe with mild pancreatitis Rason’s criteria <3
Increased conversion rate, HLOS, and operative complications in early operation in severe pancreatitis Ranson’s criteria ≥3
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Surgical approaches
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Laparoscopic
Port placement Umbilicus Subxiphoid just to the right of the
falciform at the level of the inferior liver edge
2-3cm below costal margin in midclavicular line
Anterior axillary line, below the fundus of gallbladder
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Laparoscopic
Retraction and dissection of Triangle of Calot prior to Gallbladder removal from fossa
CD may be clipped, sutured, tied, stapled
Remove gallbladder in fundus→dome direction
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Open
Right subcostal incision
Mini-cholecystectomy (5-8cm) incision associated with equivalent outcomes/complications and less post-op pain, decreased LOS
Dome down dissection technique Isolate cystic artery/duct and
suture ligate
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Lap vs. open
Conversion rate: 0.18-35% ave 4.7% CBD injury rates
Lap 0.2-0.6% Open 0-0.3%
Complication rate Lap ~1.2% Open (bile leak 1%)
LOS: shorter for Lap
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Difficult Cholecystectomy RF’s for conversion
Male sex Obesity ↑age Wide short cystic duct Low surgeon case load
Gangrenous or emphysematous chole ↑risk of conversion RR 3.2 (CI 2.5-4.2) No ↑risk of local complications or CBD injury
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Other options
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Cholecystostomy tube
Can be transhepatic or transperitoneal no difference in outcomes
Technical success 96-98% Resolution of symptoms 68-96% Mortality 3-14% Complications
Dislodged catheter 16-33% Bleeding 1.5-1.8% Recurrent cholecystitis 7-41%
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Clearing the duct
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Natural history of CBD stones
Choledocholithiasis Stones in CBD in 10-15% of symptomatic
pt’s 55-70% pass spontaneously
GSP20-30% of patients have CBD stones 85-90% pass spontaneously
Symptomatic cholecystitis 4.6% +IOC at the time of LC 97.8% pass spontaneously
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Surgical approaches
CBDE
Can be performed lap or open
Transcystic or via choledochotomy
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Surgical approaches
CBDE
Imaging duct▪ Fluorscopic guidance▪ Choledochoscopy
Clearing duct▪ Basket, snare, flush▪ +/- glucagon to relax sphincter
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Surgical approaches
CBDE
Completion cholangiogram Clip, tie or staple cystic duct stump Close choledochotomy over T-tube +/-drain external Success rate of duct clearance 75-95%
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ERCP
Efficacy 1 procedure: 71-75% Multiple procedures: 84-95%
Mortality 0.2-0.5%Complication rate 5-8%
Perforation Bleeding Pancreatitis Cholangitis
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Complications
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Complications
1-2% of patients will represent with CBD stone following cholecystectomy
Dx <2yrs post-op = retained stone
Dx > 2yrs post-op =recurrent stone
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Other Complications
Ileus Incisional/port site herniaWound infectionAbscess
Biloma/bile leak
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CBD Injury
Strasberg-Bismuth classification
A-CD stump, fossa B/C-aberrant RHD D-lateral injury E-circumferential injury to major duct
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Special circumstances
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Pregnancy
Increased risk of stones 2-12% have stones 0.05-1.2% symptomatic during
pregnancy
Risk of stones increased in: Hispanic Pre-pregnancy obesity (4x) Decreased by EtOH consumption
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Pregnancy
Biliary disease the most common non-obstetrical cause of maternal hospitalization
Cholecystitis most common 40% GSP 30% CBD stone 20% Biliary colic 10%
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Pregnancy
If symptomatic risk of recurrence high 40%-70% recur prior to delivery
If symptomatic risk of fetal loss high 10-20%
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Pregnancy
Treatment goals
Treat infection Maintain nutrition Prevent contractions/preterm labor Prevent fetal loss Prevent maternal morbidity/mortality
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Pregnancy
Surgical management associated with fewer complications than medical management Contractions equivalent (~30%) Decreased preterm delivery, need
for c-section, and recurrent symptoms
Fetal loss with LC 0-5%
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Pregnancy
Ideal timing LC/OC 2nd trimester ↓preterm labor (0% vs. 40%) ↓ fetal loss ↓ risk of fetal malformation Technically easier
1st delay to 2nd, 3rd delay to postpartum
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Pregnancy
ERCP can be performed safely with:
Low radiation exposure ▪ Fluoro time 14sec-3.2min▪ Radiation exposure 40-310 mrad
Few complications ~7%
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Pregnancy
Operative considerations
Port placement to accommodate uterus
Hassan vs. Veress likely equivalent
↓insufflation pressure 10-12
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Cirrhotics
Stones more common in cirrhotics (2x)
Diagnosis difficult Pain nonspecific Elevated LFT’s nonspecific Leukocytosis nonspecific GBW thickening nonspecific
▪ HIDA may be helpful
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Cirrhotics
Management differences Increased operative risk
▪ Morbidity 3x▪ Conversion 2x▪ Bleeding 8x
Increased risk with cholecystostomy▪ Bleeding▪ Ascites/Leak
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Cirrhotics
Mortality Overall acceptable 0.6-0.8% Significantly increased in Child’s C patients
(17%)
LC safer than OC Less bleeding Shorter OR time Shorter HLOS Possibly lower mortality (open mortality 8-
25%)
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Other pathology
Acalculous cholecystitis M>F 1.5:1 4-8% of all cholecystitis Dx with UTZ/HIDA
Gallbladder polyps
Gallbladder cancer
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Thank You