THE DISEASES OF GALLBLADDER AND

BILE DUCTS.
Gallbladder disease includes inflammation, infection, stones or blockage of the
gallbladder. The gallbladder is a sac located under the liver. It stores and
concentrates bile produced in the liver. Bile aids in the digestion of fat and is
released from the gallbladder into the upper small intestine in response to food
(especially fats).Types of gallbladder disease include:
 Cholecystitis (inflammation of the gallbladder)
 Gallstones
 Chronic acalculous gallbladder disease (in which the natural movements
needed to empty the gallbladder do not work well)
 Gangrene or abscesses
 Growths of tissue in the gallbladder
 Congenital defects of the gallbladder
 Sclerosing cholangitis
 Tumors of the gallbladder and bile ducts.

 Types of Gall stones
1. Cholesterol stones
 Constitutes about 10% of the gall stones.
 Occur in patients with increased cholesterol levels.
 Fatty women are commonly affected.
 It is single, solitary, occurs in aseptic bile. Sometimes
 they can be multiple. Precipitation of cholesterol gives
 rise to stone.
 Such stones can be silent for many years. They are radio lucent.
 Pigment can also get precipitated along with cholesterol.

2. Brown pigment stones

 Rare in gall bladder, occurs in bile duct.
 Composed of calcium bilirubinate, calcium palmitate and
 calcium stearate + cholesterol.
 Occur due to bile stasis caused by foreign bodies, endoprosthesis,
 Clonorchis sinensis and Ascaris lumbricoides.
3. Mixed stones
 They constitute about 80% of gall stones.
 They contain alternating layers of cholesterol and
 pigment with epithelial debris or vegetations, from
 infective organisms.
 They are multiple, small, faceted by mutual pressure.

4. Pigment stones
 They are found in 5 to 10% of patients.
 They are calcium bilirubinate stones.
 Commonly occur due to haemolysis. Hence, they are
 black, multiple, small, irregular concretions or sludge
 particles.
 For reasons not clear, cirrhotic patients have increased
 incidence of black pigment stones.
 Bacteria also have a major role to play in the formation
 of pigment stones. Patients with pigment stones have
 more sepsis than patients with cholesterol stones.

Mixed stones pigment stones


Symptoms
The mildest and most common symptom of gallbladder disease is intermittent
pain called biliary colic. Typically, a patient experiences a steady gripping or
gnawing pain in the upper right abdomen near the rib cage, which can be severe
and can radiate to the upper back. Some patients with biliary colic experience
the pain behind the breastbone. Nausea or vomiting may occur.
Between 1 percent and 3 percent of people with symptomatic gallstones develop
inflammation in the gallbladder (acute cholecystitis), which occurs when stones
or sludge block the duct. The symptoms are similar to those of biliary colic but
are more persistent and severe. They include pain in the upper right abdomen
that is severe and constant and may last for days. Pain frequently increases
when drawing a breath. About a third of patients have fever and chills. Nausea
and vomiting may occur.
Chronic gallbladder disease involves gallstones and mild inflammation. In such
cases, the gallbladder may become scarred and stiff. Symptoms of chronic
gallbladder disease include complaints of gas, nausea and abdominal discomfort
after meals and chronic diarrhea.
Stones lodged in the common bile duct can cause symptoms that are similar to
those produced by stones that lodge in the gallbladder, but they may also cause:
 Jaundice
 Dark urine, lighter stools or both
 Rapid heartbeat and abrupt blood pressure drop
 Fever, chills, nausea and vomiting, with severe pain in the upper right
Diagnosis
 Blood tests
 Ultrasound and other imaging techniques
Treatment
Surgery may be warranted to remove the gallbladder if the patient has gallstones
or the gallbladder is not functioning normally. Most of the time this can be
performed laparoscopically (through small incisions) as an outpatient
procedure.

BBILE DUCTS DISEASES

Bile duct diseases obstruct, or block, the flow of digestive juices (bile) made in
the liver that break down the food we eat. Obstruction happens in the biliary
tract, or the ducts that direct the bile from the liver, gallbladder, and pancreas to
the small intestine. This causes toxins to back up and damage the liver.
Stones in the gallbladder that dislodge into the biliary tract is the most
common cause of a blockage. Others include bile duct cancer (called
cholangiocarcinoma) or scarring from infections, surgery, or inflammation.
Gallstones are the most common cause of blocked bile ducts. Stones typically
form inside the gallbladder and can block the common bile duct, the drainpipe
at the base of the liver. If the duct remains blocked, bilirubin backs up and
enters the blood stream. If bacteria above the blockage accumulates and backs
up into the liver, it may cause a severe infection called ascending cholangitis . If
a gallstone stops in between the gallbladder and the common bile duct, an
infection called cholecystitis may occur.

Symptoms
Symptoms of a blocked bile duct may be abrupt and severe (for example,
when a gallstone blocks the whole drainage system all at once), or they may
appear slowly many years after bile duct inflammation started. Bile duct
diseases often cause symptoms related to liver products backing up and
leaking into the blood stream. Other symptoms result from the bile ducts'
failure to deliver certain digestive juices (bile salts) to the intestines,
preventing the absorption of some fats and vitamins. Symptoms of a
blocked bile duct includes:
 Yellowing of the skin (jaundice) or eyes (icterus), from the buildup of a
waste product called bilirubin
 Itching (not limited to one area; may be worse at night or in warm
weather)
 Light brown urine
 Fatigue
 Weight loss
 Fever or night sweats
  Abdominal pain, especially common on the right side under the rib cage
 Greasy or clay-colored stools
 A diminished appetite.
Diagnosis
 Right upper quadrant ultrasound. This provides pictures of the liver,
gallbladder and common bile duct. For example, it can show enlargement
of the ducts above a blockage
 Computed tomography (CT) scan or magnetic resonance imaging (MRI)
scan of the liver
 ERCP is an examination in which a small camera on a flexible cord is
inserted through your mouth and down past your stomach to the opening
where the common bile duct empties into your stomach. A dye can be
injected into the common bile duct that will appear on X-rays. How the
bile ducts look on the X-rays can provide clues to the problem. Sample
cells from the bile duct walls can be examined under a microscope for
evidence of cancer. Treatments to relieve blockages can be performed
during this examination.
 MRCP.
 Cholangiography (X-rays of the bile ducts), which can also be done after
dye is injected into the liver. This enables doctors to watch the flow of
bile as it drains from the liver. Tissue for biopsy can be obtained during
this procedure and any blockages or narrowing can be relieved.
 A liver biopsy sample, obtained using a needle through the skin. The
tissue is examined for evidence of inflammation or cancer.

CLINICAL FORMS OF CHOLELITHIASIS

 Pain in your upper belly, often on the right, just under your ribs
 Pain in your right shoulder or back
 An upset stomach
 Vomiting, indigestion, heartburn, and gas.
 Belly pain that lasts several hours
 Fever and chills
 Yellow skin or eyes
 Dark urine and light-colored poop

COMPLICATIONS OF ACUTE CHOLECYSTITIS

  Empyema (pus in the gallbladder)
 Gangrene
 Injury to the bile ducts draining the liver (may occur after
gallbladder surgery)
 Pancreatitis
 Perforation
 Peritonitis (inflammation of the lining of the abdomen).
 Hemorrhagic cholecystitis.
 Pericholecystic abscess.
 Ascending cholangitis.

1 Empyema of the gall bladder

Empyema may be sequel to acute cholecystitis or the result of a
mucocele becoming infected.
The gall bladder is distended with pus.
The optimal treatment is drainage.

2 Gangrenous cholecystitis
Gangrenous cholecystitis is a common complication of acute
cholecystitis that occurs in up to 30% of cases. It develops when severe
inflammation (swelling) interrupts the blood supply to your gallbladder.
Without a constant supply of blood, the tissue of the gallbladder will
begin to die. This is potentially very serious because the dead tissue is
vulnerable to serious infection, which can quickly spread throughout the
body.
Known risk factors for gangrenous cholecystitis include:

 being male
 being 45 years of age or over
 having a history of diabetes
 having a history of heart disease

It is unclear why these risk factors make a person more vulnerable to

gangrenous cholecystitis.
 Other than a very rapid heartbeat (more than 90 beats a minute),
gangrenous cholecystitis does not usually cause any noticeable
symptoms, so it is usually diagnosed on the basis of test results.

Gangrenous cholecystitis would be strongly suspected if:

 your heart rate is more than 90 beats a minute

 you have a very high white blood cell count
 the ultrasound scan shows that the wall of your gallbladder is thicker
than 4.5mm

If gangrenous cholecystitis if suspected, a cholecystectomy will usually

be carried out to remove the gallbladder as soon as possible.

3 Gallbladder perforation
Gallbladder perforation is an uncommon and serious complication of
acute cholecystitis that occurs in around 1 in 100 cases. In cases of very
severe inflammation, the wall of the gallbladder can tear and infected bile
can leak out. This can cause an infection of the lining of the abdomen
(tummy), known as peritonitis.
Symptoms of peritonitis include:

 a sudden and very severe abdominal pain

 vomiting
 chills
 a high temperature (fever) of 38C (100.4F) or above
 rapid heartbeat (tachycardia)
 feeling thirsty
 not passing any urine or passing much less urine than normal

Peritonitis is treated using a combination of antibiotic injections and

surgery to remove the gallbladder and drain away any infected bile.

POSTCHOLECYSTECTOMY SYNDROME
Post cholecystectomy syndrome (PCS) describes the presence of abdominal
symptoms two years after a cholecystectomy (gall bladder removal). These
symptoms can represent either the continuation of symptoms thought to be
caused by gallbladder pathology or the development of new symptoms normally
attributed to the gallbladder. PCS also includes the development of symptoms
caused by removal of the gallbladder (eg, gastritis and diarrhea).
In general, PCS is a preliminary diagnosis and should be renamed with respect
to the disease identified by an adequate workup. It arises from alterations in bile
flow due to loss of the reservoir function of the gallbladder. Two types of
problems may arise. The first is continuously increased bile flow into the upper
gastrointestinal (GI) tract, which may contribute to esophagitis and gastritis.
The second is related to the lower GI tract, where diarrhea and colicky lower
abdominal pain may result.
Symptoms occur in about 5 to 40 percent of patients who undergo
cholecystectomy, and can be transient, persistent or lifelong.
The pain associated with post cholecystectomy syndrome is usually
ascribed to either sphincter of oddi dysfunction or to post-surgical
adhesions.
A recent 2008 study shows that post cholecystectomy syndrome can
be caused by biliary microlithiasis.
Approximately 50% of cases are due to biliary causes such as
remaining stone, biliary injury, dysmotility and choledochocyst.
The remaining 50% are due to non-biliary causes. This is because
upper abdominal pain and gallstones are both common but are not always
related.
Non-biliary causes of PCS may be caused by a functional
gastrointestinal disorder, such as functional dyspepsia.
Chronic diarrhoea in post cholecystectomy syndrome is a type
of bile acid diarrhoea.
This can be treated with a bile acid sequestrant like cholestyramine,
colestipol or colesevelam, which may be better tolerated.

CHOLESTASIS SYNDROME

(Syndrome of Cholestasis)
Definition:
Cholestasis is a condition where bile cannot flow from the liver to
the duodenum. The two basic distinctions are an obstructive type of
cholestasis where there is a mechanical
blockage in the duct system that can occur from a gallstone or malignancy,
and metabolic types of cholestasis which are disturbances in bile formation
that can occur because of genetic defects or acquired as a side effect of
many medications.

Causes:
 pregnancy
 androgens
 birth control pills
 antibiotics (such as TMP/SMX)
 abdominal mass (e.g., cancer)
 biliary atresia and other paediatric liver diseases
 biliary trauma
 congenital anomalies of the biliary tract
 gallstones
 biliary dyskinesia
 acute hepatitis
 cystic fibrosis
 intrahepatic cholestasis of pregnancy (obstetric cholestasis)
 primary biliary cholangitis, an autoimmune disorder
 primary sclerosing cholangitis, associated with inflammatory bowel
disease
 some drugs (e.g., flucloxacillin and erythromycin)
 Drugs such as gold salts, nitrofurantoin, anabolic steroids,
chlorpromazine, prochlorperazine.

Signs and symptoms:

 Itchiness (pruritus).
Pruritus is the primary symptom of cholestasis and is thought to
be due to interactions of serum bile acids with opioidergic nerves. In
fact, the opioid antagonist naltrexone is used to treat pruritus due to
cholestasis.
  Jaundice.
Jaundice is an uncommon occurrence in intrahepatic (metabolic)
cholestasis, but is common in obstructive cholestasis.

 Pale stool.
This symptom implies obstructive cholestasis.
 Dark urine

Diagnosis:
Cholestasis can be suspected when there is an elevation of both 5'-
nucleotidase and ALP enzymes. With a few exceptions, the optimal test
for cholestasis would be elevations of serum bile acid levels. However,
this is not normally available in most clinical settings. The gamma-
glutamyl transferase (GGT) enzyme was previously thought to be helpful
in confirming a hepatic source of ALP; however, GGT elevations lack the
necessary specificity to be a useful confirmatory test for ALP.
Normally GGT and ALP are anchored to membranes of hepatocytes
and are released in small amounts in hepatocellular damage. In cholestasis,
synthesis of these enzymes is induced and they are made soluble. GGT is
elevated because it leaks out from the bile duct cells due to pressure from
inside bile ducts.
In a later stage of cholestasis AST, ALT and unconjugated bilirubin
may be elevated due to hepatocyte damage as a secondary effect of
cholestasis.
Management:
Extrahepatic cholestasis can usually be treated by surgery. Pruritus
in cholestatic jaundice is treated by antihistamines, ursodeoxycholic acid,
and phenobarbital.
Nalfurafine hydrochloride can also treat pruritus caused by chronic
liver disease and was recently approved in Japan for this purpose.

Cholestasis is a liver disease. It occurs when the flow of bile from your liver is
reduced or blocked. Bile is fluid produced by your liver that aids in the
digestion of food, especially fats. When bile flow is altered, it can lead to a
buildup of bilirubin. Bilirubin is a pigment produced by your liver and excreted
from your body via bile.
There are two types of cholestasis:
Intrahepatic cholestasis & extrahepatic cholestasis. Intrahepatic cholestasis
originates within the liver. It can be caused by:
 disease
 Infection
 drug use
 genetic abnormalities
 hormonal effects on bile flow.
Symptoms
Both types of cholestasis result in the same symptoms:
 jaundice, which is a yellowing of your skin and the white of your eyes
 dark urine
 light-colored stool
 pain in your abdomen
 fatigue
 nausea
 excessive itching.
 Not everyone with cholestasis has symptoms, and adults with chronic
cholestasis are often symptom-free.

Jaundice
Definition:

Jaundice is a condition in which the skin, whites of the eyes and

mucous membranes turn yellow because of a high level of bilirubin, a
yellow-orange bile pigment

Types:

There are three main types of jaundice: pre-hepatic, hepatocellular,

and post-hepatic.

1. Pre-Hepatic

In pre-hepatic jaundice, there is excessive red cell breakdown which

overwhelms the liver’s ability to conjugate bilirubin. This causes an
unconjugated hyperbilirubinemia.
 Any bilirubin that manages to become conjugated will be excreted
normally, yet it is the unconjugated bilirubin that remains in the blood
stream to cause the jaundice.

2. Hepatocellular

In hepatocellular (or intrahepatic) jaundice, there is dysfunction of the

hepatic cells. The liver loses the ability to conjugate bilirubin, but in cases
where it also may become cirrhotic, it compresses the intra-hepatic
portions of the biliary tree to cause a degree of obstruction.

This leads to both unconjugated and conjugated bilirubin in the blood,

termed a ‘mixed picture’.

3. Post-Hepatic

Post-hepatic jaundice refers to obstruction of biliary drainage. The

bilirubin that is not excreted will have been conjugated by the liver, hence
the result is a conjugated hyperbilirubinemia.
References:
1. Lectures of Assoc Prof Vasilevsky V. P.
2. Propaedeutics of Internal Diseases (GrSMU, 2018),
Pronko T. P., Surmach E. M., Pirochkin A. B. Page
no. 374-375
3. Bailey and Love’s Short Practice of Surgery (27th
edition), London, UK. Page no. 1188-1211
4. Manipal Manual of Surgery (4th edition), India
Page no. 550-616
5. https://en.wikipedia.org/wiki/Cholestasis
Information № 2

What are the types of gallbladder disease?

There are many different types of gallbladder disease.
Gallstones (also refers as cholelithiasis)
Gallstones develop when substances in the bile (such as cholesterol, bile salts,
and calcium) or substances from the blood (like bilirubin) form hard particles
that block the passageways to the gallbladder and bile ducts.
Gallstones also tend to form when the gallbladder doesn’t empty completely
or often enough. They can be as small as a grain of sand or as large as a golf
ball.
Numerous factors contribute to your risk of gallstones. These include:
being overweight or obese
having diabetes
being age 60 or older
taking medications that contain estrogen
having a family history of gallstones
being female
having Crohn’s disease and other conditions that affect how nutrients are
absorbed
having cirrhosis or other liver diseases
Cholecystitis
Cholecystitis is the most common type of gallbladder disease. It presents itself
as either an acute or chronic inflammation of the gallbladder.
Acute cholecystitis
Acute cholecystitis is generally caused by gallstones. But it may also be the
result of tumors or various other illnesses.
It may present with pain in the upper right side or upper middle part of the
abdomen. The pain tends to occur right after a meal and ranges from sharp
pangs to dull aches that can radiate to your right shoulder. Acute cholecystitis
can also cause:
fever
nausea
vomiting
jaundice
Chronic cholecystitis
After several attacks of acute cholecystitis, the gallbladder can shrink and lose
its ability to store and release bile. Abdominal pain, nausea, and vomiting may
occur. Surgery is often the needed treatment for chronic cholecystitis.
Choledocholithiasis
Gallstones may become lodged in the neck of the gallbladder or in the bile
ducts. When the gallbladder is plugged in this way, bile can’t exit. This may
lead to the gallbladder becoming inflamed or distended.
The plugged bile ducts will further prevent bile from traveling from the liver to
the intestines. Choledocholithiasis can cause:
extreme pain in the middle of your upper abdomen
fever
chills
nausea
vomiting
jaundice
pale- or clay-colored stools
Acalculous gallbladder disease
Acalculous gallbladder disease is inflammation of the gallbladder that occurs
without the presence of gallstones. Having a significant chronic illness or
serious medical condition has been shown to trigger an episode. Symptoms
are similar to acute cholecystitis with gallstones. Some risk factors for the
condition include:
severe physical trauma
heart surgery
abdominal surgery
severe burns
autoimmune conditions like lupus
blood stream infections
receiving nutrition intravenously (IV)
significant bacterial or viral illnesses
Biliary dyskinesia
Biliary dyskinesia occurs when the gallbladder has a lower-than-normal
function. This condition may be related to ongoing gallbladder inflammation.
Symptoms can include upper abdominal pain after eating, nausea, bloating,
and indigestion. Eating a fatty meal may trigger symptoms. There are usually
no gallstones in the gallbladder with biliary dyskinesia.

it may need to use a test called a HIDA scan to help diagnosis this condition.
This test measures gallbladder function. If the gallbladder can only release 35
to 40 percent of its contents or less, then biliary dyskinesia is usually
diagnosed.
Sclerosing cholangitis
Ongoing inflammation and damage to the bile duct system can lead to scarring.
This condition is referred to as sclerosing cholangitis. However, it’s unknown
what exactly causes this disease.
Nearly half the people with this condition don’t have symptoms. If symptoms
do occur, they can include:
fever
jaundice
itching
upper abdominal discomfort.
Approximately 60 to 80 percent Trusted Source of people with this condition
also have ulcerative colitis. Having this condition does increase the risk of liver
cancer as well. Currently, the only known cure is a liver transplant.
Medications that suppress the immune system and those that help break down
thickened bile can help manage symptoms.
Gallbladder cancer
Cancer of the gallbladder is a relatively rare disease. There are different types
of gallbladder cancers. They can be difficult to treat because they’re not often
diagnosed until late in the disease’s progression. Gallstones are a common risk
factor for gallbladder cancer.
Gallbladder cancer can spread from the inner walls of the gallbladder to the
outer layers and then on to the liver, lymph nodes, and other organs. The
symptoms of gallbladder cancer may be similar to those of acute cholecystitis,
but there may also be no symptoms at all.
Gallbladder polyps
Gallbladder polyps are lesions or growths that occur within the gallbladder.
They’re usually benign and have no symptoms. However, it’s often
recommended to have the gallbladder removed for polyps larger than 1
centimeter. They have a greater chance of being cancerous.
Gangrene of the gallbladder
Gangrene can occur when the gallbladder develops inadequate blood flow.
This is one of the most serious complications of acute cholecystitis. Factors
that increase the risk of this complication include:
being male and over 45 years old
having diabetes
The symptoms of gallbladder gangrene can include:
dull pain in the gallbladder region
fever
nausea or vomiting
disorientation
low blood pressure

Abscess of the gallbladder

Abscess of the gallbladder results when the gallbladder becomes inflamed with
pus. Pus is the accumulation of white blood cells, dead tissue, and bacteria.
Symptoms may include upper right-sided pain in the abdomen along with fever
and shaking chills.
This condition can occur during acute cholecystitis when a gallstone blocks the
gallbladder completely, allowing the gallbladder to fill with pus. It’s more
common in people with diabetes and heart disease.

What is cholelithiasis?
Cholelithiasis is the medical name for hard deposits (gallstones) that may form
in the gallbladder. Six percent of adult men and 10% of adult women are
affected.
The cause of cholelithiasis is not completely understood, but it is thought to
have multiple factors. The gallbladder stores bile and releases it into the small
intestine when it is needed for digestion. Gallstones can develop if the bile
contains too much cholesterol or too much bilirubin (one of the components of
bile), or if the gallbladder is dysfunctional and cannot release the bile.
Different types of gallstones form in cholelithiasis. The most common type,
called a cholesterol stone, results from the presence of too much cholesterol in
the bile. Another type of stone, called a pigment stone, is formed from excess
bilirubin, a waste product created by the breakdown of the red blood cells in
the liver. The size and number of gallstones varies in cholelithiasis; the
gallbladder can form many small stones or one large stone.
The course of cholelithiasis varies among individuals. Most people with
cholelithiasis have no symptoms at all. A minority of patients with gallstones
develop symptoms: severe abdominal pain, nausea and vomiting, and
complete blockage of the bile ducts that may pose the risk of infection.
Cholelithiasis can lead to cholecystitis, inflammation of the gallbladder. Acute
gallstone attacks may be managed with intravenous medications. Chronic
(long-standing) cholelithiasis is treated by surgical removal of the gallbladder.
Left untreated, cholelithiasis can lead to serious complications such as tissue
damage, tears in the gallbladder, and infection that spreads to other parts of
the body.

What are the symptoms of cholelithiasis?

Cholelithiasis may cause irritation and inflammation of the gallbladder
(cholecystitis) that can result in a number of symptoms. The symptoms can
vary in intensity among individuals.
Common symptoms of cholelithiasis
You may experience cholecystitis symptoms daily or just once in a while. At
times, any of these common symptoms can be severe:
Abdominal pain (typically localized to the right upper quadrant of the
abdomen)
Abdominal swelling, distension or bloating
Abdominal tenderness
Clay-colored stools
Fever and chills
Loss of appetite
Nausea with or without vomiting
Pain that radiates from the abdomen to the right shoulder or back
Sweating
Yellowing of the skin and whites of the eyes (jaundice)
Serious symptoms that might indicate a life-threatening condition
Abdominal swelling, distension or bloating
High fever (higher than 101 degrees Fahrenheit)
Nausea with or without vomiting
Severe abdominal pain
What causes cholelithiasis?
In most cases, cholelithiasis is caused by excessive amounts of cholesterol in
the bile that is stored in the gallbladder. The cholesterol hardens to form
stone-like substances. Increased body weight and older age are associated
with increased levels of cholesterol in the bile. Thus, gallstones are more likely
to occur in women, in people who are obese, and in older individuals.
Some gallstones develop because the bile contains too much bilirubin, a waste
product of the liver that is a component of bile. Gallstones that develop from
excess bilirubin are called pigment stones.
What are the risk factors for cholelithiasis?
A number of factors increase your risk of developing cholelithiasis. Not all
people with risk factors will get cholelithiasis. Risk factors for cholelithiasis
include:
Age over 40 years
Crash dieting, or losing weight rapidly (the bile then contains more cholesterol)
Diabetes
Ethnicity (risk is higher in American Indians and Mexican Americans)
Family history
Female gender
Liver disease
Overweight or obesity
Pregnancy (decreases the gallbladder’s ability to empty bile)
Use of certain medications (cholesterol-lowering drugs increase cholesterol in
the bile)

How is cholelithiasis treated?

Some people with cholelithiasis never have any symptoms. If have symptoms
of cholelithiasis, y may be hospitalized and given antibiotics to prevent an
infection. Food intake is normally stopped, and intravenous fluids are
administered to let the digestive system rest. also receive medication for the
abdominal pain associated with cholelithiasis.
If have recurrent episodes of cholelithiasis, the most common treatment is
surgery to remove the gallbladder (cholecystectomy). There are two methods
for this surgery: open cholecystectomy, when the whole organ is removed
through a single incision; and laparoscopic cholecystectomy, when the
gallbladder is removed in pieces through several smaller incisions. The
laparoscopic technique is now used more frequently. Because the gallbladder
is not an essential organ, most people who have had a cholecystectomy can
live a normal life afterwards.
Treatment options for cholelithiasis
Several treatment options are now available for cholelithiasis. Laparoscopic
cholecystectomy is currently the most frequently used technique. Options
include:
Endoscopic retrograde cholangiopancreatography (ERCP), an imaging
procedure that allows treatment of some bile duct problems, including
removal of gallstones that are causing obstruction
Laparoscopic cholecystectomy (removal of the gallbladder through multiple
small incisions; this is less invasive and a more commonly used technique)
Lithotripsy (technique that uses electric shock waves to dissolve gallstones; it is
not commonly used today)
Medication to dissolve gallstones (this treatment takes a long time, and
gallstones may recur)
Open cholecystectomy (removal of the gallbladder through a single, large
incision; this is a more invasive and less commonly used technique)

Complications of Acute Cholecystitis

1. Perforation
- usually occurs in the fundus or in the neck (Hartmann’s).
- can cause cholecystoduodenal, cholecysto-intestinal or
cholecysto-biliary fistula.
2. Peritonitis
3. Pericholecystitic abscess
4. Empyema GB.
5. Ascending Cholangitis
6.Septicaemia.
7. Emphysema gallbladder, gangrenous gall bladder

Postcholecystectomy syndrome
The term postcholecystectomy syndrome (PCS) describes the presence of
symptoms after cholecystectomy. These symptoms can represent either the
continuation of symptoms thought to be caused by gallbladder pathology or
the development of new symptoms normally attributed to the gallbladder. PCS
also includes the development of symptoms caused by removal of the
gallbladder (eg, gastritis and diarrhea).
In general, PCS is a preliminary diagnosis and should be renamed with respect
to the disease identified by an adequate workup. It arises from alterations in
bile flow due to loss of the reservoir function of the gallbladder. Two types of
problems may arise. The first is continuously increased bile flow into the upper
gastrointestinal (GI) tract, which may contribute to esophagitis and gastritis.
The second is related to the lower GI tract, where diarrhea and colicky lower
abdominal pain may result. This article mainly addresses the general issues of
PCS
Treatment should be governed by the specific diagnosis made and may include
pharmacologic or surgical approaches.

SYNDROME OF CHOLESTASIS
Cholestasis is defined as a decrease in bile flow due to impaired secretion by
hepatocytes or to obstruction of bile flow through intra-or extrahepatic bile
ducts. Therefore, the clinical definition of cholestasis is any condition in which
substances normally excreted into bile are retained. The serum concentrations
of conjugated bilirubin and bile salts are the most commonly measured.
Not all substances normally excreted into bile are retained to the same extent
in various cholestatic disorders. In some conditions, serum bile salts may be
markedly elevated while bilirubin is only modestly elevated and vice versa.
However, demonstrable retention of several substances is needed to establish
a diagnosis of cholestasis. Only in rare disorders of bilirubin metabolism (eg,
Dubin-Johnson syndrome, Rotor syndrome) does an isolated increase in the
serum concentration of conjugated bilirubin appear, so increased serum
conjugated bilirubin indicates cholestasis.

The histopathologic definition of cholestasis is the appearance of bile

within the elements of the liver, usually associated with secondary
cell injury. The mechanisms of cholestasis can be broadly classified
into hepatocellular, where an impairment of bile formation occurs,
and obstructive, where impedance to bile flow occurs after it is
formed. The typical histopathologic features of hepatocellular
cholestasis include the presence of bile within hepatocytes and
canalicular spaces, in association with generalized cholate injury.
Typical of obstructive cholestasis is bile plugging of the interlobular
bile ducts, portal expansion, and bile duct proliferation in association
with centrilobular cholate injury.

CLASSIFICATION OF JAUNDICE
Jaundice happens when too much bilirubin builds up in the blood. This makes
skin and the whites of your eyes look strikingly yellowish. Bilirubin is a
yellowish pigment created as hemoglobin — a component of red blood cells —
is broken down.
Normally, bilirubin is delivered from the bloodstream into your liver. Then, it
passes through tubes called bile ducts. These ducts carry a substance called
bile into your small intestine. Eventually, bilirubin is passed out of your body
through urine or stool.
Types of jaundice are categorized by where they happen within the liver’s
process of taking in and filtering out bilirubin:
pre-hepatic: before the liver
hepatic: in the liver
post-hepatic: after the liver

DIFFERENTIAL DIAGNOSTICS OF JAUNDICE

Jaundice is a symptom with a multitude of possible causes. These can be
divided up into primary diseases of bilirubin metabolism, secondary
hyperbilirubinemia in patients with liver disease, and diseases with bile duct
occlusion. The major objective of the examination must be to exclude those
causes that represent an acute danger to the patient, in particular cholangitis
or cholecystitis. Symptoms that should cause alarm bells to ring include
abdominal pain, fever and chills. When obtaining the patient's anamnesis,
particular attention must be paid to lithiasis and previous operations.
Laboratory findings of elevated alkaline phosphatase and gamma-GT indicate
the presence of cholestasis. If an extrahepatic obstruction is suspected,
ultrasonography of the upper abdomen is required.

DIFFERENTIAL DIAGNOSTICS OF JAUNDICE