CHRONIC CHOLECYSTITIS

Particulars of the patient:

Name: Salma Khatun

Age: 40 years

Sex: Female

Religion: Islam

Marital status: Married

Occupation: Housewife

Address: Fulpur, Mymensingh

Date and time of admission: 08.02.17; 09.00am

Date and time of examination: 09.02.17;08.30am

Chief complaints:

1. Pain in right upper abdomen for 1 years.

2. Occasional fever and vomiting for 6 months.

History of present illness:

According to the statement of the patient, she was reasonably well 1 year back. Then she
developed pain in right upper abdomen which is colicky in nature, radiating to back of right side
of chest, aggravated by fatty foods and relieved by medication, associated with nausea. Patient
has similar attacks of pain for last 1year initially at an interval of 3–4 months, but for last one
month patient is having dull aching constant pain in right upper half of abdomen. Occasionally,
pain is associated with vomiting for last 6 months. She used to vomit 2-3 times daily, projectile
in nature, vomitus containing partially digested foods, bile stained, bitter in taste. There is history
of fever intermittently with chill and rigor with the attack of pain for last 6 months, which
subsided with anti-pyretic. She has no HO blood transfusion, IV drug use, tattooing (To exclude
hepatitis), no itching sensation (To exclude obstructive jaundice). She has no HO loss of
appetite, weight loss and frequent passage of loose stool (Exclude chronic pancreatitis). Her
bladder habit is normal. She has no history of cough, chest pain, coughing out blood, yellow
colouration skin or eye, passage of black stool or bone pain.

History of past illness:

She has no H/O DM, HTN, heart disease, asthma, tuberculosis.
Personal history:
Patient is non- smoker, non alcoholic (To exclude chronic pancreatitis)
Immunization history:

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 She is immunized as per EPI schedule. He is not immunized against HBV. (For surgeon’s
safety)
Socioeconomic history:
She belongs to a middle class family, lives in semi-pakka house and drinks tube-well
water, uses sanitary latrine.
Family history:
All other members of his family are enjoying good health.
Menstrual history: If Female
Age of menarche: 12 years
Menstrual cycle: 28+_2 days
Menstrual period: 4-5 days
LMP: 02.02.17
Menstrual flow: Average
Age of last child: 12 years
Drug history:
She took some tablets from local quack but could not mention the names.
General examination:
Appearance: Anxious/ill looking/normal
Body built: Average
Cooperation: Cooperative
Decubitus: On choice
Nutritional status: Average
Jaundice: Absent
Anaemia: +
Cyanosis: Absent
Pulse: 102/min
BP: 130/80 mm of Hg
Temperature: 1000 F
Respiratory rate: 14/min
Skin condition: Scratch mark over chest and abdomen
Clubbing: Absent
Leuconychia: Absent
Koilonychia: Absent
Dehydration: Present
Oedema: Absent
Thyromegaly: Absent
Neck vein: Not engorged
Lymph node: Not palpable
Hernial orifice: Intact
IV cannula, NG tube, catheter: In situ, If present (Usually absent)

Abdominal examination:
Inspection :
Shape: Scaphoid
Movement with respiration: Abdomino thoracic (Male)/ Thoraco abdominal (Female)
Umbilicus: Centrally placed, inverted and vertically slitted
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 Scratch mark: Absent
No scar mark, engorged vein, visible peristalsis, fullness in right hypochondrium (due to
distended gallbladder: Can be seen in very thin patients)

Palpation:
Temperature: Not raised
Tenderness: Non-tender
No palpable mass, muscle guard or hyperesthesia
Murphy‟s sign: Negative
Liver, spleen, kidney, UB: Not palpable

Percussion:
 Tympanic
 Fluid thrill and shifting dullness absent
Auscultation: Bowel sound present
DRE: Revealed no abnormality

Nervous system examination: Revealed no abnormality

Respiratory system examination: Revealed no abnormality
CVS examination: Revealed no abnormality

Salient feature:

Mrs. Salma Khatun, 40 years old married, muslim, non-smoker, non-alcoholic, non
diabetic, normotensive housewife, hailing from Fulpur, Mymensingh admitted to SU-III, MMCH
with the complaints of pain in right upper abdomen for year which is colicky in nature, radiating
to back of right side of chest, aggravated by fatty foods and relieved by medication, associated
with nausea. Patient has similar attacks of pain for last 1year initially at an interval of 3–4
months, but for last one month patient is having dull aching constant pain in right upper half of
abdomen. Occasionally, pain is associated with vomiting for last 6 months. She used to vomit 2-
3 times daily, projectile in nature, vomitus containing partially digested foods, bile stained, bitter
in taste. There is history of fever intermittently with chill and rigor with the attack of pain for last
6 months, which subsided with anti-pyretic. She has no HO blood transfusion, IV drug use,
tattooing, no itching sensation (To exclude obstructive jaundice). She has no HO loss of appetite,
weight loss and frequent passage of loose stool. Her bladder habit is normal. Her bladder habit is
normal. She has no history of cough, chest pain, haemoptysis, jaundice, melaena or bone pain.
On general examination, he is anxious, ill looking, co-operative, average body built and
nutritional status. Pulse 102/min, BP 130/80, RR 14/min, temperature normal, no dehydration
and oedema. He is non-anaemic, non-ecteric, no cyanosis, no lymphadenopathy, thyromegaly,
engorged vein.

On abdominal examination, abdomen is scaphoid shaped, umbilicus is centrally placed,

no scar mark, engorged vein, no scratch mark. On palpation, temperature normal, no tenderness

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present, no palpable mass, Murphy’s sign negative, no organomegaly. Tympanic on percussion
and bowel sound present. Digital rectal examination reveals no abnormality. Other system
examination reveals normal.

Provisional diagnosis: Chronic cholecystitis

Differential diagnoses:
 PUD
 Chronic pancreatitis

Investigations:
Investigation:
For diagnosis: USG of HBS with pancreas:
 Gall bladder is smaller and wall is thickened
 Bright echogenic structure with posterior acoustic shadow (Gall stones)
To exclude DD: Upper GI endoscopy (PUD)
Routine:
1. CBC
2. Urine RME
3. RBS
4. S. Creatinine
5. CXR
6. ECG
7. HBs Ag
Treatment: Cholecystectomy. This may be-
 Open
 Laparoscopic

Why do you say that it is a case of Chronic cholecystitis?

1. Female patient
2. Age 40 years
3. Recurrent attack of colicky pain in rt hypochondriac region
4. Abdominal discomfort after taking fatty food
5. Fever during attack of pain
What are your DDs?
 PUD
 Chronic pancreatitis
Why do you say PUD?
 Recurrent attack of upper abdominal pain
 Vomiting associated with pain
Why not PUD ?
1. Recurrent attack of pain in rt hypochondriac region
2. Fever during attack of pain
Why do you say Chronic pancreatitis?
 Recurrent attack of upper abdominal pain
 Radiation of pain to back
 Vomiting associated with pain

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Why not Chronic pancreatitis?
 Colicky pain in rt hypochondriac region
 Fever during attack of pain
 No HO DM, malabsorption and weight loss

Murphy‟s sign:
 Patient in sitting posture
 Place the right hand just below the right costal margin on the lateral border of right rectus
and moderate pressure is exerted with finger to palpate gall-bladder
 Now ask the patient to take a deep breath in, the gallbladder descends and hurts the
examining finger, the patient will wince with catching pain if organ is inflamed.
When do you find Murphy‟s sign is positive?
Murphy’s sign is positive in acute cholecystitis. In chronic cholecystitis Murphy’s sign is
not positive.
For more curiosity:
How ultrasonography helps in diagnosis of biliary tract disease?
Ultrasonography is a reliable investigation for evaluation of biliary tract disease.
1. Gallbladder:
Size of the gallbladder: Whether gallbladder is normal sized, contracted or distended
Walls of the gallbladder: Normal wall thickness or any thickening of wall
Intraluminal calculi: Intraluminal calculi may be seen as a bright echogenic structure
with posterior acoustic shadow.
Any associated mass: In gallbladder may be seen.
2. Common bile duct:
 The upper end of common bile duct may be seen and its diameter may be measured.
 Any intraluminal calculi in the bile duct lumen may be seen.
 However, stone at lower end of bile duct may sometimes be missed on
ultrasonography.
3. Liver:
 Liver may be seen well and any solid or cystic lesion in the liver may be ascertained.
 Any dilatation of the intrahepatic biliary radicles may be seen well.
4. Pancreas:
 The pancreas may be seen and any mass in relation to the pancreas may be seen well.
 The diameter of the pancreatic duct may be measured.
 Any calculus in the pancreatic duct or parenchymal calcification may be seen.
 The parenchymal echo texture may be seen clearly and chronic or acute pancreatitis
may be diagnosed.

When will you consider doing an ERCP or MRCP in patient with gallstone disease?
1. If there is suspicion of stone in the common bile duct on USG examination.
2. If there is history of jaundice or the patient is having jaundice.
3. If LFT shows elevation of serum enzymes—ALT, AST and Alkaline phosphatase.
4. Ultrasonography shows dilatation of common bile duct.

What are the advantages and disadvantages of MRCP?

Advantages of MRCP:

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 1. Can give very good picture of the entire biliary tree.
2. Noninvasive investigation, no radiation exposure, no dye is required.
3. Biliary tract dilatation, any obstruction due to stone or growth may be ascertained.
Disadvantages of MRCP: It has only diagnostic value as no intervention is possible.

What are the advantages and disadvantages of ERCP?

Advantages of ERCP:
1. Therapeutic intervention like sphincterotomy and stone extraction or biliary stenting is
possible.
2. Biopsy from periampullary lesion or brush cytology from the bile duct may be taken.
3. Bile aspirated may be used for exfoliative cytology.

Disadvantages of ERCP:
1. Invasive investigation: Requires introduction of a gastroduodenoscope, cannulation of
bile and pancreatic duct and injection of a dye.
2. Postprocedure cholangitis or pancreatitis: Chance of postprocedure cholangitis or
pancreatitis, which may be life threatening.

Which one will you prefer-open or laparoscopic cholecystectomy?

Laparoscopic cholecystectomy
Why do you prefer laparoscopic cholecystectomy?
Laparoscopic cholecystectomy has been established as gold standard for the treatment of
gallstone diseases because:
1. Surgery is safe in the hands of a trained surgeon
2. Less pain, less hospital stays
3. Cosmetic
4. Early return to work is possible
5. More acceptance by the patient.

While you take consent for laparoscopic cholecystectomy what consent should be taken?
1. Informed consent is to be taken.
2. Patient should be explained that if laparoscopic procedure is not safe it may need
conversion to open cholecystectomy.
Describe the steps of laparoscopic cholecystectomy?
1. The patient is placed supine on the operating table.
2. Following induction and maintenance of general anaesthetic, the abdomen is prepared in
a standard fashion.
3. Pneumoperitoneum is established.
4. An open subumbilical cutdown with direct visualisation of the peritoneum to place the
initial port. This port will function as the camera port. An angled telescope (30°) is
preferred. Many surgeons use a ‘closed’ technique using a Verres needle to establish
pneumoperitoneum prior to placing the initial trocar.
5. Additional operating ports are inserted in the subxiphoid area and in the right subcostal
area.
6. Another port in RIF is also made (Not written in book but practically done)

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 7. The patient is placed in a reverse Trendelburg position slightly rotated to the left. This
exposes the fundus of the gall bladder which is retracted towards the diaphragm.
8. The neck of the gall bladder is then retracted towards the right iliac fossa exposing
Calot’s triangle.
9. This area is laid widely open by dividing the peritoneum on the posterior and on the
anterior aspect.
10. The cystic duct is carefully defined, as is the cystic artery. The gall bladder is separated
from the liver bed for about 2 cm to allow for confirmation of the anatomy.
11. Once the anatomy is clearly defined and the triangle of Calot has been laid widely open,
the cystic duct and artery are clipped and divided.
12. The gall bladder is then removed from the gall bladder bed by sharp or cautery dissection
and once free removed via the umbilicus.
[Baily and Love-26th -1110]
Which gas is used to produce pneumoperitonium and why?
CO2
Because, it is non-inflammable, cost-effective, absorbed by blood.
Can O2 be used?
No, because it can make fire during electro cautery
How many ports are made? Mention their functions?
1. Umbilical port: 10cm. 1st port to be made.
Function:
 Establishment of pneumoperitonium.
 This port will function as the camera port.
 Extraction of GB
2. Epigastric port: 10cm.
Function: Functioning port- Surgeon operates through this port
3. Right hypochondrium: 5 cm.
Function: Functioning port- Surgeon operates through this port
4. RIF: 10cm.
Function: Assistant holds the GB through this port.

Port-related complications of lapchole:

 Injury to gut
 Injury to major blood vessels i.e. inferior vena cava, abdominal aorta
 Adhesion
 Seedling of Ca to abdominal wall

What are the incisions for open cholecystectomy?

1. Right subcostal incision (Kocher’s incision)
2. Right upper paramedian incision
3. Midline incision
4. Mayo Robson’s incision. Right paramedian with extension to midline
5. Upper abdominal transverse incision

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What is cystic pedicle?
It is the two layers of peritoneum covering the cystic duct and the cystic artery and
extends from the neck of the gallbladder to the lesser omentum.
What is mini-cholecystectomy?
 Open cholecystectomy done through a small right subcostal incision of about 5 cm is
called minicholecystectomy.
 This is a good technique with very little postoperative pain, shorter hospital stay and it
has been claimed to be comparable to laparoscopic cholecystectomy.

Indications for choledochotomy:

1. Palpable duct stones
2. Jaundice or a history of jaundice or cholangitis
3. A dilated common bile duct (more than 1 cm)
4. Abnormal liver function tests, in particular a raised alkaline phosphatase.
5. Gallbladder contains a single facetted stone with cystic duct dilatation
6. Intraoperative cholangiogram shows a stone in common bile duct
[Baily and Love-26th -1110+Lecture of MMC]
Post-cholecystectomy‟ syndrome:
In up to 15 per cent of patients, cholecystectomy fails to relieve the symptoms for which
the operation was performed. Such patients may be considered to have a ‘post-cholecystectomy’
syndrome.
However, such problems are usually related to the preoperative symptoms and are merely a
continuation of those symptoms.
Management:
 Full investigation should be undertaken to confirm the diagnosis and exclude the
presence of a stone in the bile duct, a stone in the cystic duct stump or operative damage
to the biliary tree.

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  This is best performed by MRCP or ERCP, the latter which has the added advantage that
if a stone is in the common bile duct it can be removed.
[Baily and Love-26th -1111]

Acalculous cholecystitis:
Acute and chronic inflammation of the gall bladder can occur in the absence of stones
and give rise to a clinical picture similar to calculous cholecystitis is known as acalculous
cholecystitis.
Some patients have non-specific inflammation of the gall bladder, whereas others have
one of the cholecystoses.
The diagnosis is often missed and the mortality rate is high.
Predisposing factors for development of acalculous cholecystitis:
 Critically ill patients in intensive therapy unit
 Following major surgery, trauma or burns.
[Baily and Love-26th -1108]

Cholesterosis („strawberry gall bladder‟):

 There is deposition of cholesterol crystals in the submucosa and they may appear as
yellow specks and the interior of the gallbladder looks like a strawberry.
 In the fresh state, the interior of the gall bladder looks something like a strawberry; the
yellow specks (submucous aggregations of cholesterol crystals and cholesterol esters)
correspond to the seeds. It may be associated with cholesterol stones.
[Baily and Love-26th -1108]

Lithogenic bile:
 In normal bile the cholesterol, phospholipids and bile salts remain in optimum
concentration. This keeps the cholesterol in solution.
 Bile supersaturated with cholesterol is known as lithogenic bile as this predisposes to
gallstone formation.
What do you mean by silent gallstone?
Incidentally found gallstones during examination for other pathology or in routine health
check- up that does not produce symptoms are called silent gallstones.

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 GALL BLADDER
SURGICAL ANATOMY AND PHYSIOLOGY:

Gall bladder:
Position:
 Underside of the liver in the main liver scissura at the junction of the right and left lobes
of the liver.
 The relationship of the gall bladder to the liver varies between being embedded within the
liver substance to being suspended by a mesentry.
Size-Shape: Pear-shaped structure, 7.5–12 cm long.
Capacity: About 25–30 mL.
Anatomical divisions:
1. A fundus
2. A body
3. A neck
4. A narrow infundibulum.
Histology:
 The muscle fibres in the wall of the gall bladder are arranged in a criss-cross manner,
being particularly well developed in its neck.
 The mucous membrane contains indentations of the mucosa that sink into the muscle
coat; these are the crypts of Luschka.
[Baily and Love-26th -1097]

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Cystic duct:
Length: About 3 cm in, but the length is variable.
Diameter: Lumen is usually 1–3 mm
Valves of Heister: The mucosa of the cystic duct is arranged in spiral folds known as the ‘valves
of Heister’
Sphincter of Lütkens: Wall is surrounded by a sphincteric structure called the ‘sphincter of
Lütkens’.
Communication:
 The cystic duct joins the supraduodenal segment of the common hepatic duct in 80 per
cent of cases.
 Occasionally, the cystic duct may join the right hepatic duct or even a right hepatic
sectorial duct.
[Baily and Love-26th -1097]

Common hepatic duct:

Length: Usually less than 2.5 cm long
Formation: By the union of the right and left hepatic ducts.
The cystic artery, a branch of the right hepatic artery, usually arises behind the common
hepatic duct.

Common bile duct:

Length: About 7.5 cm long
Formation: Junction of the cystic and common hepatic ducts.
Divisions: Four parts:
1. Supraduodenal portion: About 2.5 cm long, running in the free edge of the lesser
omentum.
2. Retroduodenal portion
3. Infraduodenal portion: Lies in a groove, but at times in a tunnel, on the posterior
surface of the pancreas.
4. Intraduodenal portion: Passes obliquely through the wall of the second part of the
duodenum, where it is surrounded by the sphincter of Oddi, and terminates by opening on
the summit of the ampulla of Vater.

[Baily and Love-26th -1097-98]

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Calot‟s triangle or the hepatobiliary triangle:
 This was described in 1891 by Jean-François Calot.
 It is an important surgical landmark and should be identified by surgeons performing a
cholecystectomy to avoid damage to the extrahepatic biliary system.
Boundary:
Inferiorly: Cystic duct
Medially: Common hepatic
On other arm of triangle: Superior border of the cystic artery.
[Baily and Love-26th -1097-98]
Lymphatics:
Subserosal and submucosal:
 Drain into the cystic lymph node of Lund (the sentinel lymph node), (which lies in the
fork created by the junction of the cystic and common hepatic ducts).
 Efferent vessels from this lymph node go to the hilum of the liver, and to the coeliac
lymph nodes.
 Subserosal lymphatic vessels of the gall bladder also connect with the subcapsular lymph
channels of the liver, (and this accounts for the frequent spread of carcinoma of the gall
bladder to the liver.)
[Baily and Love-26th -1098]
Surgical physiology:
Bile:
 Produced by the liver and stored in the gall bladder from which it is released into the
duodenum.
 The liver excretes bile at a rate estimated to be approximately 40 mL/hour.
 About 95 per cent of bile salts are reabsorbed in the terminal ileum (enterohepatic
circulation).

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Composition: As it leaves the liver, it is composed of
1. Water: 97 per cent
2. Bile salts:
 Cholic and cheno- deoxycholic acids
 Deoxycholic and lithocholic acids
3. Phospholipids
4. Cholesterol
5. Bilirubin
[Baily and Love-26th -1098-99]
Functions Of The Gall Bladder:
1. Reservoir for bile:
 During fasting, resistance to flow through the sphincter of Oddi is high, and bile
excreted by the liver is diverted to the gall bladder.
 After feeding, the resistance to flow through the sphincter is reduced, the gall
bladder contracts and the bile enters the duodenum.
 Hormone responsible: Cholecystokinin.
2. Concentration of bile:
 By active absorption of water, sodium chloride and bicarbonate by the mucous
membrane of the gall bladder.
 The hepatic bile which enters the gall bladder becomes concentrated 5–10 times,
with a corresponding increase in the proportion of bile salts, bile pigments,
cholesterol and calcium.
3. Secretion of mucus:
 Approximately 20 mL is produced per day.
 With complete obstruction of the cystic duct in an otherwise healthy gall bladder,
a mucocoele may develop as a result of ongoing mucus secretion by the gall
bladder mucosa.
[Baily and Love-26th -1099]

CHRONIC CHOLECYSTITIS
Commonest complication of gall stone
Clinical features are due:
 Inflammation of gall bladder: Chronic cholecystitis
 Obstruction of gateway of gall bladder by impaction of gall stone in Hartman pouch:
Acute on chronic cholecystitis
Management:
Symptoms:
1. Pain:
 In right upper quadrant or epigastrium
 Colicky
 May radiate to the back
 Associated with nausea and vomiting
 Exacerbated by heavy meal
 Relieved by antispasmotic or spontaneously
 Varying degree of severity i.e. slight discomfort to excruciating
 Periodic i.e. 4-6 week interval

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 2. Fever: During attack of pain
3. Heart burn, acidity, flatulence and sensation of fullness after meal
Sign:
1. Murphy‟s sign: Negative
2. On deep palpation:
 There may be mild tenderness on right hypochondrium
 Gall bladder is not palpable
D/Ds:
 PUD
 Chronic pancreatitis
Investigation:
For diagnosis:
USG of HBS with pancreas:
 Gall bladder is smaller and wall is thickened
 Bright echogenic structure with posterior acoustic shadow (Gall stones)
To exclude DD: Upper GI endoscopy (PUD)
Routine:
8. CBC
9. Urine RME
10. RBS
11. S. Creatinine
12. CXR
13. ECG
14. HBs Ag
Treatment: Cholecystectomy. This may be-
 Open
 Laparoscopic
[Ward class of MMC + Lecture of MMC]

ACUTE CHOLECYSTITIS
Symptoms:
1. Pain: Present in 10–25 per cent of patients.
 In right upper quadrant or epigastrium
 Colicky, but more often is dull and constant
 May radiate to the back
 Associated with nausea and vomiting
 Relieved by antispasmotic or spontaneously
 Lasting for few minute to hour
2. Other symptoms:
 Dyspepsia
 Flatulence
 Food intolerance, particularly to fats, and some alteration in bowel frequency.
Sign:
On GE:
Fever
Restless

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 Tachycardia
Dehydrated
Jaundice
Per abdomen:
3. Tenderness and rigidity: In right hypochondrium
4. Murphy‟s sign: Positive
5. Palpable tender mass in right hypochondrium: Formed by inflamed GB and greater
omentum.
Differential diagnosis of acute cholecystitis:
Common:
 Appendicitis
 Perforated peptic ulcer
 Acute pancreatitis
Rare:
 Acute pyelonephritis
 Myocardial infarction
 Pneumonia – right lower lobe

Investigations: [For viva-mention first 2]

1. CBC: Leukocytosis
2. USG of hepatobilliary system with pancreas: To confirm the diagnosis
Findings:
 If stone present: Bright echogenic structure with posterior acoustic shadow
 GB wall is thickened
 Pericholecystic oedema
3. Liver function test: If jaundice present
4. Plain X-ray abdomen erect posture including both dome of diaphragm:
-To see radio-opaque shadow (10%)
-To exclude perforation of gas containing hollow viscus
5. Hepatic imino diacetic scan (HIDA scan)
Treatment:
A. Conservative measures: Non-operative treatment is based on four principles:
1. Nil per mouth (NPO) and IV fluid: Until the pain resolves.
2. Analgesics
3. Antibiotics:
 As the cystic duct is blocked in most instances, the concentration of
antibiotic in the serum is more important than its concentration in bile.
 A broad-spectrum antibiotic effective against Gram-negative aerobes is
most appropriate (e.g. cefazolin, cefuroxime or gentamicin).
4. Subsequent management:
 When the temperature, pulse and other physical signs show that the
inflammation is subsiding: Oral fluids are reinstated followed by regular
diet.
 If the pain and tenderness increase:
 Conservative treatment must be abandoned
 Operative intervention and cholecystectomy
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  if the patient has comorbid conditions: Percutaneous
cholecystostomy can be performed by a radiologist under
ultrasound control.
B. Surgery: Cholecystectomy may be performed after approximately 6 weeks.
[Baily and Love-26th -1108+Lecture of MMC]
What are the sequelae of acute cholecystitis?
1. Resolution: Inflammation subsides and patient recovers.
2. Mucocele
3. Empyema gall bladder
4. Gangrene: Infection may lead to gangrenous change in gallbladder manifested by
increasing pain, toxemia and appearance of rebound tenderness.
5. Perforation of gallbladder: Perforation may be:
 Localized: Localized abscess formation manifested by severe pain, fever with chill and
rigors, and extreme tenderness in right upper quadrant of abdomen.
 Generalized perforation: Leading to generalized biliary peritonitis manifested by
generalized pain abdomen, muscle guard or rigidity and extreme tenderness all over
abdomen. Perforation into a neighboring viscus most commonly duodenum, stomach or
colon.
[Bedside Clinics in Surgery-2nd-131-32]
Site of perforation:
1. At the fundus, which is farthest away from the blood supply
2. At the neck from pressure necrosis of an impacted calculus

GALLSTONES (CHOLELITHIASIS)

Cholecystectomy one of the most common operations performed by general surgeons. :-D

Causal factors in gallstone formation:

Gallstones can be divided into three main types:
1. Cholesterol: Cholesterol or mixed stones contain 51–99 per cent pure cholesterol plus an
admixture of calcium salts, bile acids, bile pigments and phospholipids.
2. Pigment: Pigment stone is the name used for stones containing less than 30 per cent
cholesterol. 2 types:
a. Brown: Rare in the gall bladder. They form in the bile duct and are related to bile
stasis and infected bile.
 Contain calcium bilirubinate, calcium palmitate and calcium stearate, as well
as cholesterol.
 Stone formation is related to the deconjugation of bilirubin deglucuronide by
bacterial glucuronidase. Insoluble unconjugated bilirubinate precipitates.
 Brown pigment stones are also associated with the presence of foreign bodies
within the bile ducts, such as endoprosthesis (stents), or parasites, such as
Clonorchis sinensis and Ascaris lumbricoides.
b. Black:
 Largely composed of an insoluble bilirubin pigment polymer mixed with
calcium phosphate and calcium bicarbonate.

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  Associated with haemolysis, usually hereditary, spherocytosis or sickle
cell disease.
3. Mixed stones
In the United States and Europe, 80 per cent are cholesterol or mixed stones, whereas in
Asia, 80 per cent are pigment stones.
[Baily and Love-26th -1106-07]
Pathophysiology of stone formation:
 Cholesterol, which is insoluble in water, is secreted from the canalicular membrane in
phospholipid vesicles.
 Whether cholesterol remains in solution depends on the concentration of phospholipids
and bile acids in bile, and the type of phospholipid and bile acid.
 Micelles formed by the phospholipid hold cholesterol in a stable thermodynamic state.
 When bile is supersaturated with cholesterol or bile acid concentrations are low, unstable
unilamellar phospholipid vesicles form, from which cholesterol crystals may nucleate,
and stones may form.
[Baily and Love-26th -1106]
Causes of gall stone formation:

For understanding purpose only:

 The process of gallstone formation is complex, and many areas remain unclear.
 Obesity, high caloric diets and certain medications (e.g. oral contraceptives) can increase
secretion of cholesterol and supersaturate the bile increasing the lithogenicity of bile.
 Resection of the terminal ileum, which diminishes the enterohepatic circulation, will
deplete the bile acid pool and result in cholesterol supersaturation.
 Nucleation of cholesterol monohydrate crystals from multilamellar vesicles is a crucial
step in gallstone formation.
 Abnormal emptying of the gall bladder function may aid the aggregation of nucleated
cholesterol crystals.
[Baily and Love-26th -1106-07]
Management:
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Clinical presentation: Usually patient present with features of acute or chronic cholecystitis.
Impaction of stone in the neck: FO acute cholecystitis
Due to inflammation of GB: FO chronic cholecystitis
Symptoms:
1. Asymptomatic: Being detected incidentally as imaging is performed for other
symptoms.
2. Pain: Present in 10–25 per cent of patients.
 In right upper quadrant or epigastrium
 Colicky, but more often is dull and constant
 May radiate to the back
 Associated with nausea and vomiting
 Relieved by antispasmotic or spontaneously
 Lasting for few minute to hour
3. Other symptoms:
 Dyspepsia
 Flatulence
 Food intolerance, particularly to fats, and some alteration in bowel frequency.
Sign:
1. Jaundice: May result if the stone migrates from the gall bladder and obstructs the
common bile duct.
2. Fever: Due to cholecystitis or cholangitis
3. Murphy‟s sign: Positive in acute acute cholecystitis, negative in chronic cholecystitis.
Investigations:
1. CBC: Leukocytosis
2. USG of hepatobilliary system with pancreas: To confirm the diagnosis.
Findings: Bright echogenic structure with posterior acoustic shadow
3. MRCP: If jaundice is present, an is performed to exclude choledocholithiasis.
1. Routine:
 RBS
 [Link]
 CXR PA view
 ECG
 Urine RME
Treatment:
 Observe patients: With asymptomatic gallstones
 Acute cholecystitis: Rx of acute cholecystitis
 Chronic cholecystitis: Rx of chronic cholecystitis

Effects and complications of gallstones:

In GB:
1. Biliary colic
2. Acute cholecystitis
3. Chronic cholecystitis
4. Empyema of the gall bladder
5. Mucocoele
6. Perforation

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In CBD and pancreas:
1. Biliary obstruction
2. Acute cholangitis
3. Acute pancreatitis
In intestine: Intestinal obstruction (gallstone ileus)

[Baily and Love-26th -1107+Lecture of MMC]

Why it is necessary to remove GB instead of removing only stones?
Abnormal emptying of the gall bladder function may aid the aggregation of nucleated
cholesterol crystals; hence, removing gallstones without removing the gall bladder inevitability
leads to gallstone recurrence.
[Baily and Love-26th -1106]

Prophylactic cholecystectomy: May be considered for

1. Diabetic patients
2. Congenital haemolytic anaemia
3. Patients undergoing bariatric surgery for morbid obesity: As it has been found in
these groups that the risk of developing symptoms is increased.
[Baily and Love-26th -1108]
Saint‟s triad:
1. Gall stone
2. Diverticulosis of colon
3. Hiatus hernia
Nucleation:
Is a process by which cholesterol monohydrate crystal forms and aggregates.

MUCOCELE OF GALL BLADDEE/HYDROPS OF GB / RAMS HORN

Definition:
It may be defined as the distension of gall bladder by a clear watery mucinous secretion
due to total obstruction of the cystic duct.
Pathogenesis:
When there is obstruction to the cystic duct or the neck of the gallbladder by a stone or a
growth then the contained bile in the gallbladder is absorbed by the gallbladder epithelium and is
replaced by mucus secreted by the gallbladder epithelium. The content is usually a clear sterile
fluid.
Aetiology: Obstruction due to any cause-
 Stone in the cystic duct (most commonly)
 Neoplasia involving the cystic duct ie cholangio carcinoma (in 10% cases)
 Kinking of the duct
Macroscopically:
1. Hugely distended
2. Thin walled
3. Normal colour
4. Vascular markings
5. Stone at the neck
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Microscopically: Mucosa becomes atrophied having no columnar or cuboidal cell.
Clinical feature:
1. Usually asymptomatic or any feature of chronic cholecystitis
2. Painless ,palpable ,non-tender gall bladder without jaundice.
Investigation: USG of HBS & pancreas:
 GB is enlarged, thin walled
 May contain single or multiple bright echogenic structure casting an acoustic shadows
Treatment: Cholecystectomy

EMPYEMA OF THE GALL BLADDER/ PYOCELE / SUPPURATIVE

CHOLECYSTITIS
Definition:
It is the condition in which gall bladder is filled up with frank pus
Pathogenesis:
Empyema may be a sequel of acute cholecystitis or the result of a mucocoele becoming
infected. The gall bladder is distended with pus. In 50% cases the contained pus is sterile.

Aetiology:
1. Acute cholecystitis
2. When a mucocele becomes infected.
Source of infection:
1. Ascending infection
2. Local infection (Liver infection)
3. Cystic artery
4. Portal vein
Macroscopically:
1. Gall bladder is enlarged, bright red, green violet in colour.
2. Wall is thick, opaque, lustreless
3. Vessel can not be seen
4. Serosa is covered by fibrinous exudate
Management:
Clinical feature:
Symptoms:
1. Pain
2. Fever with Chills, rigor
3. Nausea & vomiting
Signs:
1. Patient is toxic
2. Raised temperature
3. Tachycardia
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 4. Localised tenderness and muscle guarding
5. A tender lump may be palpable
Investigation:
1. CBC: Polymorphonuclear lcukocytosis
2. USG of HBS and pancreas
Treatment:
A. Conservative:
1. NPO
2. NG suction
3. IV fluid
4. Analgesic
5. Parenteral antibiotic
B. Observation for 24-48 hours: Monitor pain, Pulse, temperature, general condition
1. If improvement: Continue conservative management, cholecystostomy(drainage)
and interval cholecystectomy after 6-8 weeks.
2. If condition deteriorates: Emergency cholecystectomy
[Baily and Love-26th -1108+Lecture of MMC]

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 OBSTRUCTIVE JAUNDICE (DUE TO CHOLEDOCHOLITHIASIS)
Particulars of the patient:

Name: Mushfiqur Rahim

Age: 30 years

Sex: Male

Religion: Islam

Marital status: Married

Occupation: Farmer

Address: Fulpur, Mymensingh

Date and time of admission: 28.01.17; 09.00am

Date and time of examination: 28.01.17;08.30am

Chief complaints:

1. Pain in left loin for 21 days.

2. Fever for same duration.
3. Yellow coloration of eye and skin for same duration.

History of present illness:

According to the statement of the patient, he was reasonably well 21 days back. Then he
developed pain in right upper abdomen which is colicky in nature, radiating to back of right side
of chest, aggravated by fatty foods and relieved by medication, associated with nausea and
occasional vomiting. There is history of fever intermittently with chill and rigor with the attack
of pain for last 1 months, which subsided with anti-pyretic. Patient complains of yellowish
discoloration of eyes, skin and urine for last 21 days. The onset of jaundice was preceded by an
attack of pain, yellowish discoloration was increasing in intensity initially, but during last one
week the intensity of yellowish discoloration is diminishing. Patient complains of itching all over
the body and passing clay colored stool for same duration. He has no history of repeated blood
transfusion, consanguinal marriage of parents (Exclude jaundice due congenital haemolytic
anaemia), no history of contact with jaundice patient, bowel- bladder habit is normal (Exclude
hepatic jaundice). He gave no history of weakness, pallor, weight loss, chest pain, cough,
haemoptysis, bone pain or haematemesis (General and metastatic features of Ca: To exclude Ca
of head of pancreas and periampullary carcinoma).

History of past illness:

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 He has no H/O DM, HTN, heart disease, asthma, tuberculosis. He has no history of
previous gallbladder surgery (may lead to bile strictures and jaundice.)

Personal history:
Patient is non- smoker, non alcoholic, no history of IV drug using and no extramarital
sexual exposure. (To exclude hepatocellular jaundice)
Immunization history:
He is not immunized against HBV. (For surgeon’s safety)
Socioeconomic history:
He belongs to a middle class family, lives in semi-pakka house and drinks tube-well
water, uses sanitary latrine.
Family history:
All other members of his family are enjoying good health.
Menstrual history: If Female
Age of menarche: 12 years
Menstrual cycle: 28+_2 days
Menstrual period: 4-5 days
LMP: 02.02.17
Menstrual flow: Average
Age of last child: 12 years
Drug history:
He took some tablets from local quack but could not mention the names.
General examination:
Appearance: Anxious/ill looking/normal
Body built: Average
Cooperation: Cooperative
Decubitus: On choice
Nutritional status: Average
Jaundice: +++ (May be absent. Because there is intermittent jaundice)
Anaemia: Absent
Cyanosis: Absent
Pulse: 102/min
BP: 130/80 mm of Hg
Temperature: 1000 F
Respiratory rate: 14/min
Skin condition: Scratch mark over chest and abdomen
Clubbing: Absent
Leuconychia: Absent
Koilonychia: Absent
Dehydration: Present
Oedema: Absent
Thyromegaly: Absent
Neck vein: Not engorged
Lymph node: Not palpable
Hernial orifice: Intact
IV cannula, NG tube, catheter: In situ, If present

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Abdominal examination:
Inspection :
Shape: Scaphoid
Movement with respiration: Abdomino thoracic (Male)/ Thoraco abdominal (Female)
Umbilicus: Centrally placed, inverted and vertically slitted
Scratch mark: Present all over the abdomen.
No scar mark, engorged vein, visible peristalsis, fullness in right hypochondrium (due to
distended gallbladder: Can be seen in very thin patients)

Palpation:
Temperature: Not raised
Tenderness: Non-tender
No palpable mass, muscle guard or hyperesthesia
Murphy‟s sign: Negative
Liver, spleen, kidney, UB: Not palpable

Percussion:
 Tympanic
 Fluid thrill and shifting dullness absent
Auscultation: Bowel sound present
DRE: Revealed no abnormality

Nervous system examination: Revealed no abnormality

Respiratory system examination: Revealed no abnormality
CVS examination: Revealed no abnormality

Salient feature:
Md. Kurban Ali, 30 years old, muslim, non-smoker, non-alcoholic, non diabetic,
married farmer, hailing from Muktagancha, Mymensingh admitted to MMCH with complaints of
pain right hypochondrium which is colicky in nature, radiating to back of right side of chest,
aggravated by fatty foods and relieved by medication, associated with nausea and occasional
vomiting. There is history of fever intermittently with chill and rigor with the attack of pain for
last 1 months, which subsided with anti-pyretic. Patient complains of yellowish discoloration of
eyes, skin and urine for last 21 days. The onset of jaundice was preceded by an attack of pain,
yellowish discoloration was increasing in intensity initially, but during last one week the
intensity of yellowish discoloration is diminishing. Patient complains of itching all over the body
and passing clay colored stool for same duration. He has no history of repeated blood
transfusion, consanguinal marriage of parents, no history of contact with jaundice patient, no
H/O extramarital sexual exposure or IV drug use. bowel- bladder habit is normal. He gave no
history of weakness, pallor, weight loss, chest pain, cough, haemoptysis, bone pain or
haematemesis. All other members of his family are well.

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 On general examination, patient is ill looking, average body built and nutrition,
cooperative. Pulse 102/min, BP 130/80 mm of Hg, RR 14/min, temperature 1010F. Patient is
severely ecteric but non-anaemic. Scratch marks are present over chest and abdomen. Clubbing,
leuconychia, koilonychia, dehydration, oedema, thyromegaly absent. Neck vein not engorged,
lymph nodes not palpable, hernial orifice intact.
On abdominal examination, abdomen is scaphoid shaped, umbilicus is centrally placed,
no scar mark, engorged vein but scratch mark present all over the abdomen. On palpation,
temperature normal, no tenderness present, no palpable mass, Murphy’s sign negative, no
organomegaly. Tympanic on percussion and bowel sound present. Digital rectal examination
reveals no abnormality. Other system examination reveals normal.

Provisional diagnosis: Obstructive jaundice due to choledocholithiasis

Differential diagnoses:
 Periampullary Ca
 Ca head of pancreas

Investigations:
For diagnosis:
1. USG of whole of abdomen
2. Liver function tests:
 [Link] (Not a LFT actually)
 [Link]
 SGPT
 ALP
 PT with INR (International normalization ratio)

Routine investigations for GA fitness:

1. CBC
2. RBS
3. [Link]
4. CXR PA view
5. ECG
6. Urine RME
7. HBs Ag (For surgeons safety)

Confirmatory diagnosis: Obstructive jaundice due to choledocholithiasis

Treatment:
Cholecystectomy with choledocholithotomy with T-tube insertion (Must be said
accordingly maintaining the serial)

Why do you say that it is a case of obstructive jaundice?

6. Yellow colouration of sclera (/eye), skin
7. High colour urine and pale stool
8. Itching sensation
9. Scratch marks present
Why due to stone in common bile duct?

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 1. Painful
2. Fever
3. Intermittent jaundice
Why not due to Ca of head pancreas?
In such case there should be -
3. Painless
4. Progressive jaundice
Why not due to periampullary Ca?
In such case there should be -
1. Painless
2. Fluctuating jaundice

How does palpable gall bladder feel?

When distended it can be felt as tense globular swelling projecting downwards and forwards
from below the liver just lateral to the outer border of rectus muscle (Below the 9th rib tip)
 Moves with respiration
 Upper limit continuous with liver
 Can be moved slightly from side-to-side.
Murphy‟s sign:
 Patient in sitting posture
 Place the right hand just below the right costal margin on the lateral border of right rectus
and moderate pressure is exerted with finger to palpate gall-bladder
 Now ask the patient to take a deep breath in, the gallbladder descends and hurts the
examining finger, the patient will wince with catching pain if organ is inflamed.

Cause of palpable gallbladder :

1. Mucocele
2. Empyema
3. Obstructive jaundice due to carcinoma pancreas
4. Carcinoma of gallbladder

Courvoisier‟s Law:
In a patient with jaundice if there is a palpable gallbladder it is not due to stones on
common bile duct.

Explanation:
 In pathology of gallbladder like calculus cholecystitis there will be fibrosis of the
gallbladder and hence it can not enlarge if there is a distal obstruction.
 But if the pathology is there outside gallbladder due to CBD carcinoma, pancreatic
carcinoma you can palpate the gallbladder.

Exceptions to this Law:

 Double impaction of stone—one in CBD and other in cystic duct
 Oriental cholangiohepatitis
 Pancreatic calculus obstructing ampulla of vater

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  Mucocele due to stone in cystic duct
SURGICAL JAUNDICE (OBSTRUCTIVE JAUNDICE)
Definition:
Jaundice due to mechanical obstruction to the biliary tree, usually in the common bile
duct which can be corrected surgically.
[Lecture of MMC]
Causes:
A. In the lumen:
1. Stone
2. Round worm
B. In the wall:
1. Stricture:
 Post-operative
 Sclerosing cholangitis
 Congenital atresia
2. Cholangiocarcinoma
C. Outside the wall:
1. Periampullary carcinoma
2. Ca of head of pancreas
Common causes:
 Choledocholitiasis
 Periampullary carcinoma
 Ca of head of pancreas
[Lecture of MMC]
Common Bile Duct Stones:
Primary:
 Formed in bile duct itself
 Brown pigment stones
Secondary: Formed in gallbladder and enters CBD (Cholesterol stones).

Surgical approach to case of jaundice:

A. First identify the type of jaundice: Haemolytic, hepatocellular or obstructive
Haemolytic:
 Usually at young age
 Mild jaundice
 Anaemia = +
 Organomegaly= Hepatosplenomegaly
Hepatocellular:
 Mild to severe jaundice
 Fever
 Pain in right hypochondrium
Obstructive:
 Severe jaundice
 May be associated with pain and fever
B. Locate the site of obstruction:
1. Stone of CBD:
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  Painful
 Fever
 Intermittent jaundice: When obstructs jaundice present. But when pressure of
bile increases, multifaceted stone rotate and bile passes by causing disappearance
of jaundice.
2. Ca of head pancreas:
 Painless
 Progressive jaundice: As tumour enlarges and causes increasing pressure
effect causing progressively increasing jaundice.
3. Periampullary Ca:
 Painless
 Fluctuating jaundice: As the mass increases more rapidly than angiogenesis,
there is necrosis of growing part. So, jaundice reduces but doesn’t touch the
baseline. When mass grows again, jaundice increases.
[Lecture of MMC]
Management:
A. Symptoms:
1. Pain:
 In right hypochondrium
 Colicky in nature
 Radiating to inferior angle of scapula or tip of righr shoulder
 Aggravated by fatty foods and relieved by medication
 Associated with nausea and occasional vomiting.
2. Fever: Intermittent fever with chills and rigor if cholangitis develops.
3. Jaundice:
 Intermittent (If due to stone)/ Progressive (If due to Ca of head pancreas)/
Fluctuating (Periampullary Ca)
 Generalized itching, more in trunks and extremities
 Dark coloured urine
 Pale offensive bulky stool which float on water (In the pan)
B. On GE:
Anaemia: May be present in malignancy
Jaundice (See in symptoms)
Temperature: May be raised in cholangitis
Skin condition: Scratch mark over chest and abdomen
Dehydration: Present
Lymph node: Palpable in malignancy
Per abdomen:
Tenderness in right hypochondrium
Lump in epigastrium: Ca head of pancreas
Gall bladder:
Palpable: Ca head of pancreas
Impalpable: Choledocholithiasis
Liver: May be enlarged in malignancy
Ascites: Present in malignancy
DRE: Pelvic deposition may be present in Ca of head of pancreas

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Investigations:
Specific:
A. USG of HBS and pancreas:
Findings: Dilated CBD proximal to obstruction
B. Liver function tests:
1. Serum bilirubin: Total, conjugated and unconjugated bilirubin
 Increased direct bilirubin (Suggests obstructive type)
2. ALP: Elevated > 10 times normal is strongly suggestive of obstruction
3. Gamma-glutamyl transferase: Simultaneous elevation confirms obstruction
(increases up to 40 fold)
Sources of gamma-glutamyl transferase:
 Hepatocyte
 Bile duct epithelium
 Reticuloendothelial system
 Placenta
 Testes and ovary
4. Prothrombin time with INR (International Normalized Ratio): Vitamin K is fat
soluble vitamin, absorption of which requires presence of bile salts in intestine
which is absent in patients with obstructive jaundice due to obstruction. So,
reduced absorption of vit K dependent clotting factor leads to prolonged PT.
5. SGPT and SGOT: Normal or slightly raised
C. Ba-meal X-ray: To see Ca head of pancreas.
 Widening of C curve
 Duodenul appearance inverted three sign
 Irregular filling defect of duodenum: Rose thorn pattern
D. Endoscopic retrograde cholangiopancreatography (ERCP): When USG shows
dilated extrahepatic biliary tree but cause is unknown.
E. Magnetic resonance cholangiopancreatography (MRCP)
F. CT scan of abdomen: More specific in detecting the level of obstruction and the
cause of obstruction than ultrasound.
G. PTC (Percutaneous transhepatic cholangiopancreatography): When USG shows
dilated intrahepatic biliary tree but cause is unknown.

Routine:
1. CBC
2. Urine RME
3. RBS
4. S. Creatinine
5. S. calcium
6. CXR
7. ECG
8. HBs Ag
Treatment:
A. Preoperative preparation in a case with obstructive jaundice:
Metabolic problems in a patient with obstructive jaundice:

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 1. Malnutrition
2. Increased incidence of infection: Because static bile is highly infective
3. Bleeding tendency due to deficit of vitamin K
4. Renal problems: Increased chance of renal failure in postoperative period
(hepatorenal syndrome).
Causes:
 Gram-negative endotoxemia (Most common cause)
 Decreased intravascular volume
 Kidneys are more sensitive to ischemia
 Bile salt deposition in the renal tubules
 Anemia
 Diminished carbohydrate reserve
 Dehydration
Preoperative preparation involves correction of the above metabolic abnormalities
to reduce the development of postoperative complications.
1. Nutritional improvement:
 High CHO intake
 Oral glucose
 In unable to take then IV glucose
2. Correction of coagulopathy:
 In. Vit K (Konakion) IM daily for 5 days.
 If PT with INR not corrected then repeat the schedule
 If still not corrected, administer fresh frogen plasma
 Transfusion of fresh frozen plasma
3. Prevention and control of infection: 3rd generation cephalosporin+Metronidazole
4. Correction of dehydration and maintenance of renal function:
 Plenty of fluids by mouth.
 On day of operation, IV fluid is to be started from morning.
 Continuous catheterization
 In case of inadequate urine output frusemide or mannitol may be administered.
 Avoid nephrotoxic drugs

B. Surgery:
 Choledocholitiasis: Cholecystectomy with choledocholithotomy with T-tube
insertion (Must be said accordingly maintaining the serial)
 Periampullary carcinoma and Ca of head of pancreas: Whipple’s procedure
[Lecture of MMC+Rajamahendran-1st-126-132+Bedside clinics in surgery-2nd-136-150]

What structures will you remove in Whipple‟s operation?

Whipple’s pancreaticoduodenectomy involves excision of following structures:
1. Whole of duodenum up to 10 cm of proximal jejunum
2. Head and neck of pancreas including uncinate process
3. Distal 40–50% of stomach
4. Lower end of common bile duct (CbD)
5. Gallbladder
6. Pericholedochal, periduodenal and peripancreatic lymph nodes.

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 [Bedside clinics in surgery-2nd-136]
ERCP: Gold Standard for CBD Stone Removal
Other uses:
1. Stenting for inoperable tumors
2. Endoscopic basketting and stone retrieval
3. Biopsy
4. Preoperative bile drainage
5. Sphincter of Oddi dysfunction: sphincterotomy.
Complications of ERCP:
1. Acute pancreatitis (5%)
2. Duodenal perforation
3. Hemorrhage
4. Infection
5. Stent migration

Why PT is important and inj. Vit K is given?

Liver is the main site for synthesis of all coagulation proteins. Abnormalities of these
factors can be determined by measuring prothrombin time (PT)—which measures the rate of
conversion of prothrombin to thrombin, which requires vitamin K dependent clotting factors
(factor 2, 7, 9, 10).
Vitamin K is fat soluble vitamin, absorption of which requires presence of bile salts in
intestine which is absent in patients with obstructive jaundice due to obstruction.
So, prothrombin time is prolonged—hence, injection of vitamin K should normalize the
prothrombin time in obstructive jaundice.

Mirrizi Syndrome:
It refers to the obstruction or stricture of the common hepatic duct as result of extrinsic
compression by a gallstone in the Hartmann’s pouch.

Charcot‟s triad: CBD stone causing cholangitis.

1. Pain
2. Jaundice
3. Fever with chills and rigor

Reynolds pentad:
It includes charcots + septic shock+ mental status changes:
Most common organisms: E. coli, Klebsiella, S. faecalis, bacteroides
First investigation of choice: USG
Definitive investigation: ERCP (gold standard for gallstones in CBD)
Best noninvasive investigation: MRCP.

What is double duct sign?

In ERCP or MRCP or other imaging if both the bile duct and the pancreatic duct show dilatation
with constriction of both the ducts in the region of head of pancreas it is called double duct sign.
Found in:

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  Periampullary carcinoma
 Carcinoma of head of pancreas
 Chronic pancreatitis

Missed or Retained or residual bile duct stones:

Stones in the bile duct detected within two years following cholecystectomy are defined
as retained stones.
Rx:
1. If T tube present:
 Flushing with heparinized saline
 Dissolution with methyl tertbutyl ether
 Percutaneous stone extraction via T-tube tract after 4 to 6 weeks (Burhenne
technique)
2. If T tube absent: ERCP stone removal.

Recurrent bile duct stones:

Stones which form within the bile duct 2 years after initial operation are grouped as
recurrent bile duct stones. Most common due to nonabsorbable suture materials, clips get
internalized and get covered with calcium bilirubinate to form brown pigment stones
Rx:
 ERCP: 1st approach
 If duct dilated >2 cm: Choledochoduodenostomy or transduodenal sphincteroplasty.
[Bedside clinics in surgery-2nd-149+ Rajamahendran-1st-141]

Post operative management of a patient with T-tube:

1. Measure the amount of bile daily in a sterile container connected with long vertical limb.
2. Observe for:
 Jaundice: Increasing or not
 Temperature: Increasing or not
 Dressing is soaked with bile or not
 Tenderness in the hypochondrium
3. On 7th day: Clamp the t-tube.
7th POD: Clamping for 2 hours
8th POD: Clamping for 4 hours
9th POD: Clamping for 8 hours
10th POD: Clamping for 24 hours
4. On 11th day: T-tube cholangiogram should be done
5. If T-tube cholangiogram is normal then remove the t-tube on 12th or 13th day.
What investigation will you do before removal of a T-tube?
T-tube cholangiogram
When will you remove it?
If T-tube cholangiogram on 11th day is normal then remove the t-tube on 12th or 13th day.
How will you remove T-tube?
By slow and sustained traction
Name the clinical conditions where this appliance is used.
1. Choledocholithiasis

[Link] HASAN LEMON M-48 Mymensingh Medical College, Mymensingh

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 2. Palpable stone/ worm in CBD
3. Dilated CBD
4. Raised alkaline phosphatase
5. Cholelithiasis with jaundice or recent H/O jaundice
What is your next step of action?
Removal of tube by slow & sustained traction.
Why not intra-operative?
If it is intra-operative, there would shadows of instruments.
When T-tube is removed?
 No stone
 Normal flow of bile into duodenum
Which dye is used?
 Biligrafin
 Hypaque
In which route?
Through T-tube
Why clamping is required?
To alter the pathway of bile from T-tube to duodenum.

[Link] HASAN LEMON M-48 Mymensingh Medical College, Mymensingh

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