Epidemilogy of Cholelithiases
F:M 3:1
incidence increases with age. Prevalent in families.
Females w under 50 10-15% over 50 25%
Males w under 50 4-10% over 50 10-15%
Increased rate in Native Americans 50% men, 80% females

Pathophysiology of Cholelithiases

Causes of stones: Ultimately you have an overconcentration of
cholesterol, lecithin, and bile salts that tip the saturation of stuff >
crystals. Need an enucleating factor or lack of a nucleation inhibition
protein)
biliary stasis
incomplete emptying of GB.
Hemolysis
Infection

Risk factors: Fat Female Fertile Fourty

Obesity (excessive cholesterol synthesis)
Multiparity (altered steroid metabolism, GB hypomotility)
OCP
Cholesterol lowering drugs (alter bile acid formation)
Rapid weight loss (biliary stasis)
Prolonged TPN (hyperconcentration of bile and stasis)
Diseases that diminish bile acid pool Crohn's
Hemolytic diseases
Cirrhosis

Diseases of the GB

ASx stones

many people have them. Only take out a GB if its symptomatic.

Take out the porcelain GB bc it can lead to cancer

If stones are found incidentally @ other abdominal surgery, take them out bc it wont hurt and up to 70% will have post op acute cholecystitis 2 to stones from GB stasis/TPN/NPO

Acute cholecystitis

RUQ pain/Biliary colic with increased WBC and fever; PAIN IS CONSTANT

+ murphy’s sign.

LABS: WBC 12-15K; bilirubin 3-4; mod increases in other LFT’s

To Dx:

do KUB to r/o other prob. like perf or pneumoperitoneum first. Few stones are seen on KUB. Then do US for definitive Dx; can see stones, thickened GB wall, pericholecystic fluid. + ultrasonographic murphy’s is 98% + in acute cholecystitis.

Confirmatory test is HIDA – non visualizing GB after 4 hrs à acute chole.

TX: NPO, NG, ABX (for e coli, klebsiella, strep fecailis, clostridium perfiniges), lap chole in 3 days

Variations:

Acute gangrenous cholecystitis: morbitiy mortality rate of 16-25%.

Tend to have other co-morbid condx. EMERGENCY lap chole.

Acute Empysematous cholecystitis: associated with gas forming bacteria, often associated with DM. hAve A/F levels in GB or A in the GB wall or air in the GB ducts. EMERGENCY

Acute A-calculous cholecystitis: infx of a slowly draining GB; common with sick people on TPN b/c of GB stasis. Looks like actute chole, but no stones. US shows GB distension, HIDA is false negative in them.

Chronic cholecystitis

RUQ pain/Biliary colic without increased WBC, afebrile, btw episodes there is no abd pain or abnl.

Do US à if neg do oral cholecystogram.

To TX give analgesia, do chole. Explore the duct. Do cholangiogram or intraop US. If stones in duct do ERCP with sphincterotomy

Choledocholithiasis/ Acute cholangitis

15% of pts with stones have stones in the CBD.

If this gets infected then its called acute cholangitis.

Chatcots triad of RUQ pain, Jaundice, and fevers and chills

If it gets filled with puss: acute suppurative cholangitis.

Reynolds pentad: RUQ pain, Jaundice, fevers and chills plus hypotension and MS change

LABS: increased WBC L shift, increased bili (direct), increased Alk. Phos. >>AST, ALT incr amylase

Radi: US shows and duct dilation (cant see the stones). ERCP can see them. HIDA not useful.

TX: NPO, NG, Abx, IVF, blood Cx, if no acute response, do ERCP to decompress since this can lead to sepsis. Do cholecystectomy and/or ERCP with sphincterotomy.

Gallstone pancreatitis

60% of non-alcoholic pts who have pancreatitis have stones in the ampulla of vater.

Have epigastic pain radiating to back and very increased amylase (more than chronic pancreatitis)

Tx: cool down pancreas: NPO, NG, IVF, analgesia. The do cholecystectomy and cholangiography sp cool down.

Gallstone ileus

1-3% of all intestinal obstructions/25% of nonstrangulated sm int obstruction in pts over 70.

Erosion of a fistula from GB to sm int @ level of the duodenum.

Pt presents with signs of obstruciton that wax and wane until the stone impacts then its continuous obstruction.

Xray shows SBO, air in biliary tree. US can find the stone. Barium can find the fistula.

Tx: extract stone, correct fistula, do cholecystectomy. Usually pts with many comorbiditie

GB cancer

Very rare. Elderly people. W > Men

Vague RUQ pain, wt loss, malaise, jaundice, mass in RUQ.

5 year survival 5%.

Duct cancer

Progressive Jaundice wt loss, abd pain, pruritus, fever.

Prognosis is very bad.

Can treat with stents; Whipple (pancreaticojejeunostomy, choledochaljejunostomy, gastrojejeunostomy) or palliation.

Bile duct stricture …………