Kholesistitis & kholelithiasis

dr Putra Hendra SpPD

 Gallbladder Disorders

Cholelithiasis and Cholecystitis

 Definitions
 a. Cholelithiasis: formation of stones (calculi)
within the gallbladder or biliary duct system
 b. Cholecystitis: inflammation of gall bladder
 c. Cholangitis: inflammation of the biliary ducts
Gall Stones
I’ll leave you with these. 

Eww!
Common locations of gallstones
 Epidemiology

Fat, Fair, Female, Fertile, Fourty

inaccurate, but reminder of the
typical patient
F:M = 2:1
10% of British women in their 40s
have gallstones
Genetic predisposition – ask about
family history
 Those who are most at risk.
 These are all adjectives to describe the person most at
risk of developing symptomatic gallstones.

FAIR FAT FORTY FEMALE

 Gallstones
 Types of gallstone
Cholesterolstones (20%)
Pigment stones (5%)
Mixed (75%)
 Pathophysiology

1. Abnormal bile composition

2.Biliary stasis

3.Inflammation of gallbladder
 Pathogenesis
 Composition of bile:
 Bilirubin (by-product of haem degradation)
 Cholesterol (kept soluble by bile salts and lecithin)
 Bile salts/acids (cholic acid/chenodeoxycholic
acid): mostly reabsorbed in terminal ileum(entero-
hepatic circulation).
 Lecithin (increases solubility of cholesterol)
 Inorganic salts (sodium bicarbonate to keep bile
alkaline to neutralise gastric acid in duodenum)
 Water (makes up 97% of bile)
 b. Most gallstones are composed primarily of bile
(80%); remainder are composed of a mixture of
bile components

 c. Excess cholesterol in bile is associated with

obesity, high-cholesterol diet and drugs that lower
cholesterol levels

 d. If stones from gallbladder lodge in the cystic

duct
 1. There can be reflux of bile into the gallbladder
and liver
 2. Gallbladder has increased pressure leading to
ischemia and inflammation
 3. Severe ischemia can lead to necrosis of the gall
bladder
 4. If the common bile duct is obstructed,
pancreatitis can develop
 Obstructive Jaundice
Pemeriksaan:
 USG
 Will confirm gallstones in the gallbladder
 CBD dilatation i.e. >8mm (not always!)
 May visualise stone in CBD (most often does not)
 MRCP
 In cases where suspect stone in CBD but USg indeterminate
 E.g.1 obstructive LFTs but USS shows no biliary dilatation
and no stone in CBD
 E.g. 2 normal LFTS but USS shows biliary dilatation
 ERCP
 If confirmed stone in CBD on USS or MRCP proceed to ERCP
which will confirm this (diagnostic) and allow extraction of
stones and sphincterotomy (therepeutic)
 Diagnostics.
 Fecal studies.

 Serum bilirubin tests.

 Ultrasound of the
gallbladder.
 Signs and Symptoms
 Abdominal pain
 nausea./vomiting
 Fatty stools
 Anxiety, chills, fever
 Weakness
 Weight loss
 Jaundice
 Plural effusion
 Multi system failure
 Coagulation defects
 Shock

Elevated: serum amylase, lipase, glucose & urine amylase,

bilirubin, WBC
 Manifestations of
cholelithiasis
 a. Many persons are asymptomatic

 b. Early symptoms are epigastic fullness

after meals or mild distress after eating a
fatty meal

 c. Biliary colic (if stone is blocking cystic

or common bile duct): steady pain in
epigastric or RUQ of abdomen lasting up to
5 hours with nausea and vomiting

 d. Jaundice may occur if there is

obstruction of common bile duct
 Signs and Symptoms.
 Low grade fever.
 Elevated leukocyte count.
 Mild jaundice.
 Stools that contain fat – steatorrhea.
 Clay colored stools caused by a lack of
bile in the intestinal tract.
 Urine may be dark amber- to tea-colored.
 Diagnostic Tests
 a. Serum bilirubin: conjugated bilirubin is elevated
with bile duct obstruction

 b. CBC reveals elevation in the WBC as with infection

and inflammation

 c. Serum amylase and lipase are elevated, if

obstruction of the common bile duct has caused
pancreatitis

 d. USG: identifies presence of gallstones

 e. Other tests may include flat plate of the abdomen,

oral cholecytogram, gall bladder scan
Pathophysiologic classification of Jaundice

 Hemolytic Jaundice

 Hepatic Jaundice

 Obstructive
Jaundice(Cholestasis)

 Congenital Jaundice
prehepatik

hepatik

posthepatik
Mechanism of Physiologic Jaundice

Increased rbc’s

Shortened rbc lifespan

Immature hepatic
uptake &
conjugation

Increased enterohepatic
Circulation
 Hemolytic Jaundice
Pathogenesis
Overproduction
Hemolysis (intra and extra vascular)
 inherited or genetic disorders
 acquired immune hemolytic anemia
(Autoimmune hemolytic anemia)
 nonimmune hemolytic anemia
(paroxysmal nocturna Hemoglobinruia)
 Ineffective erythropoiesis

Overproduction may overload the liver with UB

 Hemolytic Jaundice
Symptoms
weakness, Dark urine, anemia,
Icterus, splenomegaly
Lab
 UB bilirubinuria (-)
 fecal and urine urobilinogen
 hemolytic anemia
 hemoglobinuria (in acute intravascular
hemolysis)
 Reticulocyte counts
 Hemolytic Jaundice
(pre-hepatic)

urinary changes:
 bilirubin: absent
 urobilinogen: increased or
normal
faecal changes:
stercobilinogen: normal
 Obstructive Jaundice
Pathogenesis
it is due to intra- and extra hepatic
obstruction of bile ducts
 intrahepatic Jaundice: Hepatitis,
PBC, Drugs
 Extra Hepatic Biliary Obstruction:
Stones, Stricture, Inflammation,
Tumors, (Ampulla of Vater)
 Etiology of Obstructive Jaundice
Intrahepatic
Liver cell Damage/Blockage of Bile
Canaliculi
 Drugs or chemical toxins
 Dubin-Johnson syndrome
 Estrogens or Pregnancy
 Hepatitis-viral,chemical
 Infiltrative tumors
 Intrahepatic biliary hypoplasia or atresia
 Primary biliary cirrhosis
 Etiology of Obstructive Jaundice
Extrahepatik
Obstructive of bile Ducts
 Compression obstruction from tumors
 Congenital choledochal cyst
 Extrahepatic biliary atresia
 Intraluminal gallstones
 Stenosis-postoperative or inflammary
 Tatalaksana batu empedu

Medication: (Melarutkan batu)

 ursodiol
 Mahal
 Lama
 Kambuh bila obat berhenti

Tindakan mengeluarkan batu:

 Pain & Drugs: Biliary Tract

 Morphine used to be contraindicated. It is now

known that all opiates create spasm of the
Sphincter of Oddi
 Antacids: reduce gastric acid & associated pain.
 Histamine blockers: reduce gastric acid
secretion, which stimulates pancreatic enzymes.
 Anticholenergics: reduce spasm of sphincter of
ODDI
Tindakan mengeluarkan batu
@ Shock wave lithotripsy

@ endoscopic sphincterotomy

@ Placement of aT-tube

@ Cholendoscopic:
Endoscopic Retrograde Cholangiopancreatography (ERCP)
@ Operasi:
# Teretutup:
laparoscopic cholecystectomy :
Treatment of choice: Minimally invasive procedur
with low risk of complications
# Terbuka
Surgical laparotomy (incision inside the abdomen)
to remove gall bladder
 Medical Management.
 If stones are present in the
common bile duct, an
endoscopic sphincterotomy
must be performed to remove
them BEFORE a
cholecystectomy is done.

 A number of various
instruments are inserted
through the endoscope in
order to "cut" or stretch the
sphincter.
 Once this is done, additional
instruments are passed that
enable the removal of stones
and the stretching of
narrowed regions of the
ducts.
 Drains (stents) can also be
used to prevent a narrowed
area from rapidly returning to
its previously narrowed state.
Biliary lithotripsy
 Medical Management.
 Lithotripsy  If the attack of
 for patients with only cholelithiasis is mild –
a FEW stones.  bed rest is prescribed.
 patient is placed on
NPO to allow GI tract
and gallbladder to
rest.
 an NG tube is placed
on low suction.
 fluids are given IV in
order to replace lost
fluids from NG tube
suction.
 What is a “T” Tube?

 Comes right out of bile duct

 Sutured in place on skin
 1st 24-48 hours
 200-500 ml of drainage
 Potential Complications:
 Dislodgement
 Infection
T-tube placement in the common bile duct
 Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Figure 46-2: Cholendoscopic Removal of
Gallstones

B Menu F
Retrieving the CBD Stones
Indication To Surgical Treatment

• All forms of acute calculous

cholecystitis

• Destructive and complicated forms of

noncalculous cholecystitis

• Acute catarrhal cholecystitis

• Conservative treatment of which was

uneffective
 Methods of Operative Treatment

• Cholecystectomy from the neck

(retrograde)
• Cholecystectomy from the bottom
(antegrade)
• Laparoscopic cholecystectomy
Lap Cholecystectomy

Watch for
indications of:
 Infection
 Hemorrhage
 Damage to
adjacent organs
Lap Cholecystectomy
Medical Management.

Cholecystectomy
or
Laparoscopic Cholecystectomy
– removal of the gallbladder.

This is the treatment of choice.

The gallbladder along with the cystic
duct, vein and artery are ligated.
 Complications of Gallstones
 Biliary Colic
 Acute Cholecystitis
 Gallbladder Empyema
 Gallbladder gangrene
 Gallbladder perforation

 Obstructive Jaundice
 Ascending Cholangitis
 Pancreatitis
 Gallstone Ileus (rare)
Complications
 Gallstone ileus
Pathogenesis:
 Gallstone causing small bowel obstruction (usually obstructs in
terminal ileum)
 Gallstone enters small bowel via cholecysto-duodenal fistula (not
via CBD)

AXR – dilated small bowel loops

 May see stone if radio-opaque

Treatment
 NBM
 Fluid resuscitation + catheter
 NG tube
 Analgesia
 Surgery (will not settle with conservative management) –
enterotomy + removal of stone

Diagnosis of gallstone ileus usually made at the time of surgery.

 Sequence of
pathological
processes
localising a
perforation of the
gallbladder
What is Acute Cholecystitis?
Sudden inflammation of the
gallbladder

 accumulation of bile and increased

pressure.

 The combination of concentrated bile and

pressure building up  irritate the wall of
the gallbladder causing it to swell.

 Severe inflammation of the gallbladder 

blood flow  cell death.
 By definition,
cholecystitis is an
inflammation of the
gallbladder wall and
nearby abdominal
lining.

Abdominal wall

Gallbladder
Normal Gall Bladder Inflammed Gall Bladder
 Acute Cholecystitis Causes
 Over 90% of
acute cholecystitis
cases are caused
by obstruction of
the cystic duct by
gallstones in the
gall bladder
 Numerous other pathologies may also be
causes such as an infection, trauma and
tumors of the gallbladder.
 Acute Cholecystitis
Pathogenesis:
 Due to obstruction of cystic duct by gallstone:
 Cystic duct blockage by gallstone
 Obstruction to secretion of bile from
gallbladder
 Bile becomes concentrated
 Chemical inflammation initially
 Secondarily infected by organisms released
by liver into bile stream
 Tumor. A tumor may prevent bile from draining
out of your gallbladder properly, causing bile
buildup that can lead to cholecystitis.
 Signs and Symptoms
 Pain in the right upper quadrant
 Tenderness over your abdomen
when it's touched
 An increase in pain when taking
in a deep breath
 Pain that radiates from to your
right shoulder or back
 Nausea
 Vomiting
 Fever
 Diffuse
DD Causes abdominal pain Acute pancreatitis
DKA
Gastroenteritis
Intestinal obstruction
RUQ/LUQ Peritonitis
Acute pancreatitis Mesenteric ischaemia
Lower lobe pneumonia
Myocardial ischaemia

RUQ LUQ
Cholecystitis Gastritis
Biliary colic Splenic rupture/abscess
Hepatitis
Hepatic abscess

RLQ LLQ
Appendicitis Sigmoid diverticulitis
Caecal diverticulitis
Meckel’s diverticulitis
RLQ/LLQ
IBD
Renal stones
Cystitis
Endometriosis
Ruptured ectopic pregnancy
Incarcerated hernias
Psoas abscess
Symptoms and clinical signs
Murphy's symptoms is a delay of breathing during
palpation of gall-bladder on inhalation.
Kehr's symptom is strengthening of pain at
pressure on the area of gall-bladder, especially on deep
inhalation.
Ortner's symptom — painfulness at the easy
pushing on right costal arc by the edge of palm.
Mussy's symptom — painfulness at palpation
between the legs (above a collar-bone) of right nodding
muscle.
Blumberg's signs are the increases of painfulness
at the rapid taking away of fingers by which a front
abdominal wall is pressed on. This symptom is not
pathognomic for cholecystitis but matters very much in
diagnostics of peritonitis.
 Tokyo Guidelines for acute cholecystitis
(TG 07)
• Mild - RUQ pain w/murphy’s signs and USG
findings (40-70%)
• Moderate - acute cholecystitis w/ WBC >18K;
>72hrs of symptoms; palpable tender mass
(25%-60%)
• Severe - acute cholecystitis with organ
dysfunction/s
 CT Scans

Normal size
gallbladder

Patient X, Gallbladder
diagnosed with
Cholecystitis
 Tatalaksana
 Rawat inap
 Analgetik
 Diet cair
 IVF
 Antibiotics
 95% sembuh
 Bila tifdak sembuh  CT scan
 Empyema  percutaneous drainage
 Gangrene/perforation with generalised
peritonitis emergency surgery
 Non-operative management of
cholecystitis
 Antibiotics covering gram – bacilli and
anaerobic organisms
 Gall bladder drainage procedures
 Percutaneous vs Endoscopic transpapillary
approach
 Complications of cholecystitis
 a. Chronic cholecystitis occurs after
repeated attacks of acute cholecystitis;
often asymptomatic
 b. Empyema: collection of infected fluid
within gallbladder
 c. Gangrene of gall bladder with
perforation leading to peritonitis, abscess
formation
 d. Pancreatitis
 e. liver damage
 f. intestinal obstruction