The gallbladder, gallstones,

and beyond….

Leslie Kobayashi, MD
January 31, 2012
Anatomy

 Liver
 Bile ducts
 Pancreas
 Duodenum
 Transverse colon
Anatomy

 Fundus
 Body
 Infundibulum/Neck
 Cystic duct
 Spiral Valves of Heister
Anatomy
 Triangle of calot
 Borders: CHD, cystic duct, liver edge
 Contents: Cystic artery, node of Calot
Ductal Anatomy

 Right and Left Hepatic ducts

 Common Hepatic duct
 Cystic duct
 Common bile duct
Aberrant anatomy

 Vascular

 Normally (>90%)
cystic a. arises from
RHA
 Replaced right
hepatic a.
 Replaced left
hepatic a.
Bile

 500-1500mL produced daily

 Composition: water, electrolytes, bile salts, proteins, lipids

 Ductal epithelium products

▪ Alkaline phosphatase
▪ HCO3

 Hepatocyte products
▪ Bile in conjugated soluble form synthesized from
cholesterol
▪ Primarily cholate and chenodeoxycholate
Bile

 95% of bile re-absorbed into the liver via

portal vein (enterohepatic circulation)
 85-90% in terminal ileum via active transport
 10-15% deconjugated in colon, absorbed passively
 5% excreted in stool
 Cycles 6-10x daily

 80% of bile stored in GB in

fasting state
GB

 Function store and concentrate bile

 Absorption: NaCL, H2O occurs rapidly

 Secretion: mucus, H+
 GB average capacity 30-50mL

 Can increase to 300mL with obstruction

 Normal ejection 50-70% in 30-40min
Significance

Do gallbladder problems create

a significant healthcare
burden?
YES!

 Health burden

 6.2 Billion$ in US
 1.8 million ambulatory care visits
 Increased 20% since 1980’s
 Cholecystectomy most common elective
abdominal procedure in the US
▪ 750,000 annually
Why does that happen?

Stones
Types of stones

 Cholesterol stones (75%)

 Female fat fertile
 Black stones (20%)
 Hemolytic diseases (Sickle cell disease)
 Cirrhosis *primarily form in the
 Brown stones (5%) ducts

 Infection
 PSC
Cholesterol stones

 Low calcium, radiolucent

 Created when fractional cholesterol

content of bile increased, and with
incomplete emptying of GB
 Associated with obesity, rapid weight
loss, Native American/Hispanic heritage,
↑TG’s, ↓HDL, Spinal cord injury
Cholesterol stones

 Hormonal influence

 Estrogen increases lithogenicity of bile

▪ Increased risk for females
▪ Increased risk in obesity
 Progesterone increases SM relaxation and
bile stasis, decrease bile salt secretion
▪ Increased risk in pregnancy
Cholesterol stones

 Increase risk of stone formation

 TPN
 Octreotide
 Ceftriaxone

 Decrease risk of stone formation

 Statins
 ?ursodiol
Pigmented stones

 Often radiopaque due to calcium

bilirubinate, calcium fatty acid soaps
and inorganic calcium salts
 Two types
 Black
 Brown
Pigmented stones

 Black
 Form in GB
 Bile sterile
 Associated with age, hemolytic DO’s, alcoholism,
cirrhosis, Gilbert’s syndrome, Cystic fibrosis,
pancreatitis and TPN
 Cholecystectomy curative
Pigmented stones

 Brown
 Form in ducts as well as GB
 Always infected 1O with enteric organisms, often
associated with cholangitis
 Associated with parasitic infection (liver fluke)
 Associated with IBD, duodenal diverticulae
 Will often recur after LC/OC
Stones: Where do they go?

And what
do they do?
 Stones
Asymptomatic Symptomatic

Uncomplicat
ed Complicated
Biliary
colic
No +
obstructio Obstructio
n n

+
Infection/in
Ampull
CBD a

flammation

Cholecystitis
-
Infection
+infecti
on
GSP

Choledocho Cholangitis
In the gallbladder

 Incidence: 10-30% of the population

 Asymptomatic (80%)

 Symptomatic (1-3% per year)

 No inflammation: Biliary colic
 +inflammation: acute cholecystitis
 +obstruction : choledocholithiasis, GSP
 +obstruction+inflammation: cholangitis
Biliary colic

 History
 Transient abdominal pain
 Occurs after fatty meals
 Exam
 Benign
 Labs
 Normal
 Ultrasound
 GS
 Hyperechoic masses,
dependent in
location

Acoustic shadowing
Cholecystitis

 History  Labs
 Prolonged pain  Leukocytosis
 Fevers  Mild ↑ LFT’s
 Nausea/emesis
 Imaging
 Exam
 Fever, tachycardia  Ultrasound
 RUQ TTP, Murphy’s  HIDA
sign
Cholecystitis

Gallstones
 Obstruction of gallbladder

Obstruction causes inflammation

 Inflamed wall is thickened
 Edema or emphysema of GBW
Cholecystitis

Inflammation may or may not be

associated with infection
 50-70% of bile cultures are positive

 E. coli, Klebsiella, Streptococcus,

Enterobacter
Ultrasound

 95% sensitivity/specificity

 Signs of cholecystitis
 Gallstones
 GBW >3mm
 Pericholecystic fluid
 GBW striations or air within GBW
 Sonographic Murphy’s sign
 GS with GBW
thickening
Normal GBW <3mm

Pericholecystic
fluid
HIDA

 Cholescintigraphy: Injection of Tc99

labeled hydroxyl iminodiacetic acid
 HIDA→hepatocytes→secreted into bile

 Normal visualization of GB, CBD and SB

within 30-60 min
 +scan if no visualization of GB within 1hr
and +uptake in CBD or SB
HIDA
Normal HIDA
Positive HIDA

Rim sign
*Sphincter, ↙CBD
HIDA

 False positives common in fasting

patients
 Up to 40-60% in critically ill

 Can decrease false+ rate with morphine

 ↑sphincter of Oddi pressure causing

preferential filling of the GB
Cholecystitis: Complications

 ↑Tension in GBW =↓perfusion →Necrosis

of GBW
 Gangrenous/emphysematous cholecystitis
▪ 1% of cases, 3:1 M>F
▪ Conversion rate 30-50%

 GB Perforation
▪ Assoc with ↑mortality (~20%)
▪ Gallstone ileus
Gallstone ileus
Complications

Cystic duct obstruction→ Hydrops

Bile is absorbed but GB mucosa
continues to secrete mucus
GB tense, filled with mucinous fluid
Complications
Mirrizi’s syndrome

 Impacted stone in infundibulum or CD

→External compression of the CBD
 0.7-1.4% of patients
 Assc with ↑risk of CBD
injury, GB cancer
What if the stones escape the GB?
Stones in the CBD

Stone in CBD

No obstruction + obstruction

Symptom Asympto No
+Infection
atic matic infection
Choledocholithiasis

 History: jaundice, icterus, pruritis, dark urine,

steatorrhea, acholic stools, bleeding
 Exam: jaundice, icterus, RUQ pain, Murphy’s
sign
 Labs
 Elevated LFT’s, INR
 Elevated bilirubin highest PPV 25-50%
 May be normal in up to 30% of patients
Choledocholithiasis

 Imaging
 Dilated CBD on UTZ
▪ CBD <5mm risk of stone ~1%
▪ CBD >5mm risk of stone 58%
 MRCP
 Sensitivity 95%
 Specificity 89%
 CBD dilation

Stones within the bile

duct
Cholangitis

 History/Exam: similar to choledocholithiasis

with sepsis, septic shock
 Labs/Imaging: similar to choledocholithiasis
with leukocytosis, bactermia, ±MSOF
 Charcot’s triad RUQ pain, fevers, jaundice

 Reynolds pentad Triad + ΔMS, shock

Beyond the CBD
Gallstone pancreatitis
 History: epigastric pain, nausea/emesis
 Exam: RUQ/epigastric TTP, SIRS
 Labs: amylase/lipase ↑3x nl, ±↑LFT’s,
leukocytosis
 Imaging: ±CBD dilation, pancreatic edema,
necrosis, fluid collection
Ranson’s criteria-Alcoholic

 First 24hours:  48 hours

 Glucose >200  Ca <8
 Age >55  Hct↓>10
 LDH>350  PaO2 <60
 AST>250  BUN↑>5
 WBC>16k  Base Deficit >4
 Sequestration >6L
Ranson’s criteria-Non-Alcoholic

 First 24hours:  48 hours

 Glucose >220  Ca <8
 Age >70  Hct↓>10
 LDH>400  PaO2 <60
 AST>440  BUN↑>2
 WBC>18k  Base Deficit >5
 Sequestration >6L
Ranson’s criteria

 Each category 0 or 1
 Add up total points
 Mortality
 0-2 <5%
 3-4 15%
 5-6 40%
 7-8 ~100%
Treatments
Treatment

 Medical  ERCP

 Surgical  sphincterotomy,
 stent
 Lap
 Percutaneous
 Open
 Cholecystostomy
 CBDE
tube
Treating the gallbladder
 Gallstone “Cleanse”

Preparation
Eat a diet high in alkaline-forming foods and low in fats for at least 3-5
days before the cleanse.
Help to gently prepare the liver by having a glass of fresh apple juice every
day for 1 week prior to the cleanse. Apple juice helps to dissolve the stones

Ingredients

•Epsom salts (Magnesium Sulfate): 4 tablespoons

•Olive oil: 1/2 cup or 125 ml
•Fresh pink grapefruit: squeeze 1/2 cup (125 ml) juice
•Or use 7-8 fresh lemons/limes: squeezed into 1/2 cup juice
•1 liter jar with lid
Medical

Or you could try:

 IVF hydration
 Antibiotics
 Bowel rest
Medical

 Ursodiol: used as
 Mechanism: supplemental bile acid decreases
lithogenicity of bile, dissolve existing stones
 Indications: bridge to LC/OC, too sick for OR,
cirrhotics, PSC, TPN
 Efficacy: may ↓LFT’s in PSC/cirrhotics, may
↓stones/sludge on UTZ, does not ↓symptoms,
prevent need for OR, stones recur after cessation
of medication
Medical

Diet:
Cholesterol/
Fatty acids
Carbohydrates
Legumes

Unsaturated fats
Coffee, Fiber
Vitamin C,
Alcohol
Treatment

 Failure of medical management in acute

cholecystitis 32%
 Recurrence rate of GSP 29-63%
 Surgical management results in reduced
HLOS
Treatment

 Timing of surgery for acute cholecystitis

 Within 48hrs vs >72hrs no difference in
conversion rates, OR time, LOS
 Comparing first hospitalization (<7d) vs
delayed (>6wks)
▪ 17.5% rqr emergent cholecystectomy for
recurrent/unresolving sx’s
▪ No difference in conversion rates or CBD injury
Treatment

Timing of surgery for GSP

 Early operation safe with mild
pancreatitis Rason’s criteria <3
 Increased conversion rate, HLOS, and
operative complications in early
operation in severe pancreatitis
Ranson’s criteria ≥3
Surgical approaches
Laparoscopic

 Port placement
 Umbilicus
 Subxiphoid just to the right of the falciform
at the level of the inferior liver edge
 2-3cm below costal margin in midclavicular
line
 Anterior axillary line, below the fundus of
gallbladder
Laparoscopic

 Retraction and dissection of Triangle of

Calot prior to Gallbladder removal from
fossa
 CD may be clipped, sutured, tied,
stapled
 Remove gallbladder in fundus→dome
direction
Open

 Right subcostal incision

 Mini-cholecystectomy (5-8cm) incision

associated with equivalent
outcomes/complications and less post-op
pain, decreased LOS
 Dome down dissection technique
 Isolate cystic artery/duct and suture ligate
Lap vs. open

 Conversion rate: 0.18-35% ave 4.7%

 CBD injury rates
 Lap 0.2-0.6%
 Open 0-0.3%
 Complication rate
 Lap ~1.2%
 Open (bile leak 1%)
 LOS: shorter for Lap
Difficult Cholecystectomy

 RF’s for conversion

 Male sex
 Obesity
 ↑age
 Wide short cystic duct
 Low surgeon case load
 Gangrenous or emphysematous chole
 ↑risk of conversion RR 3.2 (CI 2.5-4.2)
 No ↑risk of local complications or CBD injury
Other options
Cholecystostomy tube

 Can be transhepatic or transperitoneal no

difference in outcomes
 Technical success 96-98%
 Resolution of symptoms 68-96%
 Mortality 3-14%
 Complications
 Dislodged catheter 16-33%
 Bleeding 1.5-1.8%
 Recurrent cholecystitis 7-41%
Clearing the duct
Natural history of CBD stones

 Choledocholithiasis
 Stones in CBD in 10-15% of symptomatic pt’s
 55-70% pass spontaneously
 GSP20-30% of patients have CBD stones
 85-90% pass spontaneously
 Symptomatic cholecystitis
 4.6% +IOC at the time of LC
 97.8% pass spontaneously
Surgical approaches

 CBDE

 Can be
performed lap or
open
 Transcystic or via
choledochotomy
Surgical approaches

CBDE

 Imaging duct
▪ Fluorscopic guidance
▪ Choledochoscopy

 Clearing duct
▪ Basket, snare, flush
▪ +/- glucagon to relax sphincter
Surgical approaches

CBDE

 Completion cholangiogram
 Clip, tie or staple cystic duct stump
 Close choledochotomy over T-tube
 +/-drain external
 Success rate of duct clearance 75-95%
ERCP

 Efficacy
 1 procedure: 71-75%
 Multiple procedures: 84-95%
 Mortality 0.2-0.5%

 Complication rate 5-8%

 Perforation
 Bleeding
 Pancreatitis
 Cholangitis
Complications
Complications

1-2% of patients will represent with

CBD stone following
cholecystectomy
 Dx <2yrs post-op = retained stone
 Dx > 2yrs post-op =recurrent stone
Other Complications

 Ileus
 Incisional/port site hernia
 Wound infection
 Abscess

 Biloma/bile leak
CBD Injury

Strasberg-Bismuth
classification
 A-CD stump, fossa
 B/C-aberrant RHD
 D-lateral injury
 E-circumferential
injury to major duct
Special circumstances
Pregnancy
 Increased risk of stones
 2-12% have stones
 0.05-1.2% symptomatic during pregnancy
 Risk of stones increased in:
 Hispanic
 Pre-pregnancy obesity (4x)
 Decreased by EtOH consumption
Pregnancy
 Biliary disease the most common non-
obstetrical cause of maternal
hospitalization
 Cholecystitis most common 40%
 GSP 30%
 CBD stone 20%
 Biliary colic 10%
Pregnancy

If symptomatic risk of recurrence

high
 40%-70% recur prior to delivery
If symptomatic risk of fetal loss high
10-20%
Pregnancy

Treatment goals

 Treat infection
 Maintain nutrition
 Prevent contractions/preterm labor
 Prevent fetal loss
 Prevent maternal morbidity/mortality
Pregnancy
 Surgical management associated with
fewer complications than medical
management
 Contractions equivalent (~30%)
 Decreased preterm delivery, need for c-
section, and recurrent symptoms
 Fetal loss with LC 0-5%
Pregnancy

Ideal timing LC/OC 2nd trimester

 ↓preterm labor (0% vs. 40%)
 ↓ fetal loss
 ↓ risk of fetal malformation
 Technically easier
1st delay to 2nd, 3rd delay to
postpartum
Pregnancy

ERCP can be performed safely

with:
 Low radiation exposure
▪ Fluoro time 14sec-3.2min
▪ Radiation exposure 40-310 mrad

 Few complications ~7%

Pregnancy

Operative considerations

 Port placement to accommodate

uterus
 Hassan vs. Veress likely equivalent
 ↓insufflation pressure 10-12
Cirrhotics
 Stones more common in cirrhotics (2x)
 Diagnosis difficult
 Pain nonspecific
 Elevated LFT’s nonspecific
 Leukocytosis nonspecific
 GBW thickening nonspecific
▪ HIDA may be helpful
Cirrhotics
Management differences
 Increased operative risk
▪ Morbidity 3x
▪ Conversion 2x
▪ Bleeding 8x
 Increased risk with cholecystostomy
▪ Bleeding
▪ Ascites/Leak
Cirrhotics
 Mortality
 Overall acceptable 0.6-0.8%
 Significantly increased in Child’s C patients (17%)

 LC safer than OC
 Less bleeding
 Shorter OR time
 Shorter HLOS
 Possibly lower mortality (open mortality 8-25%)
Other pathology

 Acalculous cholecystitis
 M>F 1.5:1
 4-8% of all cholecystitis
 Dx with UTZ/HIDA

 Gallbladder polyps

 Gallbladder cancer
Thank You