Gall Stones | Medical Science Optional Notes for UPSC PDF Download

Gall stones-Etiopathogenesis

5-F Syndrome—fair, fat, female, fertile and overforty

Gall stones-Clinical presentation

Asymptomatic in majority of the cases (80%)
Approximately 1-2% of asymptomatic patients will develop symptoms requiring surgery per year

Acute cholecystitis-Severity classification

Tokyo Consensus Guidelines for severity grading of acute cholecystitis

Gall stones-Diagnosis

History 

• Female, obese, in 40's 
• Right upper quadrant pain radiating to back

Physical Examination

• Murphy's Sign: Right upper quadrant tenderness worsened during inspiration by the examiner's right subcostal palpation. Pain may radiate to the right shoulder.
• Courvoisier's Sign: Palpable, non-tender gallbladder indicating distal common duct obstruction from a peripancreatic malignancy.

Investigations

• Plain Radiograph: Reveals gallstones in 10% of patients; skilled examination may show a Sea Gull or Mercedes-Benz sign where the stone center may contain radiolucent gas in a triradiate or biradiate fissure.
• USG Abdomen: Readily available, inexpensive, and quick; assesses gallbladder size, wall thickness, and stone presence.
• CT Abdomen: Identifies 75% of gallstones; can detect gallbladder and pancreatic cancers.
• MRCP: Non-invasive visualization of gallbladder and biliary system.
• ERCP: Invasive and serves both diagnostic and therapeutic purposes, including stone removal and stent placement.

Gall stones-Complications

Complications of Stones with in Gall Bladder

Complications of stones outside Gall Bladder

Gall stones-Treatment

Timing of laparoscopic cholecystectomy

• Laparoscopic cholecystectomy performed early during acute cholecystitis is considered safe and reduces the overall duration of hospital stay.
• For cases where early operation is recommended (acute cholecystitis), it is advisable to undertake the surgery within 5-7 days from the onset of the attack.
• In situations where an early operation is not indicated (grade I or II disease according to Tokyo guidelines), it is recommended to wait for approximately 6 weeks to allow inflammation to subside before opting for an elective cholecystectomy.

Laparoscopic cholecystectomy

• The procedure is performed under general anesthesia.
• Pneumoperitoneum is established to create a working space in the abdominal cavity.
• A camera port is inserted through an open subumbilical cutdown.
• Additional ports are inserted in the subxiphoid and right costal areas to facilitate access.
• A crucial aspect of the surgery involves identifying and safely dissecting Calot's triangle.
• The patient is positioned in a reverse Trendelenburg position, slightly rotated to the left.
• Clear anatomical landmarks should be defined before proceeding, and a cholangiogram is indicated if there is uncertainty.
• The fundus of the gallbladder is retracted toward the diaphragm, and the neck of the gallbladder is retracted toward the right iliac fossa.
• Calot's triangle is carefully dissected to ensure a wide opening for further procedures.
• The cystic duct and cystic artery are clipped and divided.
• Subsequently, the gallbladder is removed.

• Recovery following laparoscopic cholecystectomy is characterized by reduced pain and a quicker return to normal activities compared to open cholecystectomy.

Complications

• The mortality during the operation is less than 1%.
• Complications may arise in 10-15% of cases.

Rare complications 

• Bowel injury 
• Port site infection
• Port site hernia

Gall bladder-Repeats

Q1: Write short notes on Complications of Gall-stones. (2002)

Q2: A 40-year-old female fair in color presented to casualty department with history of severe upper abdominal pain and vomiting after heavy fatty meal. On examination, tenderness is present in right hypochondrium. (2017)
(i) What is the diagnosis of the above-mentioned clinical condition, its aetiopathogenesis and differential diagnosis?
(ii) Outline the management of chronic cholecystitis with Cholelithiasis. 

Q3: Briefly enumerate the principles of laparoscopic cholecystectomy and the complications which can occur during the procedure. (2013)