Masrul Lubis

Gastroenterology and Hepatology Division

Internal Medicine Departement
Medical Faculty of USU
USU Hospital and Adam Malik Hospital
A. Cholelithiasis and Cholecystitis
 1. 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
 2. Pathophysiology
◦ a.Gallstones form due to
 1.Abnormal bile composition
 2.Biliary stasis
 3.Inflammation of gallbladder
 Types of gallstone
 Cholesterol stones (20%)
 Pigment stones (5%)
 Mixed (75%)

 Epidemiology
 Fat, 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
 Cholesterol
 Imbalance between bile salts/lecithin and cholesterol allows
cholesterol to precipitate out of solution and form stones
 Pigment
 Occur due to excess of circulating bile pigment (e.g.
Heamolytic anaemia)
 Mixed
 Same pathophysiology as cholesterol stones

 Other Factors
 Stasis (e.g. Pregnancy)
 Ileal dysfunction (prevents re-absorption of bile salts)
 Obesity and hypercholesterolaemia
 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
Risk factors for cholelithiasis
 a. Age
 b. Family history, also Native Americans
and persons of northern European heritage
 c. Obesity, hyperlipidemia
 d. Females, use of oral contraceptives
 e. Conditions which lead to biliary stasis:
pregnancy, fasting, prolonged parenteral
nutrition
 f. Diseases including cirrhosis, ileal
disease or resection, sickle-cell anemia,
glucose intolerance
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
Manifestations of acute cholecystitis
 a. Episode of biliary colic involving RUQ pain
radiating to back, right scapula, or shoulder;
the pain may be aggravated by movement, or
deep breathing and may last 12 – 18 hours
 b. Anorexia, nausea, and vomiting
 c. Fever with chills
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, liver damage, intestinal
obstruction
Collaborative Care
 a. Treatment depends on the acuity of symptoms and
client’s health status
 b. Clients experiencing symptoms are usually treated
with surgical removal of the stones and gallbladder
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. Ultrasound of gallbladder: identifies presence of
gallstones
 e. Other tests may include flat plate of the abdomen,
oral cholecytogram, gall bladder scan
Treatment
 a. Treatment of choice is laparoscopic
cholecystectomy
 b. If surgery is inappropriate due to client
condition
 1. May attempt to dissolve the gallstones with
medications
 2. Medications are costly, long duration
 3. Stones reoccur when treatment is stopped
Laparoscopic cholecystectomy
 a. Minimally invasive procedure with low risk of
complications; required hospital stay< 24 hours.
 b. Learning needs of client and family/caregiver
include pain control, deep breathing, mobilization,
incisional care and nutritional/fluids needs
 c. Client is given phone contact for problems
Some clients require a surgical laparotomy (incision inside
the abdomen) to remove gall bladder
 a. client will have nasogastric tube in place post-
operatively and require several days of hospitalization
 b. If exploration of the common bile duct is done with
the cholecystectomy, the client may have a T-tube
inserted which promotes bile passage to the outside as
area heals

Clients with cholelithiasis and cholecystitis prior to

surgery can avoid future attacks by limiting fat intake

Nursing Diagnoses
 a. Pain
 b. Imbalanced Nutrition: Less than body requirements
 c. Risk for Infection
 Biliary Colic
 Acute Cholecystitis
 Gallbladder Empyema
 Gallbladder gangrene
 Gallbladder perforation
 Obstructive Jaundice
 Ascending Cholangitis
 Pancreatitis
 Gallstone Ileus (rare)
 Bloods (already discussed)
 AXR (10% gallstones are radio-opaque)
 E-CXR (to exclude perforation – MUST!)
 ECG (to exclude MI)
 USS: 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 <8mm).
 Sometimes CBD stone can be seen.
 MRCP: To visualise biliary tree accurately (much more accurate than USS)
 Diagnostic only but non-invasive
 Look for biliary dilatation and any stones in biliary tree
 ERCP: Diagnostic and therepeutic in biliary obstruction
 Diagnostic and therepeutic but invasive
 Look for biliary tree dilatation and stones in biliary tree
 Stones can be extracted to unobstruct the biliary tree and perform sphincterotomy
 Risk of pancreatitis, duodenal perforation
 PTC
 To unobstruct biliary tree when ERCP has failed
 Invasive – higher complication rate than ERCP
 CT: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene, or
perforation and in acute pancreatitis (USS not good for looking at pancreas)
Pathogenesis
 Stone intermittently obstructing cystic duct
(causing pain) and then dropping back into
gallbladder (pain subsides)

USS confirms presence of gallstones

Treatment
 Analgesia
 Fluid resuscitation if vomiting
 If pain and vomiting subside does not need
admitting
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

USS confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid)

Complications of acute cholecystitis

 Empyema of gallbaldder
 Gangrene of gallbladder (rare)
 Perforation ofgallbaldder (rare)

Treatment
 Admit for monitoring
 Analgesia
 Clear fluids initially, then build up oral intake as cholecystitis settles
 IVF
 Antibiotics
 95% settle with above management
 If do not settle then for CT scan
 Empyema  percutaneous drainage
 Gangrene/perforation with generalised peritonitis emergency surgery
Pathogenesis:
 Stone obstructing CBD (bear in mind there are other causes for obstructive
jaundice) – danger is progression to ascending cholangitis.

 USS
 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 USS 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)

Treatment
 Must unobstruct biliary tree with ERCP to prevent progression to ascending
cholangitis
 Whilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis
Pathogenesis:
 Stone obstructing CBD with infection/pus
proximal to the blockage

Treatment
 ABC
 Fluid resuscitation (clear fuids and IVF, catheter)
 Antibiotics (Augmentin)
 HDU/ITU if unwell/septic shock
 Pus must be drained* - this is done by
decompressing the biliary tree
 Urgent ERCP
 Urgent PTC – if ERCP unavailable or unsuccesful
Pathogenesis
 Obstruction of pancreatic outflow
 Pancreatic enzymes activated within pancreas
 Pancreatic auto-digestion

USS: to confirm gallstones as cause of pancreatitis

 USS not good for visualising pancreas

CT: gold standard for assessing pancreas.

 Performed if failing to settle with conservative management to look for complications
such as pancreatic necrosis

Treatment
 Analgesia
 Fluid resuscitation
 Pancreatic rest – clear fluids initially
 Identify underlying cause of pancreatitis

 95% settle with above conservative management

 5% who do no settle or deteriorate need CT scan to look for pancreatic necrosis
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.

 Asymptomatic gallstones do not require operation

 Indications
 A single complication of gallstones is an indication for
cholecystectomy (this includes biliary colic)
 After a single complication risk of recurrent complications
is high (and some of these can be life threatening e.g.
cholangitis, pancreatitis)

 Whilst awaiting laparoscopic cholecystectomy

 Low fat diet
 Dissolution therapy (ursodeoxycholic acid) generally
useless
 All performed laparoscopically

 Advantages:
 Less post-op pain
 Shorter hospital stay
 Quicker return to normal activities

 Disadvantages:
 Learning curve
 Inexperience at performing open cholecystectomies
 After acute cholecystitis, cholecystectomy traditionally performed
after 6 weeks

 Arguments for 6 weeks later

 Laparoscopic dissection more difficult when acutely inflammed
 Surgery not optimal when patient septic/dehydrated
 Logistical difficulties (theatre space, lack of surgeons)

 Arguments for same admission

 Research suggests same admission lap chole as safe as elective chole
(conversion to open maybe higher)
 Waiting increases risk of further attacks/complications which can be life
threatening
 Risk of failure of conservative management and development of dangerous
complication such as empyema, gangrene and perforation can be avoided

 National guidelines state any patient with attack of gallstone

pancreatitis should have lap chole within 3 weeks of the attack
Complication History
Biliary Colic - Intermittent RUQ/epigastric
pain (minutes/hours) into
back or right shoulder
- N&V
Acute Cholecystitis -Constant RUQ pain into back
or right shoulder
-N&V
-Feverish
Empyema -Constant RUQ pain into back
or right shoulder
-N&V
-Feverish
Obstructive Jaundice -Yellow discolouration
-Pale stool, dark urine
-painless or assocaited with
mild RUQ pain
Ascending Cholangitis Becks triad
-RUQ pain (constant)
-Jaundice
-Rigors
Acute Pancreatitis -Severe upper abdominal pain
(constant) into back
-Profuse vomiting
Gallstone Ileus - 4 cardinal features of SBO
Examination Blood tests
-Tender RUQ -WCC (N) CRP (N)
-No peritonism - LFT (N)
-Murphy’s –
-Apyrexial, HR and BP (N)
-Tender RUQ -WCC and CRP (↑)
-Periotnism RUQ -LFT (N or mildly (↑)
(guarding/rebound)
-Murphy’s +
-Pyrexia, HR (↑)
-Tender RUQ -WCC and CRP (↑)
-Peritonism RUQ -LFT (N or mildly (↑)
-Murphy’s +
-Pyrexia, HR (↑), BP (↔ or ↓)
-More septic than acute
cholecystitis
-Jaundiced -WCC and CRP (N)
-Non-tender or minimally -LFT: obstructive pattern
tender RUQ bili (↑), ALP (↑), GGT (↑),
-No peritonism ALT/AST (↔)
-Murphy’s – -INR (↔ or ↑)
-Apyrexial, HR and BP (N)
-Jaundiced -WCC and CRP (↑)
-Tender RUQ -LFT : obstructive pattern
-Peritonism RUQ bili (↑), ALP (↑), GGT (↑),
-Spiking high pyrexia (38-39) ALT/AST (↔)
-HR (↑), BP (↔ or ↓) -INR (↔ or ↑)
-Can develop septic shock
-Tender upper abdomen -WCC and CRP (↑)
-Upper abdominal or -LFT: (N) if passed stone or
generalised peritonism obstructive pattern ifstone
-Usually apyrexial, HR (↑), BP still in CBD
(↔ or ↓) -Amylase (↑)
-INR/APTT (N) or (↑) if DIC
-distended tympanic abdomen
-hyperactive/tinkling bowel
sounds
Questions?