Gallstones are found in 12% men and 24% women
Prevalence increases with advancing age
10-20% become symptomatic
Over 10% of those with stones in the gallbladder have stones in the common bile duct
40,000 cholecystectomies are performed annually in UK
More than 4,000 common bile ducts are cleared of stones
Mixed stones are probably a variant of cholesterol stones
10% of gallstones are radio-opaque
Cholesterol stones result from a change in solubility of bile constituents
Bile acids act as a detergent keeping cholesterol in solution
Bile acids, lecithin and cholesterol result in the formation of micelles
Bile is often supersaturated with cholesterol
This favours the formation of cholesterol microcrystals
Biliary infection, stasis and changes in gallbladder function can precipitate stone
Bile is infected in 30% of patients with gallstones
Gram-negative organisms are the most common isolated
- 90% cases result from obstruction to the cystic duct by a stone
- Increased pressure within the gallbladder results in an acute inflammatory response
- Secondary bacterial infections occurs in 20% of cases of acute cholecystitis
- Most common organisms are E. coli, Klebsiella and strep. faecalis
- Constant pain (usually greater than 12 hours duration) in right upper quadrant
- Fever, tachycardia
- Tenderness in right upper quadrant
- Murphy's sign - guarding in right upper quadrant on deep inspiration
- Ultrasound is the initial investigation of choice
- Diagnostic features on ultrasound include
- Presence of gallstones
- Distended thick-walled gallbladder
- Pericholecystic fluid
- Murphy's sign demonstrated with ultrasound probe
- If diagnostic doubt a HIDA scan may be useful
- Will show failure of isotope (hydroxyiminodiacetic acid) uptake by gallbladder
- Initial management is usually conservative
- Patient is fasted, given intravenous fluids and opiate analgesia
- Intravenous antibiotics (e.g. second generation cephalosporin) should be given to prevnt secondary
- 80% patients improve with conservative treatment
- If fit, should be considered for a laparoscopic cholecystectomy
- Timing of surgery is controversial
- Evidence now suggests that early surgery (<72 hours) is safe
- Has low conversion rate
- Avoids the complications of conservative treatment failure
- If patient unfit for surgery, percutaneous cholecystotomy my be beneficial
- Particularly useful in acalculus cholecystitis
Complications of acute cholecystitis
- Gangrenous cholecystitis
- Gallbladder perforation
- Cholecystoenteric fistula
- Gallstone ileus
Picture provided by Mr J C Campbell, Derriford Hospital, Plymouth
Treatment of gallbladder stones
First open cholecystectomy performed by Langenbuch in Berlin in 1882
Throughout this century open cholecystectomy has been associated with significant
Today mortality is approximately 0.5%
Specific complications - bile duct damage, retained stones, bile leak
General complications - wound dehiscence, pulmonary atelectasis
Lead to the development of 'mini' cholecystectomy through a 5 cm transverse incision
Laparoscopic cholecystectomy introduced in 1988
High complication rate
Poor long-term results
Extra-corporeal shock wave lithotripsy
Routine use of nasogastric tubes and catheter controversial
CO2 pneumo-peritoneum induced using either Veress needle or open technique
Open (Hasson) technique is believed to be safer
Over half of bowel injuries are caused by Veress needles or trocars
Abdominal pressure set to 12-15 mm Hg
High intra-abdominal pressure can:
Surgery usually performed using 4 standard ports (2 x10 mm & 2 x 5 mm)
Patient positioned with head up tilt and rolled to the left
Calot's triangle dissected using a retrograde technique
Cystic duct and artery identified
Ligated with clips or endo-loops
About 50% surgeons routinely use intra-operative cholangiography
Laparoscopic surgery in acute cholecystitis
In those with acute cholecystitis operation has usually been deferred 6-8 weeks
Recently shown that early laparoscopic cholecystectomy is safe
Associated with reduced conversion rate
Trend towards early surgery during first admission
Potential future improvements
Dennison A R, Azoulay D,
Oakley N et al. What should I do about my patients gall
stones. Postgrad Med J 1995; 71: 725-729.
Downs S H et al.
Systematic review of the effectiveness and safety of laparoscopic cholecystectomy.
Ann R Coll Surg 1996; 78: 241 - 324.
Darzi A, Gould S.
Minimally invasive surgery. In: Johnson C D, Taylor I eds. Recent advances in Surgery 22.
Churchill Livingston 1999; 63-72.
Chitre V V, Studley J G N.
Audit of methods of laparoscopic cholecystectomy.
Br J Surg 1999; 86:
Cuschieri A. How I do it:
laparoscopic cholecystectomy. J R Coll Surg Ed 1999; 44: 187-192.
Geoghegan J G, Keane F B.
Laparoscopic management of complicated gallstone disease. Br
J Surg 1999; 86:
Indar A A, Beckingham I J. Acute cholecystitis. Br Med J
2002; 325: 639-643
Kiviluoto T, Siren J,
Luukkonen, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis.
Lancet 1998; 351: 321-325.
Lomas D J, Gimson A. Magnetic resonance cholangiopancreatography. Hosp
Med 2000; 61: 395-399.
Parks R W. Biliary tract emergencies. Hosp Med 2002; 63:
Perrisat J. Management of bile duct stones
in the era of laparoscopic cholecystectomy. Br J Surg 1994.
81; 799 - 810.
Paterson-Brown S. Emergency laparoscopic surgery.
Br J Surg 1993; 80: 279 - 281.
Svanvik J. Laparoscopic cholecystectomy for acute cholecystitis. Eur J Surg 2000;
166 (Suppl 585): 16-17.
Tait N, Little J M.
The treatment of gall stones. Br
Med J 1995; 311: 99-105.