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CHOLELITHIASIS

Shoofii Dzakiyyah Ulhaq

Preceptor:
dr. Liza Nursanty, Sp.B, M.Kes, FinaCS
BASIC SCIENCE
ANATOMY OF GALLBLADDER
 The gallbladder is a pear-shaped sac, about 7 to 10
cm long, with capacity of 30 to 50 mL.
 Location in a fossa on the inferior surface of the liver.
 The gallbladder is divided into four anatomic areas:
 the fundus  (rounded, 1-2 cm long, contains
smooth muscles)
 the corpus (body)  (the main storage area and
contains most of the elastic tissue. extends from the
fundus and tapers into the neck that connects with
the cystic duct. )
 the infundibulum,
 the neck  a gentle curve, the convexity of which
may be enlarged to form the infundibulum or
Hartmann’s pouch that extends into the free portion
of the hepatoduodenal ligament
Vascularization
Venous Drainage
• Cystic veins join
the right branch of the
portal vein.
• The veins of
the fundus and body of
the gallbladder pass
directly into the liver.
Lymphatic Drainage
Gallbladder
lymph node

Cystic lymph
node

Hepatic
lymph node

Coeliac
lymph node
Innervation
• Sympathic  Celliac
plexus nerve
• Parasympathic  CN-X
HISTOLOGY OF GALL BLADDER
• Mucosa
• Simple columnar epithelium
• Lamina propria  the
tubuloalveolar glands
• Muscularis
 Thin, contains circular
longitudinal and oblique
fibers muscle
• Serosa
• External adventitia
• Perimuscular subserosa
contains connective tissue,
nerves, vessels, lymphatics,
and adipocytes
PHYSIOLOGY OF BILE
• Bile formed in the hepatic lobules • Function of bile:
is secreted into a complex network
of canaliculi, small bile ductules, • Digestion and absorption
and larger bile ducts with total
daily secretion is 500-600 Because bile acids can:
ml/day. • Emulsification large fat
• Major salute components of bile:
• Bile acids (80%),
particles into small
• Lecithin and traces of phospholipids particles
(16%),
• Absorption of last fat
• Unesterified cholesterol (4.0%),
• Conjugated bilirubin, product which ingested
• Proteins, from intestine mucosal
• Electrolyte, membrane
• Mucus,
• Drugs and their metabolites. • Waste product excretion
 bilirubin and
cholesterol ↑
PHYSIOLOGY OF BILE
• Secretion
Hepatocyte secreting bile  1st secretion: bile acid, cholesterol, others
organic components  secreted into bile canaliculi  bile ductules  bile
ducts  hepatic duct  common bile duct  gallbladder  duodenum
• Storage
Bile secretion  storage in gallbladder because water, natrium, chloride,
small electrolyte absorbed in gallbladder  remnant concentrations: bile
salt, cholesterol, lechitin, bilirubin
• Emptying gallbladder
Fatty foods reach the duodenum (30 minutes after eat) small intestine gets
stimulation to secreting CCK hormones  gallbladder wall contracts
ritmically which helped by ACh from vagal nerve  ↑ bile flow to common
bile duct  Sphincter of Oddi is relaxation  ↑ bile flow to duodenum
CHOLELITHIASIS
DEFINITION
 Cholelithiasis is the
disease presence of
stones (gallstones) in
the gallbladder and /
or in the ductus
 Cholecystolithiasis is
stone that formed in
gallbladder
 Primer
 Sekunder
EPIDEMIOLOGY
• Worldwide prevalences  11-36%.
• Quite prevalent in most Western countries.

• Women has 3x greater prevalence than Men.

• 1st degree relatives of patients with gallstones have

2x greater prevalence.
• Peak incidence  > 40 years old.
ETIOLOGY
 Imbalance of bile salts, lecithin (stabilizer), diluted
substances (cholesterol, calcium carbonate, bilirubin),
and gallbladder stasis.
RISK FACTORS
• Chronic hemolytic
Fat anemias
• Crohn disease
Family Female
history
• Terminal ileal resection

6Fs • Gastric surgery

Fair- Fertile • Genetics


skinned
• Activity
Forty
• Food
PATHOGENESIS

Cholesterol
(80%) Black
Gallstone (10%)
Pigmented
(20%) Brown
(10%)
Cholesterol Gallstone
 Shaped oval, multifocal or
mulberry contains more than
70%
 Cholesterol gallstone > 90%
are cholesterol, 10%
(calcium carbonat, calciu
palmitrat, and calcium
bilirubinar)
 Pure cholestrol stones are
rare
Pigmented Gallstone (BROWN)
 BROWN GALLSTONE
 Colored brown / dark
brown, soft, easy to
destroy and contains
calcium-bilirubinat (main
component)
 Due to  stasis factor +
bile duct infection
 Stasis: Oddi sphincter dysfunction, stricture,
biliary surgery, and parasitic infections
 Bile duct infections, (E. Coli), glucoronidase
(bacterial) enzyme levels  hydrolysis 
free bilirubin & glucoronic acid. Calcium +
bilirubin  calcium bilirubinate (not
soluble)
Pigmented Gallstone (BLACK)

 BLACK GALLSTONE
 Black / brownish black
powder and rich in
unextracted black
residues
 Many are found in
patients with chronic
hemolysis or cirrhosis
of the liver
PATHOGENESIS
• Abnormal hepatic cholesterol metabolism  ↑ cholesterol
concentration in bile + ↓ bile salts & lecithin  ...
• Hypersaturated bile  biliary sludge  cholesterol stone or mixed stones
• Bile acids malabsorption  cholesterol precipitation
• Gallbladder hypomotility & bowel rest  bile stasis
• Other stone type:
• Black pigmented stone
↑ hemolysis  hypersaturation of bilirubin  bilirubin precipitation &
stone formation
• Brown pigmented stone  calcium carbonate stone
Caused by bacteria, biliary parasites, and stasis
Post prandial or
night
Biliary colic
May radiate to
the epigastrium,
right shoulder
Nausea
Assymptomatic
(60-80%)
Clinical Vomiting
Features
Symptomatic
Feelings of
satiety

Bloating

Dyspepsia
DIAGNOSTICS

Assymptomatic Mild RUQ Laboratory

DIAGNOSTICS
HISTORY TAKING

PHYSICAL EXAMINATION
Symptomatic tenderness • WBC, liver function
during an test  normal (in
• Biliary colic episode of pain uncomplicated
• Nausea gallstones)
• Vomiting Radiographic
• Feelings of • USG  shows
gallstones with
satiety posterior accoustic
• Bloating shadow, possible
sludge
• Dyspepsia
Cholecystography

Contrast for standard diagnostics  look


gallbladder under USG/CT
Principle :
Patient don’t eat fatty food or any food
for 6 hours. Than, patient took a contrast
tablet  dissolved and absorption in
liver  secretion to bile duct

Purpose :
1. Clinical Patology of Gallbladder
2. Condition ofcystic duct & common
bile duct
CT Scan

CT Scan Examination

• Location of Stoness
• Existence of obstruction
• Dilatation of cystic duct and
common bile duct
• Complication  Ruptur of
gallbladder
ERCP (Endoscopic Retrograde Cholangio
Pancreatography)
Prosedur: sebuah kanul yang
dimasukan ke dalam duktus
koledukus dan duktus pancreatikus
→ bahan kontras disuntikkan ke
dalam duktus tsb.

 Function:
1. Facilitates direct visualization of biliary structures and facilitates access to the distal bile
ducts to remove gallstones
2. Distinguish jaundice-induced jaundice, jaundice of cellular hepato & jaundice induced
biliary obsInvestruction
3. Investigate gastro intestinal symptoms in patients whose gall bladder has been removed
TREATMENTS

CONSERVATIVE SURGICAL

• Fasting or dietary • Laparoscopic


modification (decreased cholecystectomy
fat intake) • Gold standard treating
• Spasmolytics
symptomatic cholelithiasis
• Indications:
• Analgesia
• Presence of symptoms
• Presence of prior complication
• Presence of underlying condition
predisposing complication
CONSERVATIVE TREATMENT
Lisis batu dengan obat-obatan Disolusi kontak

Terapi disolusi dengan asam


ursodeoksilat untuk melarutkan Prinsip :
batu empedu kolesterol PTC (Percutaneous transhepatic
dibutuhkan waktu pemberian obat cholangiogram) pelarut kolesterol
6-12 bulan dan diperlukan langsung kekandung empedu.
monitoring hingga dicapai disolusi.

Melalui kateter yang diletakkan


Terapi efektif pada ukuran <1 cm perkutan langsung ke kantung
dengan angka kekambuhan 50% empedu
dalam 5 tahun Prosedur ini invasif dan kerugian
utamanya adalah angka
kekambuhan yang tinggi.
Litotripsi (Extarcorporeal Shock
Wave Lithotripsy = ESWL)

 Indication
 Stones larger than 5 mm + Persistent pain
not resolved with adequate anelgetic
treatment
 The presence of persistent obstruction with
the risk of kidney damage
 Infection of the urinary tract,
 Bilateral obstruction
OPERATIVE TREATMENT
 Indication
Urgency (within 24-72 hours)
 Acute cholecystitis
Open cholecystectomy
 Cholecystitis emphysema

 Empyema of the gallbladder

 Perforation of the gallbladder

 History of Choledocholithiasis

 Elective
 Diskinesia biliaris
 Chronic cholecystitis
 Symptomatic cholelithiasis
Laparoscopic Cholecystectomy
CBD Exploration with T Tube Insertion
Transduodenal Sphincterotomy

Indication

 Impacted stone in
ampulla
 Papillary stenosis
 Multiple stone with
nondilatated duct
COMPLICATIONS

Chronic
Inflammatory Mechanical Gallbladder
Inflammation
• Cholecystitis • Gallbladder • Formation of
• Cholangitis perforation porcelain
• Gallbladder • Gallstone ileus gallbladder
empyema • Gallstone • Shrunken
• Gallbladder pancreatitis gallbladder
gangrene • Mirrizi syndrome • Gallbladder
• Liver abscess cancer
PROGNOSIS
• Quo ad vitam: ad bonam
• Quo ad sanationam: dubia ad bonam
• Quo ad functionam: ad bonam
REFERENCES
• Moore, Keith L, dkk. 2010. Clinically Oriented Anatomy Sixth
Edition. Philadelphia: Lippincot Williams & Wiskins.
• Mescher, Anthony L. Junqueira’s Basic Histology: Text and
Atlas, 12e. Mc-Graw-Hill Companies.
• Guyton, Arthur C., John E. Hall. 2006. Textbook of Medical
Physiology, 11e. Philadelphia: Elsevier Saunders.
• Kasper, Denis L, dkk. Harrison’s Principle of Internal Medicine
16th e. 2005. USA: Mc-Graw-Hill Companies, Inc.
• Brunicardi, Charles, dkk. 2006. Schwartz’s Manual of Surgery
8th Edition. USA: McGraw-Hill Companies.
• Sjamsuhidajat, R., Wim de Jong. 2010. Buku Ajar Ilmu Bedah.
Jakarta: EGC.
THANKS FOR YOUR
ATTENTION