Gallstone Disease

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

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

Gallstones

• Common (20% population)• Cholesterol stones in West• Female proponderance (3/1)• Risk factors

– Obesity– Oestrogen– Hypercholesterolaemia– Increasing age– 5 F’s

Clinical Manifestations

• Asymptomatic• Cholecystitis• Biliary colic• Complications

– Jaundice– Pancreatitis– Cholangitis– Gallstone ileus– Carcinoma of gallbladder

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)

Acute Cholecystitis Clinical Features

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

Acute Cholecystitis

Signs• Pyrexia (37.5-38.5)• Associated jaundice signifies CBD blockage

– CBD stone or Mirrizi’s Syndrome• Abdominal tenderness localized to RUQ• Murphys’ sign positive

Murphys’ Sign

• Inspiratory arrest with manual pressure below the gallbladder

Murphy’s Sign

Biliary Colic

• Pain associated with passage of stone

• Usually not colicky but constant (a misnomer)

• As cholecystitis but notnot associated with fever/ leucocytosis and positive Murphys’ sign

• Usually resolves after minutes- few hours

Complications

• Empyema/ mucocele

• Obstructive jaundice

• Ascending cholangitis

• Pancreatitis

Charcots’ Triad- Ascending cholangitis

1. Pain

2. Fever

3. Jaundice

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

Acute Cholecystitis - Investigation

• Bloods– FBC (WCC)– LFT’s (Bilirubin, GGT, Alk Phos)– Amylase

• Imaging– CXR– Ultrasound– CT

• Special tests

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

Acute Cholecystitis – Management

• Restrict Oral intake (NPO)– Intravenous fluids– Ng tube aspiration (for vomiting)

• Analgesia– Morphine

• Intravenous antibiotics– Gram negative cover

(co-amoxiclav—gentamicin—piperacillin)• Cholecystectomy after resolution

Biliary Colic - Management

• Acute attack usually resolves spontaneously

• Analgesia

• Investigations as for cholecystitis

• Prolonged attacks treated as cholecystitis

• Elective cholecystectomy

Ascending Cholangitis

• Charcots’ Triad

• Investigations– FBC, LFT's, Amylase, US

• Management– Resuscitation (IV fluids)– Antibiotics (G-negative cover)– Intensive monitoring (urometry)

Ascending Cholangitis

• Definitive management

– ERCP and stone removal +/- stent

– Cholecystectomy after resolution

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

Gallstone Pancreatitis

• Supportive– Fluid resuscitation– Antibiotics– Analgesia

• Definitive– ERCP & stone retrieval– Elective cholecystectomy

Laparoscopic Cholecystectomy

• Commonest elective surgical procedure

• Standard treatment for gallstone disease

• May be performed as daycase

• Converted to open in small number

Complications

• Trauma• Common bile duct (CBD)• Intestine• Liver

• Haemorrhage• Vessel injury• Liver injury• Cystic artery clips

• Infection• Biliary peritonitis

Late Complications

• Post cholecystectomy syndrome– Rare– Pain – Occasionally due to stones in the biliary tree

• Port site hernia– Umbilical– 10mm port sites

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

Summary

• Gallstones are common• Usually asymptomatic• Clinical manifestations

– Cholecystitis– Biliary colic

• Complications– Ascending cholangitis (Charcots' Triad)

• Treatment– Laparoscopic cholecystectomy– ERCP

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