COMPLICATIONS OF GALLSTONE DISEASE

Shankar Zanwar

Jewellery from gall stone

BACKGROUND Reports of gall stones in history dates back

Babylonian era before 2000 yrs Prevalence of gall stones in India 4.3% half of the

western world percentage

RK Tandon WJG 2000

NATURAL HISTORY OF GALLS STONE DISEASE

COMPLICATIONS OF GALL STONES Cholecystitis Cholangitis Mirrizi’s syndrome Gall stone ileus Emphysematous cholecystitis Perforation Biliary pancreatitis Carcinoma gall bladder

CHOLECYSTITIS Of all patients with gall stones 2% will become

symptomatic every year (for first 5 years and later decrease)

Of symptomatic gall stones 2% will develop complications per year

Ranshoff Ann Int Med 1993

Acute cholecystitis is the most common complication of gall stone disease

ACUTE CHOLECYSTITIS Pathogenesis

Stone embedding in cystic duct

Chr. Obstruction

Stasis of bile in GB

Mucosal trauma by gall stones

Release of phospholipas

e A

Conversion of lecithin

lysolecithin

Luminal irritation

Release of cytokinins

cholecytitis

CLINICAL FEATURES Nearly 75% have prior attacks of biliary pain

Fever – but usually <102, higher – gangrene or perforation

Jaundice – 20%, in 40 % elderly patients, usually <4mg/dl if >4 suspect CBD stone

Murphy’s sign – sensitivity – 97%, specificity 48%Singer Ann Int Med 1996

GB is palpable in 33% of pts. more if the attack is for first time.

NATURAL HISTORY Untreated cholecystitis – pain relives in 7-10 days

Sequelae Resolution – 83% Gangrenous cholecystitis – 7% Empyema – 6% Perforation – 3% Emphysematous – 1%

DIAGNOSIS Hemtological and biochemical alterations

Mild amylase and lipase elevation may be seen in absence of pancreatitis

USG – Sonographic tenderness – 90% PPV Non specific

GB wall thickening >4mm (in absence of hypoalbu) Pericholecystitic fluid (in absence of ascites)

Cholescintigraphy – HIDA/DISIDA scan Assesses patency of cystic duct Normal scan – GB seen within 30 min Non visualisation – s/o cholecystitis Sensitivity – 95%, specificity – 90 % False positive – fasting, CLD, TPN, critically ill False negative virtually absent

CT can useful when complications like – perforation, emphysema abscess, or pancreatitis suspected.

TREATMENT IV fluids, Electrolyte replacement, cultures.

Broad spectrum antibiotic coverage, in complicated patient extend coverage for anerobes

Definitive therapy – cholecystectomy

Study from KMC, Manipal Bile culture + ve in 70% Aerobes - 56.8% Anerobes – 13.6%

CHOLANGITIS Most serious and lethal of all complications All causes of cholangitis 85% are due to stones

embedded in the CBD Same organisms as in cholecystitis

Thus urgent decompression needed

Obstruction

biliary pressur

e

regurg of bac.

from bile in hep.

venous sinuses

Bacteremia

fever and chills,

sepsis & shock

CLINICAL FEATURES AND LABS Charcots triad – pain, fever and jaundice – 70% of patients

Pitt WB Ac. Cholangitis 1987

Fever – 95%, - usually > 102

RUQ tenderness – 90%

Jaundice – 80%

Leucocytosis – 80%, Bil >2mg – 80%.

IMAGING Stones in CBD seen only in 50% cases, CBD dilatation

>6mm may give indirect evidence in remaining 25%Yusuff, GE clinic of N Amer 2003

MRC for stones Sensitivity 93%, specificity -94% Recommended when low to moderate clinical probability

EUS Sens – 95%, spec – 97%, NPV – 98% Recommended when low to moderate clinical probability

ERCP – sens and spec – 95% Recommended when high probability and therapeutic

intent

TREATMENT IV fluids, cultures, antibiotics in severe cases with

shock cover anerobes

Decompression ERCP Failed PTBD Cholecystectomy.

MIRRIZI’S SYNDROME. First described in 1948 by Mirrizi

Stone impacted in the neck or GB or cystic duct narrowing of CHD.

Occurs in 0.1 -0.7% of patients with gall stonesHazzan Surg Endo 1999

Risk of GB ca. In these group of patients is higher then the rest – 25%

Redaelli Surgery 1997

CLASSIFICATIONS

Older – McSherry Type 1 – external compression of CHD by calculus in cystic

duct/Hartmanns’s pouch Type 2 – Cholecysto-choledochal fistula partial/ complete

Newer - Csendes classification

Only external compression

Cysto-biliary fistula <1/3rd of circumference of CHD

Upto 2/3rd of CHD circum

Complete destruction

DIAGNOSIS

Symptoms and signs same as cholecystitis

Lab parameters mimic cholecystitis or cholangitis

USG – correct diagnosis – 8-62%

Nearly 100% can be diagnosed with ERCP or EUS

TREATMENT -

When preop diagnosis made – open preferred over lap chole

When found intra-op during lap surgery – mandate open conversion

Though reported(and sparsely) lap should be avoided unless expert is available

Type 1 - cholecystectomy alone If phlegmon or fibrous reaction at Calot’s triangle – stone

extraction & partial cholecystectomy – safe

Type 2-4 using remnant of GB to repair fistula with T-tube, Other safest alternative is Roux en Y bilio- enteric anastomosis

Prognosis of type – excellent

Higher types – poorer with complications like Increased postop morbidity Biliary fistulae – 10% or more Strictures Hepatic abscess

CHOLECYSTO-ENTRIC FISTULA - GALLSTONE ILEUS Not a true ileus – rather mechanical obstruction First description – Bartholin – 1654 Seen in 0.5% of gall stone patients Occurs in nearly 1-3% of all small bowel mechanical

obstructionsCooperman Ann Surg, 1986

Accounts for nearly 25% of all SB obstructions in elderly women (>65 y)

Reisner RM Am J Surg 1994 Females more common - 3-16 times Mortality – 15-18 %

PATHOGENESIS Fistula formation from bile duct to the intestine due to

pressure necrosis by gall stone against the biliary wall

Most common entry point into the bowel – duodenum followed by hepatic flexurestomachjejunum

Occur in 2-3% with cholecystitis

Mirrizi’s syndrome is associated in 90% of cases of cholecysto-enteric fistulae.

CLINICAL PRESENTATION Gall stone ileus results when gallstone is large in

size majority - >2.5cm

Commonest site of impact 50-70% – distal ileum, since narrowest

Presents as intermittent sub-acute obstruction

“Tumbling obstruction” – due to stone tumbling down the bowel lumen

Mean symptoms period before presentation – 5days

Occasional hematemesis due to hemorrhage at the entry site of the stone.

Bouveret’s syndrome – Gastric outlet obstruction due to impacted gall stone in duodenum or pylorus

DIAGNOSIS Clinical diagnosis made infrequently Prep-op diagnosis is made only in 20-50% of cases

Chou WJG 2007 Rigler’s triad on imaging

Partial or complete intestinal obs – 50% Pneumobilia – 30-60% Aberrant gall stones - <15%

X-ray – detects all 3 in 17-35% cases USG + X-ray 74% Plain CT – 93%

TREATMENT Surgery after intial resuscitaion

Ongoing debate – one stage vs 2 stage

One stage – treating obs, cholecystectomy and fistula division withor without CBD exploration

Two stage – only explorative laparotomy and enterolithotomy first in second stage rest all.

Benefits of one stage operation – prevents further biliary complications, recurrent ileus and treats fistula

Largest review of 1000 cases by Reissner – mortality rate 16.9% in one stage vs 11.7% for enterolithotomy alone

But recurrence of GS ileus is seen in only 5-9% of cases where enterolithotomy done

And only 10% require reoperation for biliary symptoms

Fistula may close spontaneously and unclosed fistula complicates rarely

A study by Tan (Singapore Med J 2004) Significantly increased operating time in one stage No significant morbidity and mortality differences in the

2 groups

Many authors conclude – one stage procedure should be reserved for otherwise

healthy patients and without serious fibrosis in RUQ Two stage – be considered in younger patients with risk

of further biliary complications

EMPHYSEMATOUS CHOLECYSTITIS Acute infection of gall bladder by gas forming

organisms

Surgical emergency

Seen in 1% of all cases of acute cholecystitis

Mortality rates between 15-25%

PATHOGENESIS Vascular compromise of the gall bladder – occlusion or

stenosis of vessels, usually arteriosclerotic cystic artery

More in male, DM(in up to 55%patients), elderly.

Vascular compromise facilitates growth of gas forming organisms

This is also reported in cases of pts. treated with sunitinib for GIST due to VEGF inhibition.

Common causative agents Clostridum spp – 46% E. coli – 40% Klebsiella Enterococci

Symptoms and presentation is similar to acute cholecystitis except for higher degree of fever

Lab findings are similar to acute cholecystitis

IMAGING X- ray – air in side the GB – can be

negative in 60% cases

USG sensitivity 90-95% Stage 1 - gas in lumen Stage 2 - gas in wall Stage 3 - gas in the pericholecystic tissue

Effervescent GB tiny foci floating on the

nondependent wall Curvilinear gaseous artifact, ring down

effect, comet-tail sign - diagnostic

CT confirms emphysematous cholecystitis, when USG is in doubt

HPE shows full thickness necrosis of GB, gangrene seen in 75% of cases.

Medical treatment same as for sever cholecystitis

In hemodynamically unstable patient and those who can not tolerate GA percutaneous cholecystectomy can be done to stabilize the patient.

Interval cholecystectomy after 4-6week can be done

Adjuvant therapy with hyperbaric oxygen- rationale – anerobes is cause in majority

HBO is given within 8 hours of surgery for 5 daysKraljevic Hepatogastroenterology 1999

GB PERFORATION Neimeier classification

Type 1 – Acute Type 2 – Subacute Type 3 – Chronic

Managed similarly as emphysematous cholecystitis

In a study by Hung stable patients can be taken up for early lap cholecystectomy with equal outcomes and lesser LOS as compared elective interval cholecystectomy after PTBD.

GALL STONE PANCREATITIS

Of all gall stone patients only 3-7% develop pancreatitis

But amongst the pancreatitis patients 40% are caused due to gall stones

In thesis – 17/53(32.07%) patients had biliary cause of pancreatitis, 3 severe, 3 moderate and rest 11 mild, no mortality

All underwent cholecystectomy except 2 severe ones

MANAGEMENT - TIMING OF CHOLECYSTECTOMY

mild pancreatitis – Review of studies with total of 998 patients

no readmissions if operated during index admission vs 18% readmission in patient with interval cholecystectomy(p<0.0001)

No difference in operative complications, conversion or mortality

Ann Surg 2012

Severe – of 187 patients 78 had early and 109 late cholecystectomy

William Ann Sur 2004Since the patients with acute severe pancreatitis often have peripancreatitic complications and SIRS operating is challenging and may invite complications should be avoided till 4-6 weeks till pancreatitis settles

Early(%) Late(%)Resolution of associated fluid collection

21 40

Percutaneous drainage required

50 18

Sepsis 47 6Complications of cholecystectomy

44 5.5

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