Gallstones Types

1. GallstonesTypes • Cholesterol stones • Pigment stones • black stones • brown stones

3. Factors associated with black pigment stones formation • Chronic liver disease (increased frequency with severity) • Ileal resection • Chronic haemolysis • sickle cell anaemia • hereditary spherocytosis • thalassemia major • Total parenteral nutrition • Vagotomy

4. Reasons for gallstone formation in cirrhosis • Cirrhotic liver unable to convert all unconjugated bilirubin into bilirubin mono- and di-glucuronides • Small fraction of unconjugated bilirubin spills into bile • Unconjugated bilirubin precipitated with calcium

5. Brown pigment stones formation Bilirubin diglucuronide hydrolysis by -glucuronidase Unconjugated bilirubin +Ca ion Calcium bilirubinate

6. Cholesterol gallstonesPathogenesis • Supersaturated bile with cholesterol due to enhanced hepatic synthesis • Low bile salt pool • Poor contractility of gallbladder • Excessive bile mucus glycoprotein

11. Calcified shadow at right upper abdomen in X-rayDifferential diagnosis

12. Cholecystectomy for asymptomatic gallstonesIndication • Calcified gallbladder • Young patients with sickle cell disease • Patients on long-term TPN

13. Complications of gallstonesInside the gallbladder • Acute cholecystitis • Empyema gallbladder • Mucocele of gallbladder • Carcinoma

14. Complications of gallstonesOutside the gallbladder • Perforation into peritoneal cavity •  peritonitis or abscess • Perforation into duodenum, colon •  gallstone ileus • Perforation into liver bed •  liver abscess • Perforation into CBD •  bile duct obstruction (Mirizzi syndrome)

15. Mirizzi syndrome (Cholecystocholedochal fistula)

16. Complications of gallstonesIn the common bile duct • Obstructive jaundice • Acute cholangitis • Acute pancreatitis

17. Postcholecystectomy syndrome • Persistent symptom after cholecystectomy • Due to technical complication of cholecystectomy and/or missed pathology which is the real cause of original symptom

18. Postcholecystectomy syndromeInvestigation • CBP, RFT, LFT, amylase • Upper endoscopy • US/CT • ERCP • HAG SMA

19. Acute cholangitisAetiology • Stones • Malignancy • Biliary stricture • Anastomotic stricture

20. To hepatic vein cholangiovenous reflux Cholangio-lymphatic reflux Venous system Stones obstructing the bile duct

21. Acute cholangitisAetiology • Predisposing causes • obstruction to bile duct • bacterial growth in bile

22. Acute cholangitis • Reynold’s pentad • Fever/chill/rigor • Right upper quadrant pain • Jaundice • Hypotension • Mental confusion

23. Acute cholangitisManagement - initial & conservative • Nil by mouth • IV fluid • Blood tests • Blood crossmatch • Antibiotic • Analgesic • Monitoring • BP, pulse, temperature, urine output

24. Acute cholangitisRationale of conservative treatment • 70% will resolve • Related to spontaneous stone disimpaction

25. Acute cholangitisClinical manifestation of failure of conservative treatment •  temperature, pulse •  BP •  urine output •  sensorium •  abdominal tenderness, guarding

26. Acute cholangitisTreatment for failure of conservatism • Invasive monitoring • CVP • arterial line • pulmonary artery wedge pressure • Inotrope • Mannitol

27. Acute cholangitisTreatment for failure of conservatism • Biliary decompression and drainage • Surgery • choledochotomy • exploration of CBD • T-tube drainage • avoid choledochoscopy • avoid cholangiography • ± cholecystectomy

28. Function of T-tube after exploration of common bile duct • Serves to allow infected bile draining into the external environment and prevent elevation of intraductal pressure (and bile leakage through the suture line or holes) if there is oedema of lower end of CBD or residual CBD stones • For postoperative cholangiogram on day 7-10

29. Action after T-tube cholangiogram No residual CBD stone Spigot T-tube Fever + Fever - Release spigot Keep T-tube spigot for 6 weeks Re-do cholangiogram for possible CBD stone Remove T-tube

30. Action after T-tube cholangiogram Residual CBD stone + Keep T-tube for 2-3 months Choledochoscopy via fibrous T-tube tract

31. T-tube in common bile duct and residual CBD stones T-tube induces formation of fibrous tissue around it

32. Fibrous tract formed around T-tube serves as a conduit for choledochoscopy

33. Insertion of choledochoscope into the common bile duct through T-tube tract for extraction of residual CBD stones

34. Acute cholangitisTreatment for failure of conservatism • Biliary decompression • Endoscopy • endoscopic retrograde cholangio-pancreatography • endoscopic papillotomy • basket removal of stone • nasobiliary drainage • endoprosthesis

36. Nasobiliary drainage (NBD) Nose

39. Endoprosthesis

40. Acute cholangitisComparison of treatment result

41. Acute cholangitisTreatment for failure of conservatism • Biliary decompression • Radiology percutaneous transhepatic biliary drainage (PTBD)

42. Percutaneous transhepatic biliary drainage (External type)

43. Percutaneous transhepatic biliary drainage (External-internal type)

48. Acute cholangitis Strategy of treatment Conservatism Failure Success Endoscopic drainage Imaging of bile duct Radiological drainage Surgery Surgical drainage