Complications of gall stone disease

1. COMPLICATIONS OF
GALLSTONE DISEASE
ShankarZanwar
Jewellery from gall stone

2. 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
RKTandon WJG 2000

3. NATURAL HISTORY OF GALLS STONE
DISEASE

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

5. 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

6. ACUTE CHOLECYSTITIS
 Pathogenesis
Stone
embedding in
cystic duct
Chr.
Obstruction
Stasis of bile in
GB
Mucosal
trauma by gall
stones
Release of
phospholipase
A
Conversion of
lecithin 
lysolecithin
Luminal
irritation
Release of
cytokinins
cholecytitis

7. 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.

8. NATURAL HISTORY
 Untreated cholecystitis – pain relives in 7-10 days
 Sequelae
 Resolution – 83%
 Gangrenous cholecystitis – 7%
 Empyema – 6%
 Perforation – 3%
 Emphysematous – 1%

9. 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)

10.  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.

11. 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%

12. 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
pressure
regurg of
bac. from
bile in hep.
venous
sinuses
Bacteremia
fever and chills,
sepsis & shock

13. 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%.

14. 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

15. TREATMENT
 IV fluids, cultures, antibiotics in severe cases with shock cover
anerobes
 Decompression
 ERCP
 Failed PTBD
 Cholecystectomy.

16. 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 stones
Hazzan Surg Endo 1999
 Risk of GB ca. In these group of patients is higher then the rest –
25%
Redaelli Surgery 1997

17. 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

18. 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

20. 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

21.  Type 2-4
 using remnant of GB to repair fistula withT-tube,
 Other safest alternative is Roux enY bilio- enteric anastomosis
 Prognosis of type – excellent
 Higher types – poorer with complications like
 Increased postop morbidity
 Biliary fistulae – 10% or more
 Strictures
 Hepatic abscess

22. 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 obstructions
Cooperman 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 %

23. 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 flexurestomachjejunum
 Occur in 2-3% with cholecystitis
 Mirrizi’s syndrome is associated in 90% of cases of cholecysto-
enteric fistulae.

24. 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

25.  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

26. 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%

28. 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

29.  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

30.  A study byTan (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

31. 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%

32. 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 toVEGF inhibition.

33.  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

34. 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

35.  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

36.  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 days
Kraljevic Hepatogastroenterology 1999

37. 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.

38. 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

39. 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

40.  Severe – of 187 patients
 78 had early and 109 late cholecystectomy
WilliamAnn Sur 2004
 Since 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 6
Complications of cholecystectomy 44 5.5

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