CME - Dr. Amarchand Bajaj (Revised)

Gallstone Disease
Dr.Amarchand Bajaj
Senior Consultant Surgeon and Departmental Lead
Sitaram Bhartia Institute of Science and Research
Gallstone Disease (NICE guidelines)
• Gallstone disease refer to the presence of stones in the gallbladder or common bile
duct and the symptoms and complications they cause.
• Most people with gallstone disease have asymptomatic gallbladder stones, meaning
the stones are confined to the gallbladder and they do not have any symptoms.
• The following aspects of gallstone disease are included in this guideline:

 Asymptomatic gallbladder stones
 Symptomatic gallbladder stones, including biliary colic, acute Cholecystitis, Mirrizi
syndrome, and Xanthogranulomatous Cholecystitis
 Common bile duct stones, including biliary colic, cholangitis, obstructive jaundice
and gallstone pancreatitis
• Other complications of gallstones (such as gastric outlet obstruction, or gallstone
ileus) and other conditions related to the gallbladder (such as gallbladder cancer, or
biliary dyskinesia) are not included in this guideline.
Gallstones
• Types of gallstone
 Cholesterol stones (75%)
 Pigment stones (Brown & black-5%)
 Mixed (20%)
 In USA and Europe 80% are cholesterol or mixed stones.
 In Asia 80% are pigment stones
• Epidemiology
 F:M = 2:1
 Genetic predisposition
Pathogenesis
Anatomy of Biliary System
Clinical Presentation
• 80% Asymptomatic
• 20% are sypmtomatic and do so on recurrent basis
• Symptomatic: Right upper Quadrant or Epigastric pain- colicky or

dull aching associated with nausea & vomiting
• Other symptoms: Dyspepsia, Flatulence, food intolerance

particularly after fatty food, alteration in bowel habits
• Jaundice: if stone migrates from gallbladder & obstructs the CBD

Differential Diagnosis of RUQ pain
• Gallstone disease (and its related complications)
• Gastritis/duodenitis
• Peptic ulcer disease/perforated peptic ulcer
• Acute pancreatitis
• Acute Appendicitis
• Right lower lobe pneumonia
• Myocardial Infarction
Diagnosis
• History- Recurrent pain, jaundice, etc
• Examination- Rt hypochondrial tenderness
• Blood tests
 Complete blood count
 Liver function test
 CRP
 Coagulation profile
 Serum amylase and lipase
• Ultrasound whole abdomen
Investigations for gallstone disease
• Bloods: Raised Leukocytes, Deranged LFT, Raised Amylase/Lipase
• USG: first line investigation in gallstone disease

 Confirms presence of gallstones
 Gall bladder wall thickness (if thickened suggests Cholecystitis)
 Biliary tree calibre (CBD/extrahepatic/intrahepatic) – if dilated suggests stone in CBD
(normal CBD <6mm)
 Not always but sometiime CBD stone can be visualised
• MRCP: To visualise biliary tree accurately (much more accurate than USG)
• Diagnostic only
• Look for biliary dilatation and any stones in biliary tree
• ERCP: Diagnostic and therapeutic in biliary obstruction

 Diagnostic and therapeutic but invasive
 Look for biliary tree dilatation and stones in biliary tree
 Stones can be extracted to relieve the obstruction and perform sphincterotomy
 Risk of pancreatitis
• CT: Not first line investigation. Mainly used if suspicion of gallbladder empyema,
gangrene, or perforation and in acute pancreatitis (USG not good for looking at
pancreas)
Complications of Gallstones
• Biliary Colic
• Acute Cholecystitis
 Gallbladder Empyema
 Gallbladder gangrene
 Gallbladder perforation
• Obstructive Jaundice
• Ascending Cholangitis
• Pancreatitis
• Gallstone Ileus (rare)
Biliary Colic
Pathogenesis
 Stone intermittently obstructing cystic duct or common bile duct
USG confirms presence of gallstones
Treatment
 Analgesia
 Fluid resuscitation
 Laparoscopic Cholecystectomy
Acute Cholecystitis
Pathogenesis:
• Due to obstruction of cystic duct by gallstone:
Cystic duct blockage by stone
Diagnosis:
• USG confirms diagnosis (gallstones, thickened gallbladder wall, peri-
cholecystic fluid)
• Treatment:
 Admit for monitoring
 Analgesia
 Antibiotics
 Laparoscopic Cholecystectomy
Obstructive Jaundice
Pathogenesis:
• Stone obstructing CBD
Diagnosis:
• USG
 Will confirm stones in the gallbladder
 CBD dilatation i.e. >6mm with or without IHBR dilation
 May or may not visualise stone in CBD
• MRCP
 In cases where suspect stone in CBD but USG indeterminate
 Deranged LFT with or without dilated biliary tract
• ERCP
 If confirmed stone in CBD on USG or MRCP proceed to ERCP which will
confirm this (diagnostic) and allow extraction of stones and sphincterotomy
(therapeutic)
Treatment:
• ERCP
• Laparoscopic Cholecystectomy
Acute Pancreatitis
Pathogenesis
• Obstruction of pancreatic outflow
 Pancreatic enzymes activated within pancreas
 Pancreatic auto-digestion
Diagnosis:
Raised Serum Amylase & Lipase
USG: to confirm gallstones as cause of pancreatitis
• USG not good for visualising pancreas
CT: for assessing pancreas.
• Performed if failing to settle with conservative management to look for
complications such as pancreatic necrosis, Acute fluid collection.
Treatment
• Analgesia
• Fluid resuscitation
• Conservative management
Gallstone ileus
Pathogenesis
• Gallstone causing small bowel obstruction (usually obstructs in terminal
ileum)
• Gallstone enters small bowel via cholecysto-duodenal fistula (not via CBD)
Diagnosis
Abdominal X Ray – dilated small bowel loops
• Stone can be seen if radio-opaque
Treatment
• NPO
• Fluid resuscitation
• NG tube aspiration
• Analgesia
• Surgery (will not settle with conservative management) – enterotomy +
removal of stone
Cholecystectomy
• Indications
 Symptomatic patient
 Asymptomatic gallstones with Diabetes, large solitary stone,
Polyp> 1 cm, haemolytic disease
Laparoscopic Cholecystectomy
• Procedure of choice for gallstone disease

Gold standard: conventional 4 port
Other methods: Three Port, Two Port, Single Port
• Advantages
 Less post-op pain
 Better cosmesis
 Decrease in wound size
 Improved vision
 Decrease infection, bleeding, herniation
 Shorter hospital stay
 Quicker return to normal activities
Cholecystectomy when to perform?
• Acute Cholecystitis< 5-7 days laparoscopic cholecystectomy
• Acute Cholecystitis> 5-7 days cholecystectomy traditionally performed after
6 weeks
• Arguments in favour of cholecystectomy 6 weeks later

 Laparoscopic dissection more difficult when acutely inflamed
 Surgery not optimal when patient septic/dehydrated
 Logistical difficulties (theatre space, lack of surgeons)
• Arguments in favour of cholecystectomy in same admission

 Research suggests same admission laparoscopic cholecystectomy as safe as
elective cholecystectomy (in experience hands)
 Waiting increases risk of further attacks/complications which can be life
threatening (recurrent/necrotising pancreatitis)
 Risk of failure of conservative management and development of complications
such as empyema, gangrene and perforation can be avoided
Thank You
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Gallstone Disease

• The following aspects of gallstone disease are included in this guideline:

• 20% are sypmtomatic and do so on recurrent basis

• Symptomatic: Right upper Quadrant or Epigastric pain- colicky or

• Other symptoms: Dyspepsia, Flatulence, food intolerance

• Jaundice: if stone migrates from gallbladder & obstructs the CBD

• Gallstone disease (and its related complications)

• Peptic ulcer disease/perforated peptic ulcer

• Right lower lobe pneumonia

• USG: first line investigation in gallstone disease

• ERCP: Diagnostic and therapeutic in biliary obstruction

USG confirms presence of gallstones

• Procedure of choice for gallstone disease

• Arguments in favour of cholecystectomy 6 weeks later

• Arguments in favour of cholecystectomy in same admission

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