elusive gallstones elusive gallstones interactive clinical scenarios aiming at safe & sound...

Elusive GallstonesElusive Gallstones Interactive Clinical ScenariosInteractive Clinical Scenarios

Aiming at Aiming at Safe & Sound Safe & Sound managementmanagement

byby

Professor M Al-Fallouji PhD (London), FRCS Ed, FRCS Glas, FRCSIProfessor M Al-Fallouji PhD (London), FRCS Ed, FRCS Glas, FRCSI

Q1Q1

35 years-old woman post delivery complained 35 years-old woman post delivery complained of right loin pain. O/E there was right loin of right loin pain. O/E there was right loin tenderness. Urine was murky and on exam. tenderness. Urine was murky and on exam. showed pus cells. U/S revealed normal showed pus cells. U/S revealed normal kidneys, spleen, and pancreas, but kidneys, spleen, and pancreas, but gallbladder was full of medium size stones.gallbladder was full of medium size stones.

Discuss the management?Discuss the management?

A1: A1: Incidental Asymptomatic GallstonesIncidental Asymptomatic GallstonesTreat Treat her her UTI with UTI with high fluid intake high fluid intake and and antibiotic.antibiotic.

For gallstones: Do nothing and Discharge her without For gallstones: Do nothing and Discharge her without Follow upFollow up

In Leed’s study, 25% of postmortem patients harbour silent In Leed’s study, 25% of postmortem patients harbour silent gallstones. Although gallstones affect 10% of people in gallstones. Although gallstones affect 10% of people in Western World, more than 80% are asymptomatic.Western World, more than 80% are asymptomatic.

However, in potential infection, Asymptomatic gallstones However, in potential infection, Asymptomatic gallstones may be treated in immunocompromised patients and prior may be treated in immunocompromised patients and prior to organ transplantation (e.g. kidney). Also in sickle cell to organ transplantation (e.g. kidney). Also in sickle cell disease or hereditary spherocytosis, porcelain fallbladder disease or hereditary spherocytosis, porcelain fallbladder (risk of malignancy), and those on long-term parenteral (risk of malignancy), and those on long-term parenteral nutrition (develop sludge in gallbladder).nutrition (develop sludge in gallbladder).

It can also be treated in Morbid Obesity surgery, to avoid It can also be treated in Morbid Obesity surgery, to avoid further surgery in such high risk patientfurther surgery in such high risk patient..

Q2Q2

89 years-old man presented to ER with right 89 years-old man presented to ER with right upper quadrant pain. O/E there was mild upper quadrant pain. O/E there was mild tenderness in right hypochondrium with positive tenderness in right hypochondrium with positive Murphy’s sign. FBC revealed leucocytosis. Murphy’s sign. FBC revealed leucocytosis.

U/S showed normal-looking gallbladder and no U/S showed normal-looking gallbladder and no gallstones. Upper GI endoscopy was normal gallstones. Upper GI endoscopy was normal apart from a moderate size hiatus hernia.apart from a moderate size hiatus hernia.


A2: A2: Non-Calculous Cholecystitis (20%)Non-Calculous Cholecystitis (20%)

Acute Acalculous Cholecystitis Can occur in elderly Acute Acalculous Cholecystitis Can occur in elderly patients, especially those who are already critically ill.patients, especially those who are already critically ill.

Admit for iv fluids, nill by mouth, antibiotic cover for Admit for iv fluids, nill by mouth, antibiotic cover for aaeerobes and anaerobes (13%) and iv analgesia (e.g. robes and anaerobes (13%) and iv analgesia (e.g. Pethidine) with buscopan (to counteract peripheral Pethidine) with buscopan (to counteract peripheral narcotic side-effect of sphincter spasm).narcotic side-effect of sphincter spasm).

Book patient for URGENT (before discharge) Book patient for URGENT (before discharge) Laparoscopic / Open Cholecystectomy.Laparoscopic / Open Cholecystectomy.

Hiatus hernia is not GORD and if it is non symptomatic, Hiatus hernia is not GORD and if it is non symptomatic, then no treatment.then no treatment.

Q3Q3

55 years-old woman presented to ER with upper 55 years-old woman presented to ER with upper abdominal pain penetrating in nature associated abdominal pain penetrating in nature associated with vomiting. O/E there was a tinge (trace) of with vomiting. O/E there was a tinge (trace) of jaundice, epigastric tenderness with guarding. jaundice, epigastric tenderness with guarding. FBC showed leucocytosis, abnormal LFT profile, FBC showed leucocytosis, abnormal LFT profile, and high serum amylase. U/S revealed normal and high serum amylase. U/S revealed normal kidneys, spleen, and pancreas; however, kidneys, spleen, and pancreas; however, gallbladder wall was slightly thickened, but gallbladder wall was slightly thickened, but without gallstones.without gallstones.

Discuss the management in details?Discuss the management in details?

A3: A3: Gallstone-induced Acute PancreatitisGallstone-induced Acute PancreatitisThere may have been a tiny solitary CBD stone which sparked acute There may have been a tiny solitary CBD stone which sparked acute

pancreatitis and then spontaneously passed away (majority of stones pancreatitis and then spontaneously passed away (majority of stones pass away into the stool – famous study), or there is a tiny stone in thepass away into the stool – famous study), or there is a tiny stone in the intra-duodenal portion of CBD undetected on U/S.intra-duodenal portion of CBD undetected on U/S.

There are, therefore, There are, therefore, 3 Causes of Cholecystitis without gallstones3 Causes of Cholecystitis without gallstones: : (non-calculous Cholecystitis plus above-mentioned 2 causes).(non-calculous Cholecystitis plus above-mentioned 2 causes).

Admit for iv fluids, nill orally, antibiotic cover for areobes and aAdmit for iv fluids, nill orally, antibiotic cover for areobes and a naerobes (13%) and iv analgesia (e.g. Pethidine) with buscopan naerobes (13%) and iv analgesia (e.g. Pethidine) with buscopan (to counteract peripheral narcotic side-effect of sphincter spasm).(to counteract peripheral narcotic side-effect of sphincter spasm).

Presence of Jaundice (clinical or chemical with high direct bilirubin > 90 Presence of Jaundice (clinical or chemical with high direct bilirubin > 90 umol/L) umol/L) ++ chlangitis in severe acute pancreatitis necessitate chlangitis in severe acute pancreatitis necessitate ERCP & ERCP & endoscopic sphincterotomy endoscopic sphincterotomy Only Only if it is within 48 hr of disease onset .if it is within 48 hr of disease onset .

Book for Book for UrgentUrgent (before discharge) Lap. Cholecystectomy with intra- (before discharge) Lap. Cholecystectomy with intra-operative cholangiography. Presence of stone is not absolute indication operative cholangiography. Presence of stone is not absolute indication

for CBD exploration, as postop. ERCP can be done for stone extraction.for CBD exploration, as postop. ERCP can be done for stone extraction.

Q4Q4

Same patient in Q3 underwent laparoscopic Same patient in Q3 underwent laparoscopic Cholecystectomy and was well and discharged. Cholecystectomy and was well and discharged. But 4 years later presented to ER with jaundice But 4 years later presented to ER with jaundice of 2 weeks duration with past history of of 2 weeks duration with past history of recurrent upper abdominal pain dating to 2 recurrent upper abdominal pain dating to 2 years ago. FBC was normal. LFT showed high years ago. FBC was normal. LFT showed high direct bilirubin. U/S revealed no gallbladder and direct bilirubin. U/S revealed no gallbladder and no gallstones. Pancreas, kidneys, spleen and no gallstones. Pancreas, kidneys, spleen and liver were all normal.liver were all normal.


A4: A4: Chronic Pancreatitis with benign CBDChronic Pancreatitis with benign CBD stricture causing Obstructive Jaundicestricture causing Obstructive Jaundice

ERCP and sphincterotomy may help.ERCP and sphincterotomy may help.

If not, then choledocho-duodenostomy internal If not, then choledocho-duodenostomy internal drainage to bypass low CBD stricture and relieve drainage to bypass low CBD stricture and relieve jaundice.jaundice.

For chronic pain, refer to pain clinic. For chronic pain, refer to pain clinic.

If pain clinic fails, then pancreatic surgery. If pain clinic fails, then pancreatic surgery. Whipple’s surgery: indicated in biliary obstruction Whipple’s surgery: indicated in biliary obstruction or in gastric outlet obstruction (both are due to or in gastric outlet obstruction (both are due to inflammatory mass or pseudocyst resulting in inflammatory mass or pseudocyst resulting in fibrosis of bile ducts as a consequence of fibrosis of bile ducts as a consequence of recurrent episodes of inflammation). recurrent episodes of inflammation).

Q5Q5

45 years-old farmer presented with jaundice 45 years-old farmer presented with jaundice and right upper quadrant pain. O/E there was and right upper quadrant pain. O/E there was right hypochondriac tenderness only. Hepatitis right hypochondriac tenderness only. Hepatitis screen was negative. U/S revealed normal screen was negative. U/S revealed normal kidneys, spleen, and pancreas, slightly kidneys, spleen, and pancreas, slightly thickened gallbladder with no gallstones and thickened gallbladder with no gallstones and

no dilatation of bile ducts. no dilatation of bile ducts.


A5: A5: Chronic Active HepatitisChronic Active Hepatitis(not yet sero-converted or it is (not yet sero-converted or it is

chemical / drug-induced hepatitis)chemical / drug-induced hepatitis)

Do liver biopsy and Refer to Department Do liver biopsy and Refer to Department of Medicine.of Medicine.

No indication for surgery. Anaesthesia No indication for surgery. Anaesthesia may be harmful in hepatitis. may be harmful in hepatitis. Cholecystectomy will not cure jaundice. Cholecystectomy will not cure jaundice.

No indication for ERCP because there is No indication for ERCP because there is no stonesno stones (U/S revealed no dilated (U/S revealed no dilated ducts)ducts)..

Q6Q625 years-old woman weighing 120 kg and 1.5 25 years-old woman weighing 120 kg and 1.5 meter in height presented to OPD with meter in height presented to OPD with recurrent right upper abdominal pain. Last recurrent right upper abdominal pain. Last attack was yesterday at night after a dinner of attack was yesterday at night after a dinner of fish and chips. O/E there was right loin fish and chips. O/E there was right loin tenderness. Urine was murky and on exam. tenderness. Urine was murky and on exam. showed pus cells. U/S revealed solitary large showed pus cells. U/S revealed solitary large gallstone, but rest of examination was normal.gallstone, but rest of examination was normal. Discuss the management?Discuss the management?

A6: A6: Morbid Obesity Morbid Obesity with with mild Gallstone Cholecystitismild Gallstone Cholecystitis

Her BMI= 120/1.5 x 1.5= 53. Thus she must Her BMI= 120/1.5 x 1.5= 53. Thus she must reduce her weight first, before any surgery:- reduce her weight first, before any surgery:- Dietary regimen, Exercises, and Xenical Dietary regimen, Exercises, and Xenical (Orlistat) oral tablet ½ hour prior to each meal.(Orlistat) oral tablet ½ hour prior to each meal.

See her in OPD every 4-6 months checking her See her in OPD every 4-6 months checking her weight, aiming for BMI circa 35.weight, aiming for BMI circa 35.

Treat her UTI with high fluid intake and antibioticTreat her UTI with high fluid intake and antibiotic

W/L Laparoscopic Cholecystectomy under W/L Laparoscopic Cholecystectomy under double dose of DVT prophylaxis. double dose of DVT prophylaxis.

Q7Q765 years-old man presented with deep jaundice 65 years-old man presented with deep jaundice of 2 weeks duration and occasional right upper of 2 weeks duration and occasional right upper abdominal pain. O/E greenish jaundice with abdominal pain. O/E greenish jaundice with scratch marks but no palpable masses. LFT scratch marks but no palpable masses. LFT revealed Direct bilirubin of 350 mmol/L. revealed Direct bilirubin of 350 mmol/L. ERCP reveled 2 stones with total CBD ERCP reveled 2 stones with total CBD obstruction. Sphincterotomy was done but no bile obstruction. Sphincterotomy was done but no bile passed through, Dormia basket passed up but passed through, Dormia basket passed up but again failed to retrieve stones. Diagnosis of (?) again failed to retrieve stones. Diagnosis of (?) Malignant tumour, with 2 proximal CBD stones, Malignant tumour, with 2 proximal CBD stones, was made pre-operatively.was made pre-operatively.


A7: A7: Two CBD Stones impacted Two CBD Stones impacted above mid CBD narrow stricture portionabove mid CBD narrow stricture portion

Open Cholecystectomy & CBD exploration with Open Cholecystectomy & CBD exploration with choledochoscopy, biopsy, and T-Tube insertion.choledochoscopy, biopsy, and T-Tube insertion.

Peri-operative i.v. hydration with Vitamin K injection Peri-operative i.v. hydration with Vitamin K injection and Honey consumption. and Honey consumption.

This should settle the Jaundice, but future This should settle the Jaundice, but future recurrence of Jaundice (lithogenic bile) may recurrence of Jaundice (lithogenic bile) may necessitate a bypass surgery: either a choledocho-necessitate a bypass surgery: either a choledocho-duodenostomy or duodenostomy or (Roux-en-Y Hepatico-Jejunostomy)(Roux-en-Y Hepatico-Jejunostomy)

Q8Q8

77 years-old frail woman presented with acute 77 years-old frail woman presented with acute right upper abdominal pain of 2 days duration right upper abdominal pain of 2 days duration with history of recurrent abdominal pain. O/E with history of recurrent abdominal pain. O/E she was feverish with a tinge of jaundice, and she was feverish with a tinge of jaundice, and there was tenderness in right upper quadrant. there was tenderness in right upper quadrant. U/S revealed thick gallbladder wall with U/S revealed thick gallbladder wall with multiple gallstones.multiple gallstones.


A8: A8: Acute Gallstone Cholecystitis Acute Gallstone Cholecystitis with CBD stones in Old Frail woman with CBD stones in Old Frail woman

ERCP for CBD stones retrieval.ERCP for CBD stones retrieval.

For the hot gallstone Cholecystitis, percutaneous For the hot gallstone Cholecystitis, percutaneous Cholecystostomy, removing stones and draining Cholecystostomy, removing stones and draining gallbladder with large Foley’s catheter (done by gallbladder with large Foley’s catheter (done by Interventional Radiologist) or under Local Anaesthesia Interventional Radiologist) or under Local Anaesthesia and i.v. sedation by General Surgeon.and i.v. sedation by General Surgeon.

Optional to inject a dye one week later via the catheter to Optional to inject a dye one week later via the catheter to insure empty gallbladder.insure empty gallbladder.

And , What if there was a residual CBD stone?And , What if there was a residual CBD stone?

Q9Q965 years-old woman complained of right upper 65 years-old woman complained of right upper abdominal pain. O/E there was right upper abdominal pain. O/E there was right upper quadrant tenderness. U/S revealed gallstones quadrant tenderness. U/S revealed gallstones with thickened gall bladder wall. She with thickened gall bladder wall. She underwent Laparoscopic Cholecystectomy. underwent Laparoscopic Cholecystectomy. On 3On 3rdrd Postoperative day she start developing Postoperative day she start developing mild jaundice with low grade fever and mild mild jaundice with low grade fever and mild abdominal distension. Patient otherwise was abdominal distension. Patient otherwise was not in pain and not complaining. not in pain and not complaining.


A9: A9: Post-Lap Chole Duct injury, Post-Lap Chole Duct injury, Biliary Peritonitis, and Paralytic IleusBiliary Peritonitis, and Paralytic Ileus

Emergency Laparotomy with abdominal cavity Emergency Laparotomy with abdominal cavity lavage of bile.lavage of bile.

Most likely injury is trans-section of CBD Most likely injury is trans-section of CBD during the clipping of a tented low cystic duct during the clipping of a tented low cystic duct insertion. CBD repair by doing choledocho-insertion. CBD repair by doing choledocho-dochostomy with T-Tube insertion and on-dochostomy with T-Tube insertion and on-table cholangiography.table cholangiography.

Remove T-Tube on 7-10Remove T-Tube on 7-10thth postoperative day. postoperative day.

Q10Q1070 years-old man presented with Jaundice noticed 2 70 years-old man presented with Jaundice noticed 2 weeks earlier with vague upper abdominal pain. He weeks earlier with vague upper abdominal pain. He consulted a physician, who did for him plain abdominal consulted a physician, who did for him plain abdominal X-ray revealing widened duodenum. U/S revealed X-ray revealing widened duodenum. U/S revealed gallstones with minimal wall thickening and nothing else. gallstones with minimal wall thickening and nothing else. OGD was performed for abdominal pain; it was normal OGD was performed for abdominal pain; it was normal apart from compressed antrum from which he took apart from compressed antrum from which he took biopsies (showed chronic inflammation). The Doctor biopsies (showed chronic inflammation). The Doctor then did ERCP, which did not show anything sinister. then did ERCP, which did not show anything sinister. Patient was then referred to surgeon to do ‘Open Patient was then referred to surgeon to do ‘Open Cholecystectomy with CBD exploration’. Cholecystectomy with CBD exploration’. Postoperative T-tube cholangiogram was normal with no Postoperative T-tube cholangiogram was normal with no residual stone, and so tube was removed, and patient residual stone, and so tube was removed, and patient was discharged. Eight (8) months later, patient was discharged. Eight (8) months later, patient developed jaundice again. developed jaundice again. Discuss the management?Discuss the management?

A10: A10: Obstructive Jaundice due to Obstructive Jaundice due to Carcinoma of Pancreatic Head Carcinoma of Pancreatic Head

& Secondary Biliary Stones (Red Herring)& Secondary Biliary Stones (Red Herring)Gallstones diagnosis should never be confidently Gallstones diagnosis should never be confidently entertained in the presence of obstructive jaundice and/or entertained in the presence of obstructive jaundice and/or widened C -loop of Duodenum. widened C -loop of Duodenum. Also, Biopsies from OGD & ERCP are False Negative Also, Biopsies from OGD & ERCP are False Negative (Positive biopsy of Pancreatic Carcinoma preoperatively (Positive biopsy of Pancreatic Carcinoma preoperatively is not always possible). This is a dilemma and surgical is not always possible). This is a dilemma and surgical nightmare. nightmare.

Story of Steve Jobs, Inventor of iPhone.Story of Steve Jobs, Inventor of iPhone.

Do Whipple’s operation for obstructive jaundice due to Do Whipple’s operation for obstructive jaundice due to pancreatic compression whether by tumour or by Chronic pancreatic compression whether by tumour or by Chronic Pancreatitis (biopsy negative).Pancreatitis (biopsy negative).

Q11Q1155 years-old woman complained of recurrent 55 years-old woman complained of recurrent right upper abdominal pain at night every time right upper abdominal pain at night every time after eating fish and chips over last 3 years. after eating fish and chips over last 3 years. She had U/S done one week prior to her last She had U/S done one week prior to her last admission, and shown solitary gallstone with admission, and shown solitary gallstone with thickened wall of Gallbladder, no dilatation of thickened wall of Gallbladder, no dilatation of biliary ducts, and liver, spleen, and pancreas, biliary ducts, and liver, spleen, and pancreas, were all normal. She was previously reluctant were all normal. She was previously reluctant to surgery. O/E patient was jaundiced (with to surgery. O/E patient was jaundiced (with blood test confirming mild elevation of direct blood test confirming mild elevation of direct bilirubin). There was right upper quadrant bilirubin). There was right upper quadrant tenderness. tenderness. Discuss the management?Discuss the management?

A11: A11: Mirizzi’s syndrome Type IMirizzi’s syndrome Type IMost recent U/S revealed no dilatation of biliary ducts Most recent U/S revealed no dilatation of biliary ducts excluding intrabiliary pathology; the fact that pancreas excluding intrabiliary pathology; the fact that pancreas was also normal suggest the possibility of extrinsic was also normal suggest the possibility of extrinsic compression of CBD due to a very recent gallstone compression of CBD due to a very recent gallstone impaction in the neck of inflamed gallbladder or cystic impaction in the neck of inflamed gallbladder or cystic duct (solitary stone). duct (solitary stone).

Type II Mirizzi’s syndrome occurs when there is erosion Type II Mirizzi’s syndrome occurs when there is erosion of the stone into CBD, creating a fistula.of the stone into CBD, creating a fistula.

If conservative treatment is unsuccessful in reduction of If conservative treatment is unsuccessful in reduction of inflammation and resolution of jaundice, Urgent Open inflammation and resolution of jaundice, Urgent Open Cholecystectomy is recommended. This will be a difficult Cholecystectomy is recommended. This will be a difficult Cholecystectomy. The stone must be released, by lateral Cholecystectomy. The stone must be released, by lateral incision to minimise risk of CBD & CHD, but removal of incision to minimise risk of CBD & CHD, but removal of gallbladder neck is unwise. A temporary bile leak is gallbladder neck is unwise. A temporary bile leak is anticipated with drain placed in the area. anticipated with drain placed in the area.

Q1Q122

5511 years-old woman complained of right upper abdominal pain years-old woman complained of right upper abdominal pain

of 12 hr duration, last night following a meal of French Fries.of 12 hr duration, last night following a meal of French Fries.

O/E there was No jaundice. There was however, right upper O/E there was No jaundice. There was however, right upper quadrant tenderness, and Murphy’s sign was briskly positive. quadrant tenderness, and Murphy’s sign was briskly positive. U/S on admission revealed gallstones, with very thickened U/S on admission revealed gallstones, with very thickened Gallbladder wall, but without dilatation of biliary ducts; liver, Gallbladder wall, but without dilatation of biliary ducts; liver, spleen, and pancreas, were all normal. She underwent open spleen, and pancreas, were all normal. She underwent open Cholycystectomy, and because of obscure anatomy a Calot’s Cholycystectomy, and because of obscure anatomy a Calot’s triangle, the surgeon was forced to perform Fundus-First triangle, the surgeon was forced to perform Fundus-First Cholecystectomy. For 5 post-operative days, patient was Cholecystectomy. For 5 post-operative days, patient was discharging copious amounts of bile through subhepatic drain, discharging copious amounts of bile through subhepatic drain, which then became associated with epigastric pain and rapid which then became associated with epigastric pain and rapid pulse rate, hypotension and tinge of jaundice. pulse rate, hypotension and tinge of jaundice. What exactly had happened? Was Surgeon wise in doing What exactly had happened? Was Surgeon wise in doing Fundus-First operation? What else could have been done? Fundus-First operation? What else could have been done? What procedures should be done What procedures should be done NOWNOW and in and in LATELATE future? future?

A12: A12: Postoperative Leak/Fistula with signs of WWS. Postoperative Leak/Fistula with signs of WWS. Upper abdominal pain with tachycardia and persistent Upper abdominal pain with tachycardia and persistent hypotension following postoperative bile leak into hypotension following postoperative bile leak into subhepatic drain subhepatic drain are classical signs of are classical signs of Waltman-Walters Waltman-Walters syndrome, indicating local or general biliary peritonitis, syndrome, indicating local or general biliary peritonitis, secondary to iatrogenic (doctorogenic) injury to CBD.secondary to iatrogenic (doctorogenic) injury to CBD.

Yes, he was wise in doing Fundus-First cholecystectomy; Yes, he was wise in doing Fundus-First cholecystectomy; paradoxically and ironically in such obscure anatomy he paradoxically and ironically in such obscure anatomy he could have inadvertently done an excessive mobilization could have inadvertently done an excessive mobilization and GB traction, thus tenting CBD and pulling out right and GB traction, thus tenting CBD and pulling out right hepatic artery of their normal alignment, rendering them hepatic artery of their normal alignment, rendering them liable to be clamped or included in ligature (late stricture).liable to be clamped or included in ligature (late stricture).

Thus, it was better if he had done Subtotal Cholecystectomy.Thus, it was better if he had done Subtotal Cholecystectomy.

Percutaneous drainage of bile collection under U/S and Percutaneous drainage of bile collection under U/S and ERCP stenting to seal the leakage point and heal fistula and ERCP stenting to seal the leakage point and heal fistula and stabilise patient for later CBD repair by doing standard stabilise patient for later CBD repair by doing standard Hepatico-Jejunostomy with Roux-loop & Entero-EnerostomyHepatico-Jejunostomy with Roux-loop & Entero-Enerostomy..

elusive gallstones elusive gallstones interactive clinical scenarios aiming at safe & sound...

Documents