GALLSTONE DISEASE

(1.5 hours)

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Objectives
By the end of this lecture, the student should be able to;

1. Describe the surgical anatomy of the biliary tree

2. Describe the risk factors and clinical presentations of gallstone diseases

3. Discuss the diagnostic investigations and treatment modalities

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Outlines
• Introduction
• Surgical anatomy
• Risk factors
• Causes of Gallstones
• Types of gallstones
• Clinical features
• Complications
• Management
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Introduction

• Gallstone disease refers to a condition where stones are either in the

gallbladder or the common bile duct.

• The presence of stones in the gallbladder is referred to as cholelithiasis.

• If gallstones migrate into the ducts of the biliary tract, the condition is

referred to as choledocholithiasis.

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Surgical anatomy
The gallbladder

• A pear shaped organ lying beneath the liver.

• It is divided into three sections:

The fundus is the rounded base, angled so that it faces the abdominal wall.

The body lies in a depression in the surface of the lower liver.
The neck tapers and is continuous with the cystic duct, part of the biliary
tree.

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Surgical anatomy cont.
• Cystic duct - lined by cuboidal epithelium, has contracting circular
muscles (Valve of Heister), that prevent migration of stone to CBD. It
is 3 cm long and drains the Gall bladder.

• The cystic duct unites with the common hepatic duct to become

the common bile duct.

• At the junction of the neck of the gallbladder and the cystic duct, there
is an out-pouching of the gallbladder wall forming a mucosal fold
known as "Hartmann's pouch“.
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Anatomy of the biliary tree

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Surgical anatomy cont.
Function of GB
• Reservoir

• Concentration

• Mucus secretion

Bile
• Secreted from hepatocytes 250-1000/day, 98% water, inorganic ions,
cholesterol, bile acid(maintain cholesterol in solution).
• Fatty food stimulate GB to contract(CCK) and relax of Sphincter of Oddi.
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Gallstone
• This is a crystalline concretion formed within the gallbladder by
accretion of bile components.

• These calculi are formed in the gallbladder but may distally pass
into other parts of the billiary tract.

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Gallstone cont.
• Gallstones develop insidiously, and they may remain asymptomatic for
decades.

• Migration of a gallstone into the opening of the cystic duct may block
the outflow of bile during gallbladder contraction.

• The resulting increase in gallbladder wall tension produces a

characteristic type of pain (billiary colic).

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Gallstone cont.
• Cystic duct obstruction leads to acute gallbladder inflammation (acute
cholecystitis).

• Gallstones may cause progressive fibrosis and loss of function of the

gallbladder, a condition known as chronic cholecystitis.

• Chronic cholecystitis predisposes to gallbladder cancer.

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Risk Factors
1. Age
Risk increases with age, uncommon in children.
2. Sex:
Female have greater risk than males.
3. Diseases associated with gallstone disease
• Diabetes mellitus
• Hyperlipidaemia
• Cirrhosis of liver
• Fistulae on treatment with total parenteral nutrition
• Gastric surgery

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Causes of GSD

• Metabolic
o Bile Acid : Cholesterol ratio
o Normal 25:1 but <13:1(critical ratio)-GS Risk
o Obesity BMI>30 kg/m2, ↑calorie diet, medication-steroids

• Infection (80%); tonsillitis, tooth, bowel - lead to mixed stones

• Bile Stasis:
o Pregnancy, Oral Contraceptives, Vagotomy

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Causes cont.
• Haemolytic Anemia:
• SCD
• Heredity spherocytosis
• ↑uncj bilirubin due to↑RBC break+ Ca → Ca bilirubinate(pigment
stone).

• Parasitic Infestation;
• clonorchis sinensis,
• Liver Flukes
• ascaris lumbricoides

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Formation Of GB Stones:

• The presence of free fatty acids, deconjugated bilirubin, and bile acids
leads to the formation of insoluble calcium bilirubinate particles.

• With the loss of bile acids, cholesterol becomes insoluble, resulting in

the formation of biliary sludge.

• The sludge also contains mucin and bacterial cytoskeletons, which

further aid in stone formation

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Formation Of GB Stones:
• Gallstone formation occurs because certain substances in bile are
present in concentrations that approach the limits of their solubility.

• When bile is concentrated in the GB it can become supersaturated

which then precipitate from the solution as microscopic crystals.

• The crystals are trapped in gallbladder mucus producing gallbladder

sludge.

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Formation Of GB Stones:

• Bile stasis, bactibilia, chemical imbalances, pH imbalances, increased

bilirubin excretion, and the formation of sludge are among the principal
factors thought to lead to the formation of these stones.

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Types of GS
1.CHOLESTEROL STONES(10%) 3.PIGMENT STONE
• 5-10%
• Single • Ca bilirubinate,
• Solitary • black,
• aseptic bile. • small,multiple,irregular
Pt with ↑ cholesterol level(fat
women), Radiolucent, silent for yrs.

2. MIXED STONE (80%) 4.BROWN PIGMENT;

- chol + ep. debris + bacteria Common in BD. Ca (bilirubinate,
- Multiple, small sized palmitate, stearate)+cholesterol
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Clinical Presentation
• Gallstone disease may be thought of as having the following 4 stages:

I. Lithogenic state, in which conditions favor gallstone formation.

II. Asymptomatic gallstones.
III. Symptomatic gallstones, characterized by episodes of biliary colic
IV. Complicated cholelithiasis

• Symptoms and complications result from effects occurring within the

gallbladder or from stones that escape the gallbladder to lodge in the
CBD

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Clinical presentation cont.

Biliary colic

• Occurs when gallstones or sludge fortuitously impact in the cystic duct

during a gallbladder contraction, increasing gallbladder wall tension.

• In most cases, the pain resolves over 30 to 90 minutes as the gallbladder

relaxes and the obstruction is relieved.

• Episodes of biliary colic are sporadic and unpredictable.

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Clinical presentation cont.

• The pain occurs on the epigastrium or right upper quadrant and

radiates to the right scapular tip (Collins sign ).

• The pain begins postprandial (usually within an hour after a fatty meal),
is often described as intense and dull, and may last from 1-5 hours.

• From onset, the pain increases steadily over about 10 to 20 minutes and
then gradually wanes when the gallbladder stops contracting and the
stone falls back into the gallbladder.

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Physical examination:

• Uncomplicated biliary colic – Pain that is poorly localized and

visceral; an essentially benign abdominal examination without
rebound or guarding; absence of fever

• Well-localized pain in the right upper quadrant, usually with rebound

and guarding; positive Murphy sign.

• a positive Murphy sign (inspiratory arrest on deep palpation of the

right upper quadrant during deep inspiration).
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 Complications of GB stones

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1. Acute Cholecystitis

Pathogenesis

• Acute cholecystitis is secondary to gallstones in 90% to 95% of cases.

• Acute acalculous cholecystitis is a condition that typically occurs in

patients with other acute systemic diseases.

• In <1% of acute cholecystitis, the cause is a tumor obstructing the

cystic duct
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Acute Cholecystitis cont.
• Obstruction of the cystic duct leads to gallbladder
• Distention
• Inflammation
• edema of the gallbladder wall.

• Cause of inflammation with cystic duct obstruction is unknown. It is

probably related to the duration of obstruction of the cystic duct.
• Acute cholecystitis is an inflammatory process, mediated by the
mucosal toxin lysolecithin, a product of lecithin, as well as bile salts
and platelet-activating factor{PAF}

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Acute Cholecystitis cont.
• Secondary bacterial contamination contributes 15% to 30% of patients
undergoing cholecystectomy for acute uncomplicated cholecystitis.

• In acute cholecystitis the gallbladder:

• Grossly thickened
• Reddish with subserosal hemorrhages
• Pericholecystic fluid
• Hyperemic mucosa
• Patchy necrosis.
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 Acute Cholecystitis cont.
• In severe cases 5% to 10%, the inflammatory process progresses and leads
to ischemia and necrosis of the gallbladder wall.

• More frequently the gallstone is dislodged and the inflammation resolves.

• When the gallbladder remains obstructed and secondary bacterial infection

supervenes
• An acute gangrenous cholecystitis develops
• Abscess or empyema
• Perforation
• Fistula
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Acute Cholecystitis cont.
Clinical Manifestations:

• Acute cholecystitis begins as an attack of biliary colic, the pain does

not subside; it is unremitting and may persist for several days.

• The pain is typically in the right upper quadrant or epigastrium and

may radiate to the right upper part of the back or the interscapular
area.

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Acute Cholecystitis cont.
• It is usually more severe than the pain associated with uncomplicated
biliary colic

• The patient is often;

• Febrile
• Complains of anorexia, nausea, and vomiting
• Reluctant to move

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Acute Cholecystitis cont.
Assessment
• On physical examination, focal tenderness and guarding are usually
present in the right upper quadrant.

• The gallbladder may be adherent omentum and be palpable.

• A Murphy’s sign-an inspiratory arrest with deep palpation in the right

subcostal area, is characteristic of acute cholecystitis.

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2. Acalculous Cholecystitis

• Acalculous cholecystitis typically develops in critically ill patients in the

intensive care unit can occur without gallstones.

• Patients on parenteral nutrition with extensive burns, sepsis, major

operations, multiple trauma, or prolonged illness with multiple organ
system failure are at risk for developing acalculous cholecystitis.

• The Gallbladder distention with bile stasis and ischemia has been
implicated as causative factors.

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 3. Chronic cholecystitis
• Gallstones may cause progressive fibrosis of the gallbladder wall and
loss of gallbladder function.

• The repeated attacks of acute cholecystitis may play a role, as may

localized ischemia produced by pressure of stones against the
gallbladder wall.

• Fibrotic gallbladder may become shrunken and adherent to the

adjacent viscera.

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Courvoisier's law

“In a jaundiced patient, if the gall bladder is palpably

enlarged, it is not due to stones

In case of stones, previous inflammation would have made

gall bladder fibrotic and hence, will not be palpable”.

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Exceptions to Courvoisier's law

1. Double impaction: One stone in the CBD and one stone in the cystic
duct.

2. Periampullary carcinoma in a patient who has undergone

cholecystectomy.

3. Primary oriental cholangiohepatitis causing stones in the CBD (gall

bladder is normal in these cases).

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4. Gallbladder adenocarcinoma
• It is uncommon cancer that usually develops in the setting of
gallstones and chronic cholecystitis.

• Gallbladder cancers commonly invade the adjacent liver and common

bile duct, producing jaundice.

• The prognosis is poor unless the cancer is localized to the gallbladder,

in which case cholecystectomy may be curative.

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5. Mirizzi’s syndrome
• The presence of a stone impacted in the cystic duct or the gallbladder
neck, causing inflammation and external compression of the common
hepatic duct and thus biliary obstruction.

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Classification of Mirizzi Syndrome

• Type I:Compression of CBD without lumen narrowing.

• Type II: Compression of CBD with lumen narrowing.

• Type IJI: Compression causing CBD wall necrosis.

• Type IV: Stone ulcerating into CBD resulting in cholecystocholedochal

fistula
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Other Complications Of GSD…

6. Mucocele
• stone block CD with sterile bile
• Bile absorbed replaced by Over production of mucus by GB
epithelium.

7. Gallbladder empyema
• Overgrowth of colonizing bacteria in the gallbladder often occurs, and,
in severe cases, accumulation of pus in the gallbladder.
• The gallbladder wall may become necrotic, resulting in perforation and
pericholecystic abscess.
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Differential Diagnoses for GS.

• Acute Pancreatitis
• Appendicitis
• Bile Duct Strictures
• Bile Duct Tumors
• Cholangiocarcinoma
• Cholecystitis
• Gallbladder Cancer
• Pancreatic Cancer
• Peptic Ulcer Disease
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Investigations for GSD
• Patients with uncomplicated cholelithiasis or simple biliary colic
typically have normal laboratory test results.

• Asymptomatic gallstones are often found incidentally on plain

radiographs, abdominal sonograms, or CT scan for workup of other
processes.

• Cholesterol and pigment stones are radiopaque and visible on

radiographs in 10-30%

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 Hematologic Studies

• In patients with suspected gallstone complications, blood tests

should include;

• FBP count with differential.

• Liver function panel.

• Amylase and lipase.

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Plain abdominal X-rays

• Upright abdominal radiographs

• Supine abdominal radiographs

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Abdominal USS

• It is the most sensitive, specific, noninvasive, and inexpensive test

for the detection of gallstones.  

• It is simple, rapid, and safe in pregnancy

• It does not expose the patient to harmful radiation or intravenous

contrast.

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 Abdominal CT-Scan

• Computed tomography (CT) scanning is more expensive and less

sensitive than USS for the detection of gallbladder stones.

• It provides excellent images of all the abdominal viscera.

• CT scanning is superior to USS for the demonstration of gallstones in

the distal common bile duct.

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 Magnetic Resonance Imaging

• MRCP an excellent imaging study for noninvasive identification of

gallstones anywhere in the biliary tract, including the common bile
duct.

• It is usually reserved for cases in which choledocholithiasis is

suspected.

• MRI is a secondary imaging study if ultrasound images do not result in

a clear diagnosis of acute cholecystitis or gallstones. 

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Medical Treatment

• It is indicated for pure cholesterol stones only.

• Indication
• functioning gall bladder proven
• Young, thin, female patients.
• Tiny(< 5 mm), translucent, floating stones

Drawbacks
• Recurrence of stones once treatment is stopped
• Life-long maintenance is needed.
• After dissolution of the stones, lithotripsy or extracorporeal shock
wave Iithotripsy should be done.
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Types of medical treatment

1. Oral dissolution treatment

Drugs used: CDCA-chenodeoxycholic acid and UDCA-

ursodeoxycholic acid

2. Direct contact dissolution

Drugs used: MTBE-methyl terbutyl ether

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Surgical Treatment of Gallstones
• Surgical treatment of asymptomatic gallstones without medically
complicating diseases is discouraged.
• Cholecystectomy for asymptomatic gallstones may be indicated in the
following patients:
- Large gallstones, greater than 2 cm in diameter.
- Nonfunctional or calcified (porcelain) gallbladder observed on
imaging studies and who are at high risk of gallbladder carcinoma.
- Sickle cell anemia in whom the distinction between painful crisis and
cholecystitis may be difficult.

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Treatment of Patients with Symptomatic Gallstones

• Cholecystectomy
• indicated in patients who have experienced symptoms or
complications of gallstones.

• Cholecystostomy
• Temporary drainage of pus from the gallbladder preferred to allow
stabilization and to permit later cholecystectomy under elective
circumstances.

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Relative indication
• Patients with risk factors for complications of gallstones may be offered
elective cholecystectomy, even if they have asymptomatic gallstones.

• These include persons with the following conditions and demographics:

• Cirrhosis
• Portal hypertension
• Transplant candidates
• Diabetes
• Calcified or porcelain gallbladder -risk of carcinoma (25%).

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Summary
• Gallstone disease can either be cholelithiasis or choledocholithiasis.

• The relevant anatomy involves; the gall bladder, cystic duct, common bile
duct, ampulla of vater and sphincter of Oddi.

• Risks of GSD are; age, sex, pregnancy, obesity, rapid weight loss, cirrhosis,
hemolytic anemias.

• Gallstones can be; cholesterol stones, pigment stones, mixed stones and
brown pigment stones.
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Summary cont.
• Gall stone disease has a; lithogenic, asymptomatic, symptomatic &
complications stage.

• Complications of GSD include; acute cholecystitis, acalculous cholecystitis,

chronic cholecystitis, gall bladder adenocarcinoma and mirizzi’s syndrome.

• GSD is investigated by blood tests and radiological imaging.

• GSD have different modes of treatment medical and surgical.

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References

• Schwartz principle of surgery 11th Edition

• Manipal Manual of surgery 4th Edition page 552-565

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