Cholelithiasis

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Treatment

Surgical Care:

Removal of the gallbladder (cholecystectomy) is the treatment of symptomatic cholelithiasis in patients who are fit for operation. Only gallstones that cause symptoms or complications require treatment. In the late 1980s, laparoscopic cholecystectomy (LC) was introduced. A minimally invasive surgical technique, LC revolutionized the treatment of biliary disease, as well as many other abdominal disease processes. A large, right subcostal incision in the traditional (open) approach was abandoned for 4 considerably smaller incisions. Recovery time and postoperative pain were diminished markedly. The procedure commonly is performed in outpatient setting. The most dreaded and morbid complication, damage to the common bile duct, increased in incidence with the advent of LC.

Although incidence of bile duct injury during LC has declined in recent years, a recent population-based study in Australia showed a 1.7 odds risk for this complication compared to open cholecystectomy. Bile duct injuries sustained during LC are not recognized during surgery in 60% of patients. Compared to the damage inflicted during open surgery, LC bile duct injuries often are more severe and occur in younger patients. Recognizing this complication at the time of surgery or in the early postoperative period and immediately referring the patient to a tertiary center is crucial to a favorable outcome in these unfortunate patients. In the elderly patient without cholecystitis, some physicians advocate endoscopic retrograde cholangiopancreato-graphy (ERCP) and sphincterotomy without cholecystectomy.

The treatment of asymptomatic cholelithiasis is controversial. Many surgeons advocate cholecystectomy due to the potential for cholecystitis and choledocholithiasis in the future. However, the rate of development of symptoms or complications from asymptomatic gallstones is low (about 5%). Patients who have asymptomatic gallstones should be considered for cholecystectomy if they meet the following criteria:
  • Patients on medications that might mask symptoms or the accuracy of an abdominal examination (corticosteroids, pain-killers, narcotics) Patients with gallstones greater than 2 cm in diameter Patients with porcelain gallbladder, seen on imaging studies

  • Patients with sensory neuropathies affecting the abdomen

  • Patients planning on receiving an organ transplant (other than liver)
    Patients with suspected concurrent common bile duct and gallbladder stones commonly are managed in one of the following ways, depending on the experience of the surgeon and the endoscopist involved:

  • Preoperative ERCP, with clearance of the common bile duct, followed by laparoscopic cholecystectomy

  • Preoperative ERCP and clearance of the common bile duct only (in selected patients)

  • Laparoscopic cholecystectomy and choledochotomy for large/impacted stones

  • Laparoscopic cholecystectomy and transcystic common bile duct exploration for small floating stones .Combined laparoscopic-endoscopic management: Endoscopic sphincterotomy and stone extraction are performed on the operation table after the surgeon has passed a guidewire through the cystic duct into the duodenum to help the endoscopist because the procedure is performed with the patient in the supine position.

  • Laparoscopic cholecystectomy, followed by observation

  • Open cholecystectomy and common bile duct exploration

  • Laparoscopic cholecystectomy, with postoperative ERCP

Cholecystotomy might be a life-saving procedure for the treatment of acute cholecystitis in a patient unfit for an immediate operation. Using radiologic guidance, insert a percutaneous drainage tube into the gallbladder. The drainage tube relieves the high intraluminal pressure and helps reperfuse the wall of the organ. When the overall condition of the patient has improved, perform interval cholecystectomy.


Medical Care:

Dissolution agents are employed infrequently. The most widely used oral bile salt compound is ursodeoxycholate, which is effective only for small, pure-cholesterol stones located in a functioning gallbladder. Despite maintenance therapy, recurrence rates are high,averaging 50-60% in most published series. Extracorporeal shock-wave lithotripsy (ESWL) has been used to break large gallstones into smaller fragments that can then spontaneously pass through the bile duct into the duodenum.

ESWL has been abandoned because of high failure rate, frequent morbidity (jaundice, pancreatitis), and high recurrence rates. However, ESWL is very effective for renal stones.

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mahendra_khanted 

patient has 21mm large calculus is noted in the neck of gallbladder. was reported during Ultra sound scan reported by Radiologist. With mild prostatomegaly and fattyliver.Ask to do surgery looking for Altirior Medicine to avoid surgery.

rosariomoral 

can you please show pictures on how a gall stone look outside

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