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 9 th costal cartilage
• The level of the 9 th 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 not 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

ERCP
Endoscopic 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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