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GENERAL SURGERY
GALLSTONES D KAHN
PATHOGENESIS
Gallstones are composed mainly of
cholesterol, bilirubin and calcium salts.
The majority of gallstones (75%) are
cholesterol stones. Non-cholesterol
stones are categorized as either black
or brown pigment stones. Black
pigment stones consist of bilirubin and
large amounts of mucin glycoproteins.
Black pigment stones occur commonly Bile, which contains high
in patients with chronic haemolytic concentrations of cholesterol and
conditions and in cirrhosis of the liver. lower concentrations of phospholipids
Brown pigment stones are thought to and bile salts, is said to be lithogenic
be related to worm infestation. About bile. In contrast, bile with low
15% of gallstones are calcified enough concentrations of cholesterol and high
to be seen on an abdominal x-ray, and concentrations of phospholipids and
of these two-thirds are pigmented bile salts is said to be non-lithogenic
stones. Calcification that is visible bile.
only on the rim of the stones are
usually cholesterol based stones. ASYMPTOMATIC GALLSTONES
Most patients with gallstones have no
Cholesterol stones form when the symptoms. Increasingly, asymptomatic
concentration of the cholesterol in the stones are discovered incidentally
bile exceeds the ability of bile to hold it during investigations for other
in solution. Bile consists of water, conditions. This is as a result of the
cholesterol, bile salts and increased use of abdominal imaging,
phospholipids (lecithin). Cholesterol is such as ultrasonography, for non-
specific abdominal symptoms.
The stone eventually disimpacts
resulting in resolution of the
inflammatory process and fibrosis. As
a result of repeated attacks of biliary
colic, the gallbladder eventually
becomes chronically scarred.
TREATMENT OF GALLSTONES
Cholecystectomy remains the
treatment of choice for symptomatic
patients with gallstone related
problems confined to the gallbladder.
Cholecystectomy can be performed as
an open operation requiring an upper calcified and in the presence of a
abdominal laparotomy. However, it is functioning gallbladder. It is also
now routine to perform only applicable to small gallstones,
cholecystectomy as a laparoscopic since large stones take too long to
operation. Both methods require a dissolve. Medical dissolution
general anaesthetic. With either therapy is contraindicated in
procedure, the surgical objectives are patients with severe symptoms, in
the same, namely, to eliminate the pregnancy, in patients with liver
gallbladder, to eliminate the disease, and in patients with
gallstones, to exclude stones in the severe atherosclerosis. The
biliary tree and to ensure that the bile disadvantages of dissolution
ducts are not damaged. therapy are that it takes
approximately 2 years to achieve
The procedure involves dissection in complete dissolution, and
Calot’s Triangle, ligation and division recurrence of the gallstones after
of the cystic artery, ligation and stopping treatment.
division of the cystic duct, and removal
of the gallbladder from the gallbladder
bed. 2. Contact Dissolution Therapy
This involves the percutaneous
Although intraoperative insertion of a catheter into the
cholangiography is no longer gallbladder and irrigation with
performed routinely, the option should methyl terbutyl ether which rapidly
always be available. All surgeons dissolves the gallstones. The
performing cholecystectomy should be disadvantages again, include the
skilled in cholangiography and recurrence of gallstones after
interpreting the result. The incidence stopping treatment, and problems
of asymptomatic common bile duct related to the spilling of the solvent
stones detected on routine operative into the duodenum.
cholangiography is 5-10%.
Intraoperative cholangiography is also 3. Extracorporeal Shockwave
useful in clarifying the biliary anatomy. Lithotripsy
This involves the use of computer
MEDICAL TREATMENT OF
focused shock waves produced by
GALLSTONES
electromagnetic or ultrasound
There are other non-surgical treatment sources to fragment gallstones.
options for gallstones. However, it is The fragments then either pass
important to emphasize that these are down the common bile duct, or can
not alternatives for symptomatic be dissolved using oral dissolution
gallstones. Surgery remains the therapy. The selection criteria are
treatment of choice for patients with
symptomatic gallstones.
1. Elective cholecystectomy
ACUTE CHOLECYSTITIS
After resolution of the acute
In acute cholecystitis a gallstone inflammatory process, the
becomes impacted in the cystic duct or patient is discharged and
Hartman’s pouch and there is readmitted 6-12 weeks later for
inflammation and infection in the an elective cholecystectomy.
gallbladder wall. The symptomatology
consists of severe colicky abdominal 2. Early cholecystectomy:
pain in the right upper quadrant which
Cholecystectomy is performed
radiates round to the tip of the
on the first elective operating
scapula. There is associated nausea
list after admission to hospital.
and vomiting. On examination the
The advantage of the latter
patient is pyrexial, there is tenderness
includes a shorter total duration
and guarding in the right upper
of the illness, a shorter hospital
quadrant and Murphy’s sign is
stay, and decreased costs.
positive.
The morbidity and mortality of
early and elective
The investigation of choice is the
cholecystectomy are similar.
ultrasound which will show the stones
in the gallbladder, the stone impacted
CHOLEDOCHOLITHIASIS
in the cystic duct, the thick walled
gallbladder and the point of maximal (Stones in the common bile duct)
tenderness. The abdominal
radiograph may show the gallstones if Choledocholithiasis occurs in 10-15%
they are radio-opaque. There is of patients with gallstones. Stones in
usually a leucocytosis of between 10 the common bile duct usually originate
and 15,000. The liver function tests in the gallbladder, although there is an
are usually normal. entity of primary duct stones.