#61 – Cholelithiasis and Cholecystitis



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Anatomy

  • 4 anatomic areas of gall bladder
    • Fundus
      • Rounded, blind end that extends 1-2 cm beyond the liver margin
      • Contains most of the smooth muscle
    • Body
      • Main storage area
      • Contains the elastic tissue allowing for distention
        • Normally holds 30-50mL and can stretch to 300mL
    • Infundibulum (Hartmann’s Pouch)
      • Mucosal outpouching at the junction of the neck and cystic duct
    • Neck
      • Lies in the deepest part of the fossa
  • Cystic Artery
    • Branch of the right hepatic artery
    • Found in the cystohepatic triangle
      • Cystic duct, common hepatic duct, superior/inferior margin of liver
      • Triangle of Calot
        • Cystic duct, common hepatic duct, cystic artery
        • Lymph node can be found in near the insertion of the cystic artery
          • Calot’s node (Lund’s or Mascagni’s)
  • Cystic duct
    • Spiral valves of Heister
      • Mucosal folds in the proximal cystic duct that make cannulation difficult
    • Joins the common hepatic duct to form the common bile duct
    • Highly variable anatomy

Physiology

  • 80% of bile is stored in the gall bladder
    • Infundibulum secretes glycoproteins to protect mucosa
  • Cholecystokinin released from neuroendocrine cells of the duodenum during meal
    • Stimulates release of bile from gallbladder
      • 50-70% over 30-40 minutes
    • Causes relaxation of Sphincter of Oddi
  • Vagal stimulation causes contraction of gallbladder

Stone Formation

  • Major solutes in bile are bilirubin, bile salts, phospholipids (lecithin), and cholesterol
  • 80% are cholesterol
    • Supersaturation of bile with cholesterol exceeds the ability of phospholipids and bile salts to maintain solubility

Pathogenesis of Cholecystitis

  • Phospholipid A (secreted by the gall bladder mucosa) released in response to gall bladder trauma (stone)
    • Catalyzes conversation of lecithin to lysolecithin
      • Leads to mucosal and luminal irritation and inflammation

Epidemiology and Risk Factors

  • 90-95% of patients with cholecystitis have stones
    • Only 20% of patients with stones with develop cholecystitis
    • 10-15% of patients have stones on autopsy
  • Risk Factors
    • High fat diet
    • Older age
    • Female > male
    • Higher BMI
      • Rapid weight loss
    • Pregnancy
    • Previous surgeries
      • Terminal ileum resection, gastric/duodenal surgery

Signs and Symptoms

  • History
    • Right upper quadrant abdominal pain
      • Steady, “boring” pain lasting hours
      • Worsened by fatty foods
    • Right scapular pain (Boas’ sign)
      • Hyperesthesia between 9th-11th rib
    • Fever, nausea, vomiting, anorexia
  • Physical Examination
    • Fever, tachycardia
    • Peritoneal signs
      • Pain with movement and percussion
    • Voluntary and involuntary guarding
    • +/- jaundice
    • Inspiratory arrest on deep RUQ palpation (Murphy’s sign)

Diagnostic Studies

  • Laboratory Studies
    • Leukocytosis with neutrophilic shift
    • LFTs generally normal, but may show:
      • Elevated direct (conjugated) bilirubin
      • Elevated alkaline phosphatase
      • Elevated GGT
  • Ultrasound is the initial test of choice
    • Length > 10 cm
    • Wall thickness > 3mm
    • Pericholecystic fluid
    • Sludge
  • Cholescintigraphy using 99m Tc-hepatic iminodiacetic acid (HIDA) Scan
    • Used if ultrasound is inconclusive
    • Intravenous injection of HIDA and visualization of dye in gallbladder, bile ducts, and small bowel within 30-60min
      • If not visualized after 1 hour, morphine can be given and waiting 3-4 hours
        • If no visualization = cholecystitis
  • Magnetic Resonance Cholangiopancreatography (MRCP)
    • Used if evidence of choledocolithiasis or elevated LFTs

Management

  • Admission
  • IV fluids
  • NSAIDs
    • Ketorolac 30-60mg IV/IM
  • Opioids
    • Meperidine NOT superior to morphine
  • Antibiotics
    • Low Risk
    • High Risk
  • Indication for Emergent Cholecystectomy
    • Necrosis
    • Perforation
    • Emphysematous cholecystitis
    • High fever
    • Hemodynamic instability
  • Interval Cholecystectomy (low risk)
    • Within 3 days of admission after therapies above and clinical improvement
    • Most can be discharged in 1-2 days postop
  • Gall bladder drainage (high risk)
    • Percutaneous cholecystostomy
      • Critically ill or septic
      • > 72 hours from symptom onset
      • Failure of antibiotic therapy
      • No coagulopathy
    • Endoscopic transpapillary/transmural drainage
      • Liver disease
      • Ascites
      • Coagulopathy
    • If improvement within 72 hours, proceed with laparoscopic cholecystectomy
      • If not, may need emergent open cholecystectomy
Percutaneous Cholecystostomy

Management Algorithm


Steps of Laparoscopic Cholecystectomy

  1. Dissect peritoneum overlying the cystic duct and artery
  2. Division and clipping of cystic duct close to gallbladder
    • Perform intraoperative cholangiogram to evaluate CBD
    • If clear, then two clips close to common bile duct and ligate
  3. Dissect cystic artery, one clip close distal and two clips proximal, and ligate
  4. Dissection of gall bladder from liver bed
  5. Cauterize, irrigate, suction, and obtain hemostasis of liver bed
  6. Remove gall bladder

Cottage Physician (1898)



References

  1. Blackbourne LH.  Surgical Recall.  6th Edition.  2012.
  2. Halpin V. Acute cholecystitis. BMJ Clin Evid. 2014; 2014:. [PDF]
  3. Haisley KR, Hunter JG. Gallbladder and the Extrahepatic Biliary System. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz’s Principles of Surgery, 11e. McGraw-Hill; Accessed June 14, 2020. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2576&sectionid=216215815
  4. Haubrich WS. Calot of the triangle of Calot. Gastroenterology. 2002; 123(5):1440. [pubmed]
  5. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996; 28(3):267-72. [pubmed]
  6. Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994; 154(22):2573-81. [pubmed]
  7. Park MS, Yu JS, Kim YH, et al. Acute cholecystitis: comparison of MR cholangiography and US. Radiology. 1998; 209(3):781-5. [pubmed]
  8. Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol. 2001; 96(4):1266-72. [pubmed]
  9. Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25(1):55-72. [pubmed]
  10. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(2):133-64. [pubmed]
  11. Hatzidakis AA, Prassopoulos P, Petinarakis I, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol. 2002; 12(7):1778-84. [pubmed]

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