Gallstones. Farhad Zamani Prof. of Gastroenterology and Hepatology IUMS,GILDR Firoozgar Hospital December 2017

Transcription

1 Gallstones Farhad Zamani Prof. of Gastroenterology and Hepatology IUMS,GILDR Firoozgar Hospital December

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14 Gallstones Gallstones are composed of a mixture of cholesterol, calcium billirubinate, proteins, and mucin. GB stone classified as: Cholesterol, with small amounts of calcium and bilirubin salts Brown pigment stones are associated with bacterial and helminthic infection of the biliary system, in the bile ducts, prior biliary manipulation Black pigment stones result from hemolysis and consist primarily of calcium billirubinate 14

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16 prevalence Prevalence of gallstones is higher in Western Caucasian, Hispanic, and Native American populations than in Eastern European, African American, and Asian populations. In the United States: 6 percent of men 9 percent of women 16

17 Prevalence in Iran Maserat, et al in southern Iran : reported that the average gallstone rate in asymptomatic subjects was 4.7% Toosi, et al. in eastern Iran reported that the average gallstone rate in asymptomatic subjects was 4.4%, respectively. 17

18 18 Prevalence in Iran

19 Thyroid dysfunction and choleduocholithiasis Middle East J Dig Dis Jul;5(3): Thyroid dysfunction and choleduocholithiasis. Ajdarkosh H 1, Khansari MR 1, Sohrabi MR 1, Hemasi GR 1, Shamspour N 1, Abdolahi N 1, Zamani F 1. Author information Abstract BACKGROUND: Disturbances in lipid metabolism which occur during hypothyroidism leadto the formation of gallstones. This study aims to evaluate the thyroid functionpattern in patients with common bile duct (CBD) stones. METHODS: This case-control study recruited 151 patients with preliminary diagnosesof CBD stone who underwent ERCP (cases). The control group comprisedhealthy people who met the study criteria in the same hospital. The controlgroup underwent ultrasonography to exclude any asymptomatic bile duct lithiasis.a questionnaire that included demographic and anthropometrics datawere completed by an assigned physician. Morning blood samples that followed12 hours of fasting were taken from all participants for measurements ofserum total thyroxin (T4), serum thyroid stimulating hormone (TSH), fastingblood sugar (FBS), triglycerides (TG), total cholesterol, low density lipoprotein(ldl) and high density lipoprotein (HDL). RESULTS: The mean TSH in patients (2.59 ± 4.86mg/dl) was higher than the controlgroup (2.53± mg/dl). In subclinical hypothyroidism, serum TSH levelshigher than 5 MU/L were found in 30.6% of cases compared with 22.5% ofcontrols [OR: 1.53; 95 % confidence interval (95% CI): ). Hypothyroidismwas detected in 10.8% of the control group and in 11.3% of cases(or: 1.87; 95% CI: ). The mean total cholesterol levels in caseswas higher than the control group (p=0.61).the levels of TG (p=0.05), HDL(73.35 vs ; p<0.01) and LDL ( vs ; p<0.01) was statisticallysignificant between both groups. CONCLUSION: There is an association between thyroid disorders and the presence of bile duct stones

20 20 Major risk factors

21 Approach to patient with incidental gallstone 21

22 NATURAL HISTORY Majority of patients with incidental gallstones will not develop symptoms Approximately 15 to 25 % will become symptomatic during up to 10 to 15 years of follow-up 22

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24 Biliary colic The classic description of biliary colic is: An intense, dull discomfort located in the RUQ, epigastrium, or (less often) substernal area that may radiate to the back Despite its name, the pain is usually steady and not colicky. The pain is often associated with diaphoresis, nausea, and vomiting, not associated with position or motion The pain typically lasts at least 30 minutes, plateauing within an hour and then gradually decrease, lasting less than six hours 24

25 CLINICAL FEATURES Biliary colic is usually caused by the gallbladder contracting in response to hormonal or neural stimulation, forcing a stone (or possibly sludge) against the gallbladder outlet or cystic duct opening, leading to increased intra-gallbladder pressure. This increase in pressure then results in pain. 25

26 CLINICAL FEATURES Eating a fatty meal is a common trigger for gallbladder contraction, and many patients report postprandial pain. However, an association with meals is not universal, and in a significant proportion of patients the pain is nocturnal 26

27 Atypical symptoms Chest pain Nonspecific abdominal pain Belching Fullness after meals/early satiety Fluid regurgitation Abdominal distension/bloating Epigastric or retrosternal burning Nausea or vomiting without biliary colic 27

28 DIFFERENTIAL DIAGNOSIS Esophageal chest pain Gastroesophageal reux disease Peptic ulcer disease Nonulcer dyspepsia Hepatitis Functional gallbladder disorder Sphincter of Oddi dysfunction Chronic pancreatitis Irritable bowel syndrome Ischemic heart disease Pyelonephritis Ureteral calculi acute cholecystitis, choledocholithiasis, acute pancreatitis, and acute cholangitis 28

29 CLINICAL FEATURES the chance of recurring biliary colick is 30 % per year in the first two years the chance of developing complications is approximately 2 to 3% per year. Once a complication develops, the chance of having additional, often more severe, complications is 30% per year 29

30 CLINICAL FEATURES Laboratory studies: should be normal in patients with uncomplicated gallstone disease, both during asymptomatic periods and during attacks of pain. Abnormal blood tests suggest the development of a complication 30

31 Diagnosis Ultrasound: gallstones appear as echogenic foci with acoustic shadow and seek gravitational dependency "Gravel" is the appearance of multiple small stones that are echogenic and cast shadows. Sludge is echogenic in appearance but does not cast an acoustic shadow 31

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35 DIAGNOSIS Stone detection by sono: sensitivity 84 % specificity 99 % Modern sonographic equipment is able to detect stones as small as 1.5 to 2 mm Smaller stones may be missed, and the sensitivity falls to 50 to 60 % for stones less than 3 mm 35

36 DIAGNOSIS In patients with typical biliary colic but no gallstones on ultrasonography, repeat the transabdominal ultrasound in a few weeks. If the repeat transabdominal ultrasound is negative, the patient may have microlithiasis or may be a category 4 patient (typical biliary symptoms without gallstones on ultrasound). 36

37 DIAGNOSIS EUS: If the transabdominal ultrasound is negative in a patient with biliary colic, additional studies that may help with the diagnosis include endoscopic ultrasound (EUS) and bile microscopy The sensitivity and specicity of EUS for detecting cholelithiasis are 96 and 86 %, respectively The more definitive approach is to proceed with EUS to look for missed stones or sludge 37

38 DIAGNOSIS Several studies have demonstrated that EUS is useful for the detection of small stones and microlithiasis In in whom there was a clinical suspicion of cholelithiasis but with at least two normal transabdominal ultrasound examinations, EUS detected evidence of cholelithiasis in 58 % 38

39 Characteristics of stones on ultrasound Patients with uncomplicated gallstone disease may have ultrasound findings of gallstones, gravel, or sludge. False-negative or misleading results may be obtained if the gallbladder is completely filled with stones or if it is contracted around many stones 39

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41 DIAGNOSIS False- positive results may be seen if gallbladder polyps are present since they produce sonographic images similar to those seen with gallstones, though they do not cast an acoustic shadow 41

42 Imaging Gallstones are rarely seen on plain abdominal radiographs because only approximately 10% of gallstones contain enough calcium to make them sufficiently radio-opaque to be visible on a plain radiograph 42

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44 Approach to patient with Uncomplicated gallstone 44

45 Uncomplicated gallstone Uncomplicated gallstone disease refers to stones in the gallbladder that are associated with biliary colic in the absence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis. 45

46 CATEGORIZATION OF PATIENTS Category 1: Gallstones on imaging studies but without symptoms Category 2: Typical biliary symptoms and gallstones on imaging studies with no evidence of complications Category 3: Atypical symptoms and gallstones on imaging studies Category 4: Typical biliary symptoms but without gallstones on ultrasound 46

47 CATEGORIZATION OF PATIENTS category 1 should generally be left alone category 2 should undergo cholecystectomy Optimal approaches for categories of 3 and 4 are less clear. 47

48 MANAGEMENT Category 2 patients (typical biliary symptoms and gallstones) Pain management : During an acute attack of biliary colic, management is focused on pain control. Pain control can usually be achieved with NSAID, opioids and Ketorolac Those with prolonged attacks should also receive intravenous hydration. 48

49 MANAGEMENT Although meperidine may be a narcotic of choice in patients with biliary colic or gallstone pancreatitis because it has less of an effect on sphincter of Oddi motility than morphine However, a systematic review found that all opioids result in increased sphincter of Oddi pressure when measured using sphincter of Oddi manometry Thus, there are insufficient data to suggest that morphine should be avoided in patients with biliary colic. In addition, morphine has the benefit of having a longer half-life than meperidine. 49

50 MANAGEMENT Category 3 patients (gallstones but atypical symptoms) Some patients with atypical symptoms and gallstones respond to cholecystectomy, but the response rates are lower than those seen for patients with typical biliary colic. An empiric trial of oral dissolution therapy with ursodeoxycholic acid (UDCA) may help identify patients who will benfiet from cholecystectomy 50

51 MANAGEMENT Category 4 patients (typical biliary symptoms but without gallstones on ultrasound) If cholecystokinin stimulated cholescintigraphy reveals a low gallbladder ejection fraction,( a finding that is suggestive of functional gallbladder disorder,) the appropriate treatment is cholecystectomy. 51

52 52 Prophylactic cholecystectomy

53 MANAGEMENT Prophylactic cholecystectomy is not indicated for most patients with asymptomatic gallstones. Patients can typically be managed expectantly and referred for cholecystectomy if symptoms subsequently develop. 53

54 MANAGEMENT Prophylactic Cholecystectomy is indicated for: Patients at increased risk for gallbladder cancer Anomalous pancreatic ductal drainage (in which the pancreatic duct drains into the common bile duct) Gallbladder adenomas Porcelain gallbladder Large gallstones ( if larger than 3 cm) some patients with hemolytic disorders Gastric bypass 54

55 MANAGEMENT Hemolytic disorders : Patients with sickle cell disease and hereditary spherocytosis have a high incidence of forming pigment gallstones (50 % or more) perform a cholecystectomy if the patient has gallstones and a splenectomy for hereditary spherocytosis. 55

56 MANAGEMENT Gastric bypass : Morbidly obese patients who have undergone gastric bypass surgery have a high incidence of developing gallstones (greater than 30%) A prophylactic cholecystectomy at the time of the bypass is recommended by some (regardless of whether gallstones are present) 56

57 MANAGEMENT Patients with diabetes mellitus may be at increased risk for the development of severe gangrenous cholecystitis However, the magnitude of the risk and the risks and costs of cholecystectomy do not warrant prophylactic cholecystectomy in patients with asymptomatic gallstones. 57

58 Gallstone complication Acute cholecystitis ( most common ) Rare complications include gallbladder cancer gallstone illeus Mirizzi syndrome 58

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62 Indication For Surgery Symptomatic gallstone Biliary colic Acute cholecystitis Complex gallstone Gallstone pancreatitis Choledocholithiasis Mirizzi syndrome Cholecystoduodenal fistula Acalculous cholecystitis Incidental gallbladder cancer Prophylactic cholecystectomy in especial groups

63 63 Dissolution therapy

64 Dissolution therapy Dissolution therapy may be an alternative to cholecystectomy in selected patients with a view either to eliminating stones or reducing the risk of further complications who are: Symptomatic Poor surgical candidates Refuse surgery 64

65 medical management Three non-surgical approaches have been described: Oral bile salt therapy ( UDCA) Contact dissolution Extracorporeal shockwave lithotripsy 65

66 Dissolution therapy Only oral dissolution therapy remains a practical clinical approach for a small subset of patients with cholesterol gallstone disease who are not surgical candidates. Contact dissolution therapy is no longer used due to concerns about the safety of methyl tert butyl ether (MTBE) ESWL has also fallen out of favor but may be used in association with oral dissolution therapy 66

67 Dissolution therapy Patients selected for oral bile acid therapy should have the following characteristics Small stone size (<0.5 to 1 cm) Mild symptoms Good gallbladder function Minimal calcication and low density on CT % clear after 1-2 years prevents symptoms, even in patients in whom gallstone dissolution is incomplete 67

68 Gallstone recurrence Approximately 15 % of patients will recur by one year, and 45 % will recur by five years The risk appears to be highest in those with multiple stones and in whom the time to complete dissolution was longest 68

69 Approach to Gallstones in pregnancy 69

70 Gallstones in pregnancy After acute appendicitis, acute cholecystitis is the second most common non-obstetrical indication for surgery in pregnant women 70

71 Gallstones in pregnancy Gallstones are more common during pregnancy due to: decreased gallbladder motility (progesterone) increased cholesterol saturation of bile: Estrogen: increases cholesterol secretion Progesterone: reduces bile acid secretion These changes normalize one to two months following delivery. 71

72 PERSONAL RISK FACTORS The major independent risk factor for gallstones is : prepregnancy obesity multiparous Increasing age genetic background 72

73 INCIDENCE AND COURSE IN PREGNANCY New stone or sludge formation 7-10 % 1.2 % developed symptom during pregnancy Serious complication in <10% of symptomatic In the postpartum period, sludge resolved in 61 % and 30 % of stones smaller than 10 mm 73

74 Management In first episode of biliary colic only supportive care, lead to resolution of symptoms in most cases, but the symptoms frequently recur later in pregnancy Recurrent biliary colic suggest cholecystectomy Cholecystectomy can be performed safely and electively during any trimester of pregnancy. 74

75 75 Thanks For Your Attention