Surgical Students Society of Melbourne, 2011J. Bridie MeeRMH intern

www.jacksonregionalsurgery.com

Gallstone Disease

• Cholelithiasis• Choledocolithiasis• Biliary Colic• Cholecystitis

Gallstone Types

• Cholesterol stones • Pigment stones

Risk Factors

• Fair• Female• Fat• Forties• Fertile • also DM, family Hx

Epidemiology

• Why do you need to know about it?• 2nd most common abdo organ requiring

surgery• Population prevalence 5-20% of which

majority (70-80%) remain asymptomatic• 1-4% develop symptoms each year

Biliary Colic - Symptoms

• Site• Onset• Timing• Character• Radiation • Severity• Assoc sympt• Aggrav/reliev

Biliary Colic - Symptoms

• Site RUQ• Onset sudden• Timing 30 min – 6 hrs• Character dull• Radiation +/- to epigastrium, back• Severity very• Assoc sympt nausea & vomiting• Aggrav/reliev fatty foods, analgesics

Biliary Colic - Examination

• General: Restless, +/- jaundice• Obs: tachy• Abdo: RUQ tenderness, guarding

Biliary Colic - Investigations

• FBE• LFT • UEC• Amylase/lipase• CXR/AXR• Upper abdo ultrasound

Differentials• Abdo:– Acute cholecystitis– Pancreatitis– GORD– Perforate PUD– Appendicits (atypical)– pyelonephritis

• Thoracic:– Pneumonia– angina

Biliary Colic - Management

• Analgesia• Exclude complications/differentials• Elective cholecystectomy

Acute Cholecystitis

• Acute inflammation of GB following impactions of stone, +/- infective

• Symptoms:– RUQ/epigastric pain – Nausea, vomiting– Fever– Aggravated by movement, deep breathing

Acute Cholecystitis - Examination

• General distressed, still, shallow breathing,+/- jaundice (scleral)

• Obs febrile, tachycardia

• Abdo RUQ tenderness, guarding+/- Murphy’s sign/peritonism

Acute Cholecystitis - investigations

• FBE, UEC, LFT, CRP• Amylase/lipase• ECG• CXR/AXR• Upper abdo US

Acute Cholecystitis - Ultrasound

Acute Cholecystitis - Ultrasound

• 90-95% sensitive• What are the ultrasound findings?

Acute Cholecystitis - Management

• Call surg admit!• Analgesia opiods• NBM• IVFT• Antibiotics

Cholecystectomy:Indications & Timing

• Not indicated for incidental findings of cholelithiasis that are asymptomatic

• Elective for biliary colic• During admission elective or urgent for acute

cholecystitis• Alternatives if unfit for surgery – Abx and

percutaneous drainage

Laparotomy vs Laparoscopy

http://www.laparoscopy.com/pictures/lap_chol.html

Complications

• Gangrenous cholecystitis • Obstructive jaundice• Cholangitis• Gallstone ileus• Pancreatitis• Death!

Choledocolithiasis causing Obstructive Jaundice

• Post-hepatic jaundice (GGT, ALP)

• Symptoms– Hx of previous gallbladder disease– Jaundice– Pale stools, dark urine

Obstructive Jaundice – Ix

• LFT, FBE, UEC, CRP• USS – GB, CBD, stones• MRCP

MRCP

Treatment obstructive jaundice

• ERCP• Laparoscopic/open cholecystectomy with IOC

ERCP

Cholangitis

• When obstructed CBD becomes infected• Charcot’s triad of signs– RUQ pain– jaundice– High fever/rigors

• Can be life threatening, early treament essential

Gallstone Ileus

• When stone perforates GB wall and erodes into duodenum, obstructing small bowel

• Treatment - laparotomy

Pancreatitis

• When gallstone irritates pancreas causing inflammation, or distal CBD blockage causing intrapancreatic release of enzymes

• 30-50% pancreatitis caused by gallstones• Can be life threatening

Take home messages

• Gall stone disease very common, worth knowing about, understanding anatomy helps

• Feel lots of bellies• Complications can be life threatening• Get scrubbed for a cholecystectomy!