Cholelithiasis

Cholecystectomy only if she develops biliary colic

• Symptomatic gallstones are the main indication for cholecystectomy.

• Absolute contraindications for the procedure are uncontrolled coagulopathy and end-stage liver disease.

Gall stone REF: Sutton’s textbook of radiology, T^h edition, volume 1 page 713 

Mercedes Benz sign/Seagull sign/Crow feet sign:

Gall bladder stone if radiopaque has a stellate faceted appearance with gas containing fissures on the plain radiograph and is called as Mercedes Benz sign/Seagull sign or Crow feet sign

Leptospira interrogans infection REF: Nelson’s pediatrics page 1566

Conditions Associated with Cholelithiasis:

• Chronic hemolytic disease (sickle cell anemia, spherocytosis)
• Obesity
• Ileal resection or disease
• Cystic fibrosis
• Chronic liver disease
• Crohn’s disease
• Prolonged parenteral nutrition
• Prematurity with complicated medical or surgical course
• Prolonged fasting or rapid weight reduction
• Treatment of childhood cancer
• Abdominal surgery
• Pregnancy

Acute Acalculous cholecystitis usually caused by:

• Infection-Pathogens include streptococci (groups A and B), gram-negative organisms particularly Salmonella, and Leptospira interrogans. Parasitic infestation with Ascaris or Giardia lamblia may be found.
• Acalculous cholecystitis may rarely follow; abdominal trauma, burn injury
• Acalculous cholecystitis may be associated with a systemic vasculitis, such as polyarteritis nodosa.

Surgical wounds can be divided into three categories based on the amount of bacterial contamination.

Clean wounds are those in which no part of the respiratory, gastrointestinal, or genitourinary tract is entered.

Examples include herniorrhaphy and breast surgery.

Clean-contaminated wounds encompass those cases in which the above systems are entered, but without evidence of active infection or gross spillage.

Examples include elective cholecystectomy or elective colon resection with adequate bowel preparation.

Contaminated wounds are those in which there is active infection (perforated appendicitis with abscess) or gross spillage (gunshot wound with large or small bowel injuries).

While contaminated and clean-contaminated wounds require perioperative antibiotics, clean wounds need not be treated with prophylactic antibiotics.

The patient in question is a 70 years old male, with no evidence of symptomatic disease or prior history of complication.

Gall stones were accidentally detected on a routine ultrasound examination of the abdomen.

So no active intervention is indicated in such a patient for management of gall stones.

Prophylactic cholecystectomy is indicated in children with hemolytic anemia and gallstones and patients with large (>2.5) stones.

It is not recommended for diabetics, cirrhotics or patients undergoing solid organ transplantation.

Ref: General Surgery: Principles and International Practice By Kirby I. Bland, Volume 2, Pages 1035-8; Schwartz’s Principles of Surgery, 9th Edition, Chapter 32.

Most common site of intestinal obstruction by a gallstone is the ileum (60%) at the ileocecal junction which is the narrowest part, followed by jejunum (15%), stomach (15%) and colon (5%).

In the absence of an intestinal stricture a gallstone of at least 2cm is required to cause intestinal obstruction.

Contraindications for medical management are:

1.    Radio-opaque concretions

2.    Gallstones >20mm in diameter

3.    Non opacified gall bladder

4.    Acute &/or chronic cholecystitis

5.    Complications of gallstones

6.    Poor patient compliance

In carefully selected patients with a functional GB and with radiolucent stones of <10 mm diameter medical management has been useful.

Ref: Gallstone disease in the elderly By Giuseppe Del Favero, Pilotto, F. Di Mario,  Page 61; Harrison’s 16th/1884

Somatostatinoma produces somatostatin in excess. Most common tumor location is pancreas. >70 % are malignant. Cholelithiasis is seen in 65-90%. Other manifestations are diabetes and diarrhea.

Reference:
Table 350-2, Harrisons Principles of Internal Medicine, 18th Edition, Page 3057

Ans. is ‘c’ i.e., Hemochromatosis

Causes of Acute Pancreatitis

Common causes

Gallstones (including microlithiasis) – most common

Hypertriglyceridemia

Endoscopic retrograde cholangiopancreatography (ERCP), especially after biliary manometry.

Trauma (especially blunt abdominal trauma)

Postooperative (abdominal and nonabdominal operation)

Drugs ( L-asparginase, thiazide diuretics, frusomide, estrogens, azathioprime, 6-mercaptopurine, methyldopa, sulfonamide, tetracyclin, valproic acid, anti-HIV medicacations)

Sphincter of Oddi dysfunction

Uncommon causes

Vascular causes and vasculitis (ischemic-hypoperfusion states after cardiac surgery)

Connective tissue disorders and thrombotic thrombocytopenic purpura (TTP)

Cancer of the pancreas Hypercalcemia

Periampullary diverticulum Pancreas divisum

Hereditary pancreatitis Cystic fibrosis

Renal failure

Rare causes

Infections (mumps, coxsackievirus, cytomegalovirus, echovirus, parasites).

Autoimmune (i.e., Sjogren’s syndrome)

Causes to consider in patients with recurrent bouts of acute pancreatitis without an obvious etiology

Occult disease of the biliary tree or pancreatic ducts, especially microlithiasis,

sludge Drugs                                          Pancreatic

cancer                                                   Idiopathic

Hypertriglyceridemia                              Sphincter of Oddi dysfunction

Pancreas divisum                                 Cystic fibrosis

Ans. is ‘a’ i.e., Pigment

Ans. is ‘c’ i.e., Neimann Picks disease

B, C i.e. (Gall Stone), (Blunt abdominal trauma)

B i.e. USG

Ans. is ‘b’ i.e., Distal ileum

Ans is ‘b’ i.e., Proximal to Ileocaecal junction 

Answer ‘b’ i.e. Removal of obstruction

• The treatment priroity should focus on relief of obstruction and not on gall bladder and its fistulous communication. So the procedure of choice is

– Laprotomy with stone extraction.

• The gallbladder disease can be dealt on later, which includes cholecystectomy and closure of the fistulous tract.

[Note that Sabiston (18/e p1572), differs with the above management. It writes that – “Takedown of the biliary-enteric fistula and cholecystectomy during the same procedure is warranted because recurrent cholecystitis and cholangitis are common. However, in patients with a significant inflammatory process in the right upper quadrant or who are unstable to withstand a prolonged operative procedure, the fistula can be addressed at a second laparotomy.” However the above management is supported by Bailey, Harrison, Maingot’s and CSDTI

Answer is ‘a’ i.e. More common in females

• “Women are three times more likely to develop gallstones than men, and first degree relatives of patients with gallstones have a two-fold greater prevalence” – Schwartz, 9/e p1142.
• Saint’s Triad consists of:

gall stones

diverticulosis of the colon & hiatus hernia

• Limey Bile [Ref: Harrison 17/e p1997 (16/e, p1886); Bailey & Love 24/e, p 1103]

–  in this condition, there is secretion of calcium salts into the lumen of the gallbladder in sufficient concentrations to produce calcium precipitation and diffuse, hazy opacification or a layering effect on plain x-ray

– this limey bile or milk of calcium bile, is usually clinically innocuous, but cholecystectomy is recommended, especially when it occurs in a hydropic gallbladder.

• Also see what Bailey & Love write about it

“The condition tends to occur when there is a gradual obstruction of the cystic or common bile duct, for example due to chronic pancreatitis or carcinoma of the pancreas.

• Lithotripsy [Ref: Maingot’s 10/e, p 1730; Harrison 16/e, p 1884]

Though ESWL is highly successful for genitourinary stones, its only of limited value in biliary tract stones.

Ans. is (c) No surgery for gallbladder stones 

• Schwartz Pretest writes‑

“In a patient who has asymptomatic cholelithiasis as an incidental finding, however, there are no data to suggest that any therapeutic intervention is justified. Fewer than 25 percent of patients with asymptomatic cholelithiasis will develop symptoms that require intervention over a 5 year follow-up period.”

Ans is ‘a’ ie Stone is <15 mm in size 

• Medical therapy for gall stone dissolution utilizes
• two bile acids

–           Ursodeoxycholic acid (UDCA)

–           Chenodeoxycholic acid (CDCA)

[Note Harrison mentions only Ursodeoxycholic acid. CMDT mentions both UDCA and CDCA]

• Mechanism

they inhibit HMG-CoA reductase, the rate limiting enzyme for cholesterol biosynthesis, thus decrease cholesterol saturation of bile.

they cause dispersion of cholesterol from the stones by physio-chemical means

• Prerequisites for medical tit of gall stones.

1)       Radioluscent stones

2)       Size <10 mm in diameter

3)       Functioning gall bladder

4)       Non acute symptoms.

[Davidson, 17/e, p540 & Harrison 14/e, say – the stone size to be < 15 mm.]

• Harrison writes that highest success rates are achieved with floating, radioluscent stones less than 5 mm in size.
• Medical dissolution is effective only for cholesterol gall stones (not for pigment stones)
• Drawbacks of Medical therapy

low rates of complete resolution

high recurrence rate

not cost-effective (expensive drug has to be taken for upto 2 years) need for maintenance therapy to prevent recurrence.

Ans. is ‘c’ i.e. Gall Stone dissolving drug 

Answer (a) Cholecystectomy with choledocholithotomy done at same sitting

Management of suspected or proven CBD stones associated with gall bladder stones

• For gallstones – laparoscopic cholecystectomy is the procedure of choice.
• For CBD stones two things can be done:

1) If the surgeon is experienced in laparoscopic techniques of CBD stone removal then both cholecystectomy and choledocholithotomy is done in the same sitting.

– CBD stones are first confirmed by an intraoperative cholangiogram

– then the stones are removed laparoscopically via the cystic duct or by choledochotomy.

2) If the surgeon is not experienced with laparoscopic methods of CBD stone removal, preoperative endoscopic sphincterotomy with stone removal and later laparoscopic cholecystectomy is done.

• Laparoscopic cholecystectomy with choledocholithotomy in the same sitting is the preferred technique (provided the surgeon is experienced)
• But one must keep in mind here that

“for elderly, poor-risk patients with gallstones and CBD stones some have recommended ERCP and sphincterotomy as the sole treatment, leaving gallbladder and stones in situ”. – Maingot’s 10/e Usually the gallstones in these patients remain asymptomatic and if need arises can be managed by cholecystectomy

Ans. is A ie. ERCP

• The first inv. for any pt. with cholelithiasis or jaundice is U/S.
• Next inv. depends on U/S findings,
• If the intrahepatic ducts are dilated without any extrahepatic dilatation
• then the preferred inv. is —->    PTC*
• If the dilatation is in CBD —>         ERCP*.

ERCP may provide direct diagnosis of the distal CBD pathology and may be therapeutic as well for a CBD stone or stricture.

Ans is ‘d’ i.e. C3-05

Gallstone disease may refer pain to the right shoulder tip (k/a Kehr’s sign). This is because, an inflamed gallbladder irritates the diaphragm which is supplied by the phrenic ner^y (C3-05). These cervical nerve roots, also provide sensory supply to the right shoulder through supraclavicular nerves. Hence the gallbladder pain is referred to the right shoulder through the C3-05 nerve roots.

Ans. is ‘c’ i.e. Mixed 

Ans. is ‘a’ i.e. 10%

Ans. is ‘c’ i.e. Ampulla of vater 

Ans. is ‘a’ i.e. Oxalate 

Ans. is ‘d’ i.e. All of the above 

Ans. is ‘b’ i.e. There is an increased incidence of stones in diabetics 

Ans. is ‘b’ i.e. Removal of obstruction 

Ans. is ‘c’ i.e., Cholesterol 

Ans. is ‘a’ i.e., Elective open cholecystectomy for cholelithiasis 

Answer is B (Ileal resection)

Ileal resection is associated with interruption of enterohepatic circulation of bile sults thereby decreasing the ratio of bile salts to cholesterol within the bile (Lithogenic bile)

Answer is D (More common in males between 30-40 years of age)

Lithogenic bile is required for gall stone formation and gall stones. 

May be associated with increased risk of carcinoma gall bladder.

Diabetes mellitus is associated with Gall bladder hypomotility which may contribute to increased incidence of gall stone in diabetics.

Answer is C (Terminal ileum):

‘Classically there is obstruction / impaction about 60 cm proximal to ileocaecal valve’- Bailey

‘The site of obstruction by the impacted gall stone is usually at the ileocaecal valve” provided that the more proximal S.I. is of normal calibre. – Harrisons

If both choices come simultaneously in a question go for 60 cm proximal to ileacoecal valve, as, it has been defined as the narrowest part of small intestine.

Answer is C (No surgery for gallbladder stones)

Prophylactic cholecystectomy is not warranted in an asymptomatic patient.

Ans. C: Acute appendicitis

Effects and complications of gall stones:

• In the gall bladder

–         Biliary colic

–         Acute cholecystitis Chronic cholecystitis

–         Empyema of gall bladder

–         Mucocele

–         Perforation

• In the bile ducts

–         Biliary obstruction

–         Acute cholangitis

–         Acute pancreatitis

• In the intestine

–         Intestinal obstruction (gallstone ileus)

–         Cancer of the gallbladder (rarely)

–         Jaundice

–         Pancreatitis

Ans. A: Gall stone

Gall stone causes dynamic ileus (intraluminal cause)

Adynamic cause of intestinal obstruction includes 1) paralytic ileus, 2) mesenteric vascular occlusion and 3) pseudo-obstruct

Ogilvie’s syndrome is acute colonic pseudo-obstruction

Ans. ERCP