EPIDEMIOLOGY

VERY COMMON – PREVALENCE 10 %

ALL AGES – BOTH SEXES
2 – 4 TIMES MORE COMMON IN WOMEN
APHORISM : 4 F ( FAT – FERTILE – FEMALE –
FIFTIES)
AETIOLOGY
PREDISPOSING FACTORS TO GALLSTONES
FORMATION
 CHOLESTEROL SUPERSATURATION
HIGH PLASMA ESTROGEN LEVEL ( OBESITY –
PREGNANCY – ORAL CTASIS ONTRACEPTIVE )
DEPLETION BILE ACID POOL ( RESECTION
TERMINAL ILEUM )
 STASIS
FASTING - TPN – TRUNCAL VAGOTOMY
( LACK OF GALLBLADDER EMPTYING )
 INCREASED BILIRUBIN SECRETION IN BILE OR
DECONJUGATION
INCREASED BREAKDOWN RBC ( HEMOLYTIC
DISORDER : SPHEROCYTOSIS - SICKLE CELL –
MALARIA)
FAILURE OF CONJUGATION ( HEPATOCYTE
INSUFFICIENCY – EXCESS GLUCURONIDASE
CLINICAL FEATURES
 ASYMPTOMATIC STONES
INCIDENTAL
 SYMPTOMATIC STONES
CLINICALLY EVIDENT BY THE COMPLICATIONS
PHYSICAL FINDINGS
 APYREXIAL
 ABSENT ABDOMINAL TENDERNESS
 INVESTIGATION
 BLOOD EXAMINATION :
WBC AND LFT USUALLY NORMAL
 IMAGING
 MANAGEMENT
ASYMPTOMATIC STONES
OPERATION MAY BE CONSIDERED
NON FUNCTIONING GALLBLADDER
DIABETES
CHOLECYSTENTERIC FISTULA
YOUNG PATIENT
 SYMPTOMATIC STONES
INDICATION FOR OPERATION
UNLESS : PATIENT REFUSES – NON
OPERATIVE IS ATTEMPTED
STRONG MEDICAL CONTRA
INDICATIONS ( CARDIORESPIRATORY DISEASE )
NON OPERATIVE MANAGEMENT
 PHARMACOLOGICAL DISSOLUTION THERAPY
THE STONES MUST BE :
# < 1 CM IN DIAMETER
#RADIOLUCENT ( COMPLETELY COMPOSED
OF CHOLESTEROL AND NON CALCIFIED )
# TREATMENT FOR BETWEEN 6 – 24 MONTHS
# 50% RECURRENT WITHIN 5 YEARS
 MECHANICAL FRAGMENTATION AND
DISSOLUTION
# ESWL : < 3 RADIOLUCENT STONES
< 3 CM IN DIAMETER
FUNCTIONING GALLBLADDER
PATENT CYSTIC DUCT
SURGICAL MANAGEMENT
CHOLECYSTECTOMY : LAPAROSCOPIC
OPEN
 CHOLECYSTITIS
 ACUTE
CONCENTRATED BILE INITIATE CHEMICAL
CHOLECYSTITIS  SUPERIMPOSED BACTERIAL
INFECTION

CLINICAL FEATURES :
PAIN : SEVERE & PERSISTENT
NAUSEA & VOMITING
FEVER
 PHYSICAL FINDING :
TENDERNESS & GUARDING IN THE RUQ
MURPHY’ S SIGN
BOAS’S SIGN ( HYPERESTHESIA OF SKIN
OVER THE RIGHT RIBS 9 – 11 POSTERIORLY )
MASS
 INVESTIGATION :
BLOOD EXAMINATION : LEUCOCYTOSIS
BILIRUBINAEMIA
IMAGING : USG ( ENLARGED – THICKENED –
STONE )
 MANAGEMENT
# INITIAL TREATMENT :
NON OPERATIVE ( PAIN RELIEF –
SYSTEMIC ANTIBIOTIC )
# DEFINITIVE TREATMENT :
CHOLECYSTECTOMY ( LATER )
 CHRONIC
RECURRENT ATTACKS OF OBSTRUCTION AND
INFLAMMATION

CLINICAL FEATURES :
CHRONIC DISCOMFORT IN THE RUQ

INVESTIGATION :
USG

MANAGEMENT :
CHOLECYSTECTOMY
 CHOLEDOCHOLITHIASIS
CAUSES OBSTRUCTIVE JAUNDICE :
JAUNDICE
PRURITUS
DARK URINE
PALE BULKY STOOLS
 INVESTIGATION :
USG : BILE DUCTS DILATATION
DUCTAL STONES IDENTIFY
MRCP or ERCP : CONFIRMED DIAGNOSIS
DIFFERENTIATES STONE AND
OTHER CAUSES
 MANAGEMENT :
# PRE OR POST OPERATIVE ERCP IN
COMBINATION WITH LAPAROSCOPIC
CHOLECYSTECTOMY
# CHOLECYSTECTOMY AND EXPLORATION OF
CBD ( OPEN OR LAPAROSCOPICALLY )
TERIMA KASIH