Gallstone Disease

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Gallstone Disease
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Objectives

• Basic biliary anatomy and physiology
• Pathophysiology of gallstone disease
• Clinical manifestations of gallstone disease
• Complications of gallstone disease
• Investigation and management of gallstone disease

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Gallbladder Surface Anatomy

• Lies in the right upper quadrant, under the
  costal margin at the level of the 9th costal
  cartilage
• The level of the 9th costal cartilage can be
  palpated as a distinct notch

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Gallstones

• Common (20 population)
• Cholesterol stones in West
• Female proponderance (3/1)
• Risk factors
• Obesity
• Oestrogen
• Hypercholesterolaemia
• Increasing age
• 5 Fs

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Clinical Manifestations

• Asymptomatic
• Cholecystitis
• Biliary colic
• Complications
• Jaundice
• Pancreatitis
• Cholangitis
• Gallstone ileus
• Carcinoma of gallbladder

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Acute Cholecystitis

• Acute inflammation of the gallbladder
• Usually associated with calculi (stones)
• Calculus causes obstruction at Hartmann's pouch
  or cystic duct
• Less commonly with biliary sludge
• A-calculus (no-stone) cholecystitis rare
• Bacterial infection in 50 only
• Recurrent attacks result in fibrosed thickened
  gallbladder (chronic cholecystitis)

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Acute Cholecystitis Clinical Features

• Pain
• Sudden onset
• Post-prandial
• RUQaround to back
• Constant
• Associated nausea and vomiting
• May last several hours to days
• Recurrent attacks common

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Acute Cholecystitis

• Signs
• Pyrexia (37.5-38.5)
• Associated jaundice signifies CBD blockage
• CBD stone or Mirrizis Syndrome
• Abdominal tenderness localized to RUQ
• Murphys sign positive

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Murphys Sign

• Inspiratory arrest with manual pressure below the
  gallbladder

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Murphys Sign
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Biliary Colic

• Pain associated with passage of stone
• Usually not colicky but constant (a misnomer)
• As cholecystitis but not associated with fever/
  leucocytosis and positive Murphys sign
• Usually resolves after minutes- few hours

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Complications

• Empyema/ mucocele
• Obstructive jaundice
• Ascending cholangitis
• Pancreatitis

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Charcots Triad- Ascending cholangitis

• Pain
• Fever
• Jaundice

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Courvoisiers Law

• In the presence of jaundice a palpable
  gallbladder is most likely due to malignant
  obstruction of the bile duct
• Based on presumption that patients with
  gallstones have chronically inflammed, fibrosed
  gallbladders incapable of distension
• Does not always hold true e.g.
• Empyema CBD stone

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Acute Cholecystitis - Investigation

• Bloods
• FBC (WCC)
• LFTs (Bilirubin, GGT, Alk Phos)
• Amylase
• Imaging
• CXR
• Ultrasound
• CT
• Special tests

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Acute Cholcystitis Special tests

• Endoscopic Retrograde Cholecystogram (ERCP)
• Diagnostic and therapeutic
• Magnetic Resonance Imaging (MRC)
• Other forms of Cholangiography
• Intra-operative
• Percutaneous Transhepatic (PTC)
• Oral cholangiogram

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Acute Cholecystitis Management

• Restrict Oral intake (NPO)
• Intravenous fluids
• Ng tube aspiration (for vomiting)
• Analgesia
• Morphine
• Intravenous antibiotics
• Gram negative cover
• (co-amoxiclavgentamicinpiperacillin)
• Cholecystectomy after resolution

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Biliary Colic - Management

• Acute attack usually resolves spontaneously
• Analgesia
• Investigations as for cholecystitis
• Prolonged attacks treated as cholecystitis
• Elective cholecystectomy

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Ascending Cholangitis

• Charcots Triad
• Investigations
• FBC, LFT's, Amylase, US
• Management
• Resuscitation (IV fluids)
• Antibiotics (G-negative cover)
• Intensive monitoring (urometry)

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Ascending Cholangitis

• Definitive management
• ERCP and stone removal /- stent
• Cholecystectomy after resolution

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Gallstone Pancreatitis

• Commonest cause of Pancreatitis
• More severe than alcohol Pancreatitis
• Due to CBD stones irritating pancreas
• Obstruction at ampulla of Vater
• Irritation in pancreatic portion of CBD

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Gallstone Pancreatitis

• Supportive
• Fluid resuscitation
• Antibiotics
• Analgesia
• Definitive
• ERCP stone retrieval
• Elective cholecystectomy

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Laparoscopic Cholecystectomy

• Commonest elective surgical procedure
• Standard treatment for gallstone disease
• May be performed as daycase
• Converted to open in small number

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Complications

• Trauma
• Common bile duct (CBD)
• Intestine
• Liver
• Haemorrhage
• Vessel injury
• Liver injury
• Cystic artery clips
• Infection
• Biliary peritonitis

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Late Complications

• Post cholecystectomy syndrome
• Rare
• Pain
• Occasionally due to stones in the biliary tree
• Port site hernia
• Umbilical
• 10mm port sites

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ERCPEndoscopic Retrograde Cholangio Pancreato
Graphy

• Usually performed by gastroenterologists
• Diagnostic and therapeutic
• Indicated in jaundiced patients
• Ampulla of Vater cannulated
• Demonstrates ductal anatomy
• Allows biopsy of malignant lesions
• Therapeutic in relieving obstruction
• Stone retrieval or Stenting

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Summary

• Gallstones are common
• Usually asymptomatic
• Clinical manifestations
• Cholecystitis
• Biliary colic
• Complications
• Ascending cholangitis (Charcots' Triad)
• Treatment
• Laparoscopic cholecystectomy
• ERCP

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