a v short description about cholelithiasis

1. Cholelithiasis
Ayesha Qadir – Ayesha Zaheer
3rd year BDS

2. Introduction
 Gall Stones (Cholelithiasis) are the stones that
are formed within the gall bladder.
 Most common biliary pathology
 Common in Female

4. FORMATION OF GALLSTONES
Cholesterol gallstones develop when bile
contains too much cholesterol and not enough
bile salts.
Incomplete and infrequent emptying of the
gallbladder may cause the bile to become over
concentrated and contribute to gallstone
formation.
Increased concentration of bile solutes and
calcium
Gall bladder dysmotility, allowing more time
for solute to precipitate, delayed GB emptying
 increased levels of the hormone estrogen.

5. Types of Stones
 Cholesterol Stones:
• Contain 51-99% Cholesterol
• Also contain Calcium Salts, Bile Acids, Bile Pigments and Phospholipids.
• more common in west
• Pure cholesterol are often Solitary, between 2-3 cm long and rounded.
• Mixed stones are multiple
 Pigment Stones:
• It contains 30% of cholesterol
• Due to increased hemoglobin processing
• Pigment (Bilirubin) stones are small, dark, and usually numerous.
• Composed primarily of Bilirubin & Calcium Salts found in Bile and contain less then 20%
Cholesterol.
• More common in Asia about 80% and have two types
.

6. Pigment stones
Black pigment stones Brown pigment stones
• Formed in gall bladder
• Contain unconjugated billirubin plus
CaP, Ca(HCO3)2
• Associated with
o hemolytic conditions
o cirrhosis
• Constitute 70-80% of
pigment stones
• Formed in bile duct not in gall bladder
• Contain unconjugated billirubin
Plus calcium stearate, palmitate and
cholestrol
&
• Associated with
o bile stasis and infected bile
o Parasites e.g ( ascaris, clonorchis
sinensis) and foreign bodies
• Constitute 70-80% of pigment
stones

7.  Mixed stones
• Cholesterol is the major component.
• Other components includes calcium bilirubinate,
Calcium palmitate, calcium carbonate, calcium phosphate and proteins
• They are usually multiple

9. Clinical Features
• Asymptomatic in 80% of cases
• Asymptomatic pts. convert to symptomatic at rate of 1-2% per year into biliary colic and 0.2%
into actue cholecystitis
Acute cholecystitis
• Right upper quadrant or epigastric
Pain
• Pain radiate to back
• Pain is dull and constant
• Murphy’s sign- right upper
quadrant tenderness during
inspiration by the examiners right
subcostal palpation
Biliary Colic
• Typically in 10-25^ of pts.
• Severe upper right quadrant
pain
• Associated with nausea and
vomiting
• Pain radiate to chest,
frequently nocturnal
• Pain resolves after few hours

10. • MURPHY’s SIGN
• right upper quadrant tenderness
during inspiration by the
examiners right subcostal
palpation

11. Differential diagnosis
 Appendicitis
 Perforated peptic ulcer
 Acute Pancreatitis
 Myocardial Infarction
 Pneumonia- right lower lobe

12. Complication of Gall Stones
 Biliary Colic
 Acute/Chronic cholecystitis
 Empyema of Gall Bladder (Pus)
 Mucocele
 Perforation

13. Investigations
 CBC
 Urea and electrolytes
 LFTs
 Blood culture
 Serum Amylase
 Abdominal Xray
 Ultrasound- investigation of choice
 CT scan if diagnosis in uncertain

14. Conservative managemnet relieves symptoms in 90%of cases of acute
cholecystitis
It consist of
• Nil per Oral (NPO)
• Analgesics
• Antibiotics (broad spectrum effective against gram negative aerobes
• Ultrasound to ensure no complications have developed
• Conservative management must be abandoned if pain and tenderness
increase
• Time to perform cholesystectomy
o Early operation: 5-7 days
o Late operation: 6 weeks( so that inflammation subsides)
TREATMENT

15. CHOLECYSTECTOMY
• Complete Surgical Removal of
Gallbladder
• Most commonest abdominal surgery
2 types of cholecystectomy
• Open Cholecystectomy
• Closed cholecystectomy

16. INDICATIONS
• Chronic Cholecystitis
• Cholelethiasis
• Acute on Chronic Cholecystitis
• Acute Cholecystitis with complications
• Empyema Gallbladder
• Gangrenous Gallbladder
• Perforated Gallbladder
• Trauma to Gallbladder
• . Carcinoma Gallbladder
• Parasitic Infestation of Gallbladder like in Ascariasis

17. • Consent Nil by mouth for 8 hrs.
• Intravenous Fluids.
• Prophylactic Broad Spectrum Antibiotics.
• Anesthesia fitness for General Anesthesia especially with related
to respiratory function.
• Control of Hypertension & DM in affected patients.
• Arrangement of 1-2 pints of cross-matched blood.
• Correction of Any bleeding or clotting disorder
PRE OPERATIVE CONSIDERATIONS

18. • Calot's triangle Boundaries
also
known as cysto-hepatic triangle
Cystic duct
Cystic artery
The common hepatic duct
ANATOMY

19. OPEN CHOLECYSTECTOMY
-Position: Supine
-Anasthesia: General
-Incisions:
• Kocker incision – 2cm below right subcostal margin
• Right subcostal incision
• Right upper transverse incision
-Expose the gallbladder
-Placemnt of retractors and abdominal sponges
-Identify the Calot’s triangle
-Cystic duct and cystic artery are clipped and divided
-Secure hemostatis
-Remove the retractors and close the wound in layers
-Asceptic dressing applied

20. LAPRPSCOPIC CHOLECYSTECTOMY
• Has become a gold standard approach for gallbladder removal.
• If fails then convert to Open Procedure.
• Difficult to perform in Patients with Previous open Abdominal Surgeries.
• Carries some increased risk of extra- hepatic duct injuries.
• Recovery is better and early than open surgery.
• Needs specialized equipment & training of personnel.
• Usually avoided in cases of suspected malignant Disease
• Dissection is done from infundibulum to fundus Gall bllader is extracted from one of larger
port

21. Laproscopic cholecystectomy vs
open cholecystectomy
Open cholecystectomy Laproscopic cholecystectomy
• Easy.
• Can be done in peripheral centers.
• May have more post operative respiratory
complications.
• Cosmetically not good.
• Hospital Stay is longer.
• Usually Reserved for failed laparoscopic cases
& malignant Disease.
• Needs special equipment & training of
personnel.
• Learning Curve & Good Hand eye coordination
needed.
• Cost is higher.
• Hospital stay is shorter. Lesser post operative
complications.
• Avoided in Malignant Disease.
• If fails then have to proceed towards open
approach.
• Has become Gold standard treatment for Gall
bladder

22. Post operative management
• Nil by mouth till bowl sounds are present
• Continue Intravenous fluids till patient is oral free
• Adequate Analgesia
• Continue Intravenous Antibiotics for 72 hours and then change to oral for one
week.
• Change of dressing if soaked early otherwise after 72 hours.
• Removal of drain when drainage is minimal.
• Removal of Sutures when wound is healed.
• Anti-ulcer therapy if needed.
Laparoscopic cholecystectomy decreases postoperative pain,
decreases the need for postoperative analgesia, shortens the
hospital stay from 1 week to less than 24 hours, and returns the
patient to full activity within 1 week (compared with 1 month
after open cholecystectomy)

23. Thankyou.