Lecture given for surgery clerkship

1. Gallbladder Disease
Gazi Rashid
Lindsey Urquia

2. 5 Takeaways
1. Basic HPB layout and 2 important views during surgery
2. Different types of gallstones and their risk factors
3. Walk through an H&P & workup for acute cholecystitis
4. Basics of Medical vs. Surgical mgmt for acute cholecystitis
5. Presentation and acute management of ascending cholangitis
Extra: Recognize
a. Basic presentation & pathophys of gallstone ileus
b. Imaging & management of Porcelain GB
c. Surgical indications for asymptomatic cholelithiasis

3. • Anatomy : Gazi - 5 min
• Minor: Symp Chole, Choledocho,
• Physiology/types of GS/risk factors: Lindsey - 5 min
• GB pathology
• Acute chole: Lindsey - 15 min
• Patho → Pres
• DDx
• W/U – Labs, Imaging
• Medical
• Operative
• Ascending chol : Gazi - 10 min
• Patho → Pres (Triad, Pentad)
• W/U → labs, imaging
• Med/ICU mgmt
• Operative/ERCP
• Cases – core info (x3) - 10 min (6, 4) - I don’t know that we’ll have time to do 3 cases
• Biliary colic-– Lindsey/Gazi + counseling
• Acute Chole - 1 liner→ diagnosis: history/PE/labs/US/management - 5 Qs each - maybe include the “Pearls” here
• Asc Chol - 5 review Qs, as this isn’t a typical H&P
• Misc - Porcelain GB, Gallstone Ileus (5 min)
• “pearls”–
• Time for questions - 10-15 min (mention oral exams, resources to learn rest of biliary dz)
• Appendix - at their own pleasure

4. Anatomy
Draw the hepatobiliary system - gallbladder, liver,
pancreas, duodenum, and what connect them

5. CDB
- Choledocholithiasis
- Ascending Cholangitis
- Cholangiocarcinoma
- Strictures from ERCP
Gallbladder
- Cholelithiasis
- Asymp. Vs Symp
- Calculous Cholecystitis
- Porcelain GB
- Gallstone Ileus
- Acalculous Cholecystitis
- Gangrenous
Cholecystitis
- GB Carcinoma
Cystic Duct - Mirizzi Syndrome
Cancer at the Head of
the Pancreas
Sphincter of Oddi
Biliary Dyskinesia

6. Historical
Triangle
of Calot

7. Modern
Triangle
of Calot

8. Critical View
of Safety

9. Types of gallstones/risk factors
• Biliary sludge – cholesterol crystals, Ca bilirubinate granules & mucin
maxtrix
• Impaired/slow contractility or bile stasis
• Cholesterol (70-80%)
• Most common
• Increased ratio of chol:salts
• Hormone (preg, OCP)
• Pigmented (20-30%)
• Bilirubin & calcium salts (20% cholesterol)
• Cirrhosis, hemolytic anemia, hereditary spherocytosis

10. Cholelithasis

11. Acute cholecystitis
• Pain – unrelenting right upper quadrant, midepigastric pain
• Vs. Biliary colic
• Nausea & vomiting
• Fever/chills
• Labs * - elevated enzymes/Br but relatively low
• Obstruction of cyst duct from gallstone
• 95% - calculi
• 5% - acalculous (sludge)
• GB continues to produce mucous ➔ distension ➔ venous congestion
inflamed, edematous wall ➔ arterial inflow impaired ➔ stone dislodges
(ischemia 5-10%)

12. Normal Gallbladder
imaging

13. Acute Cholecystitis
imaging

14. Acute Cholecystitis
imaging

15. HIDA Scan
(Hepatobiliary Iminodiacetic acid)
imaging
If there’s a question…get a HIDA
Highly sensitive & specific! (95%)

16. Positive HIDA scan =
Acute Cholecystitis
imaging

17. Acute Cholecystitis
imaging

18. Acute Cholecystitis medical mang
treatment
• NPO
• IV fluids
• IV antibiotics
• E. Coli, Klebsiella, Enterobacter, Bacteroides,
Clostridium coverage
• 2nd gen cephalosporin (cefoxitin)
• Fluoroquinolones (Ciprofloxacin, Levofloxacin)
• Ampicillin-sulbactam (Unasyn)
• Surgery!

19. Cholecystectomy
treatment
• NPO, IVF, IV abx
• Classic: Surgery safe if within 72 hours
• Identify anatomical views & critical view
• Intraoperative cholangiogram (IOC) – high suspicion for
CBD stone
• Lap > open conversion rate 0-20%

20. Cholecystectomy
treatment

21. Ascending cholangitis
- Terms: Choledocholithiasis vs. Ascending
Cholangitis
- Acute Presentation (Charcot’s Triad):
- Jaundice, RUQ pain, Fever
- Complicated by Reynold’s pentad: Triad
+ Hypotension + AMS (Septic shock)
- Not always due to stones!

22. Workup
● Leukocytosis
● Cholestatic Pattern
of Liver Injury
○ ALP, GGT,
Bilirubin >>>
AST, ALT
○ All can be
elevated
● RUQ U/S:
○ Stone not always
seen
○ Look for CBD
dilatation

23. Management of Ascending Cholangitis
- Mild ←→ Emergency!
- Unstable patients: aggressive medical management, ICU
- BP control:fluids, fluids, fluids
- Monitoring
- Blood cultures
- Treatment:
- IV broad spectrum antibiotics
- Biliary decompression with ERCP (1st line)
- Cholecystectomy when stable

25. Porcelain Gallbladder
imaging

26. Gallstone Ileus
• Misnomer!
• Mechanical obstruction
• Large impacted stone →
Ischemia & pressure necrosis →
Erosion into intestines →
cholecystic-enteric fistula
• Bowel obstruction when stone is
stuck at ileo-cecal valve

27. Gallstone Ileus
Presentation
• Elderly women with hx of biliary disease
• Small bowel obstruction symptoms
• N/V, diffuse abd pain, obstipation
Imaging (plain films, CT scan)
• Bowel obstruction findings: Air-fluid levels
• Pneumobilia (gas in biliary tree)
• Ectopic large gallstone

28. Case 1
42 y/o woman presents to clinic with abdominal pain
1. History – LOCATES
2. Physical exam
3. DDx
4. Labs
5. Management
Bonus: What if this patient was asymptomatic and found – when
would you do a cholecystectomy?

29. Case 1
pathology
• 42 y/o female with a 2 day history of RUQ &
right upper back pain, assoc nausea.
What’s your differential diagnosis?
• Worse after meals. Similar episodes in the
past. No f/c
• Meds – OCP, MVI
• PMH/PSH – HTN, hyperlipidemia, Lap gastric
banding

30. Acute Cholecystitis
imaging

31. Diagnosis
diagnosis
• History & physical exam
• Ultrasound
• 95% sensitive
• Hyperechoic mobile densities within gallbladder
with assoc hypoechoic shadowing

32. Case 2
25 y/o female with a 2-day hx of fevers, chills, constant RUQ pain,
scleral icterus, nausea, vomiting, BP 90/54, HR 117, T 39.1:
1) Next steps of management?
2) Other DDx?
3) Workup (Labs, Imaging, etc)?
4) What will 1st line imaging show?
5) What is the 1st-line therapeutic intervention? Describe it.
Bonus: The pt.tells you that she’s had mouth sores & bloody diarrhea
for months - what is the underlying pathology in this presentation?

33. Acute cholecystitis
RUQ pain, nausea/vomiting, fever, increased WBC
U/S (1st line): pericholecystic fluid, GB wall > 3mm thick, stones, sonographic Murphy’s
HIDA 95% accurate
Anatomy
Modern Triangle of Calot: Cystic Artery, Hepatic Duct, Inf Liver Edge
CVS: See cystic artery and cystic duct entering GB
Acute cholangitis
Charcot triad: (1) fever/chills + RUQ pain + jaundice
Reynold’s pentad: Charcot’s triad + altered mental status + shock
Emergency! Need ERCP
summary

34. Symptomatic cholelithasis
Intermittent RUQ pain, nausea, fever unlikely
Diagnosis H&P, Ultrasound
Gallstone Ileus
1 liner: Elderly women w/ SBO & history of biliary disease
Transition point at ileocecal valve (stuck)
Porcelain gallbladder
Asymptomatic
25-50% assoc with gallbladder cancer
summary

35. Appendix

36. Case 2
pathology
• 79 y/o female with a 5 day history of diffuse
abdominal pain, nausea, vomiting
What’s your differential diagnosis?
• Pain begin in RUQ, progressively worse,
subjective chills
• Meds – insulin, ASA
• Pertinent hx – NH resident, diabetes

37. Gallbladder Carcinoma
pathology
• 0.5-1% of pop with cholelithiasis
• Poor prognosis (unless T1a)
• Most adenocarcinoma
• Contracted (nondistended)
• Risk Factors: adenomatous polyps,
porcelain gallbladder (50%), biliary
anomalies

38. Gallbladder Carcinoma
treatment
• Localized (lamina propria)
• Cholecystectomy
• Advanced Stage
• radical cholecystectomy
• Gallbladder + hepatic segments 4b & 5 +
LND

39. Mirrizzi Syndrome
pathology
Common hepatic duct obstruction 2/2
impacted stone in cystic duct

40. Biliary Dyskinesia
pathology
• Impaired GB emptying or
sphincter of Oddi relaxation
• Biliary colic (post-prandial
sharp RUQ pain), nausea
• NO gallstones
• Extensive w/u
• HIDA + CCK
• GB ejection fraction 35% or
less

41. Acalculous Cholecystitis
pathology
• Seen in critically ill pt
• Trauma
• Burn
• Prolonged TPN or NPO status (weeks)
• Cardiopulmonary bypass
• Often progress to gangrene or emphysematous
cholecystitis
• Fulminant course - has 40% mortality rate

43. Imaging in Gallstone Ileus
Imaging