Gallstones Complications

Anatomy of biliary tree: 

Gallstone complications 1

 

Types of gallstones:

  • Mixed (75%):
    • Most common
    • Multiple + small
    • Mainly contains cholesterol (>50%)
  • Pure cholesterol:
    • Solitary + large
    • Linked to: age, obesity, oestrogen
  • Pigment:
    • Linked to bilirubin precipitation
    • Brown: made up of calcium bilirubinate and calcium soaps, associated with biliary bacterial infection
    • Black: associated with cirrhosis and chronic haemolytic states

 

Risk factors of gallstones:

  • Female, Fat, Forty, Fertile
  • Others: Pregnancy, IBD, contraceptives, hyperlipedemia, TPN

 

Pathophysiology\aetiology of gallstones: 

gallstone-complications-2.png

 

Symptoms of biliary colic vs acute cholecystitis:

Biliary colic Acute cholecystits
–    Intermittent RUQ pain ± radiation to right shoulder + N\V + tender RUQ

–    Negative: peritonism, Murphy’s, vital signs, WBC

–    Conservative Rx

–   Constant RUQ pain ± radiation to right shoulder + N\V + tender RUQ

–   No jaundice

–   Positive: peritonism (guarding\rebound), Murphy’s, fever, high WBC

–   Boas’s sign (hyperaesthesia below the right scapula)

–   Abx + early surgery (ERCP if there’s a gallstone)

 

Complications of gallstones:

1. Acute cholecystitis:

  • Pathophysiology is the same as biliary colic: contractions against resistance (stone at the neck of gallbladder) -> if managed conservatively (fluids, NSAIDS, antispasmodics) -> biliary colic subsides -> stone might fall back into lumen
  • Distant obstruction -> stagnation of bile -> if > 6 hrs -> bacterial infection and gas fermentation -> over distension of the gallbladder
  • Most common organism? coli, Klebsiella, Enterococcus, Enterobacter
  • Usually in acute cholecystitis, the pt is not jaundiced, unless with there’s another stone obstructing CBD, or other dx like hepatitis or liver abscess (but they will be sicker)
  • Repeated or persistent biliary colic -> pt should be admitted and operated on, why? frequency and severity of biliary colic heralds an attack of acute cholecystitis
  • Treatment:
    • Standard of care is surgery as soon as possible, even though operating on an inflamed gallbladder carries a high risk of CBD injury and conversion to open surgery, there’s no point in keeping them on IV antibiotics then do interval cholecystectomy (which was the practice previously), why? b\c 30% of those treated conservatively will come w\ another complication before the planned day of surgery
  • Complications of acute cholecystitis: perforated gallbladder, empyema of gallbladder, gangrenous gallbladder, emphysematous cholecystitis ->
    • Treatment of all of them is: fluids + abx + early surgery (urgent, not emergent)

 

2. Choledocholithiasis: 

  • Causes obstructive jaundice, either biochemically or clinically.
  • However, you need 3 folds’ increase in total bilirubin to see it clinically + best seen in “sunlight” -> so absence of clinical jaundice doesn’t mean pt isn’t jaundiced
  • Other ways to clinically assess jaundice -> History (family or pt noticing turning yellow, dark urine, pale stool) or physical (pruritus or scratch marks) -> but they are all not accurate
  • Cholidocholithiasis might complicates into -> ascending cholangitis

 

3. Ascending cholangitis: 

  • Definition: infection of biliary tree
  • Why called ascending?? coli is not a usual inhabitant of the gallbladder, so how does it go up the biliary tree?
  • 70% of the liver’s blood supply is portal (inferior mesenteric v. joined by splenic v). IMV drains the colon -> so that blood is contaminated with E. coli (but normal immune system + continuous blood flow is good enough to take care of it and prevent spreading) -> so that blood goes to the liver and comes down to the bile. When there’s no obstruction -> washed out. But with obstruction -> increased bacterial load -> gives the clinical picture of infection
  • So, it’s ascending from the colon via the portal system to the bile (not from duodenum)
  • Pts w\ cholangitis are very sick (one of the few surgical diagnoses that cause rigors) + high mortality
  • Cholangitis is like an abscess (pus under pressure) -> need to relieve it -> ERCP+ES ‘endoscopic sphincterotomy) followed by cholecystectomy
  • Cholangitis is a surgical emergency! (treating it conservatively w\ fluids and abx is useless)

 

4. Biliary pancreatitis: 

  • Transient obstruction of pancreatic duct -> trauma to ampulla -> release of digestive enzymes -> auto-digestion of the gland -> acinar disruption -> increase in intra-ductal pressure
  • First wk is the wk of inflammation (where they present as SIRS, but negative blood culture), second wk is the wk of infection (sepsis)

CASE: two pts, exactly same profile, one’s US shows multiple mobile gallstones + the largest is 3 mm, the other has a solitary 2 cm gallstone. Which one is most likely to develop biliary pancreatitis?

The one w\ small stones or sludge (the 2 cm stone is less like to pass in the first place, or it might pass and cause obstructive jaundice, but not pancreatitis)

  • Usually, biliary pancreatitis doesn’t cause jaundice, unless:
    • Another stone obstructing CBD at the same time
    • Biliary pancreatitis might cause transient + slight elevation of bilirubin, how? b\c last part of CBD is intrapancreatic -> swelling of pancreas -> compresses on ampulla of vater. But this normalizes the following day + normal US
  • Treatment is conservative: fluids and electrolyte replacement, fat free diet (NPO only if not tolerating)
  • Arrange for ERCP + cholecystectomy w\in same admission

Gallstone complications 3

 

5. Gallbladder cancer:

  • Large stone -> chronic irritation -> repeated healing -> mutation -> malignancy

 

6. Mirizzi syndrome: 

  • Stone impacted in the gallbladder neck or cystic duct compresses the common hepatic duct\CBD
  • Compression -> walls fusion -> fistula
  • Pt can live w\ it normally, only slightly elevated bilirubin (due to extrinsic obstruction)
  • Must be careful while doing cholecystectomy, b\c in Mirizzi syndrome, there’s fusion of the cystic duct w\ the CBD or hepatic duct. And part of cholecystectomy is dissecting the cystic duct -> where you might accidentally cut the CBD

Gallstone complications 4

 

7. Gallstone ileus: 

  • Large gallstone (> 2.5 cm) -> compresses on duodenum -> cholecystenteric fistula -> impaction of gallstone in bowel -> mechanical bowel obstruction
  • Clues? Elderly (needs chronicity to develop), air in gallbladder, stone in right iliac fossa
  • Treatment is surgical -> laparotomy with removal of the stone via a small enterotomy proximal to the point of obstruction.
  • Cholecystenteric fistula is left alone b\c many close spontaneously -> bring pt back 6 mo later for cholecystectomy

 


Download the PDF version: here


References:

  • Dr Alabeidi’s lecture and clinical sessions’ notes

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