Gallbladder Disease
Robert C Moesinger, MD/FACS
Northern Utah Surgeons
Ogden Surgical-Medical Society
May 17, 2013
Disclosures
• I have no conflicting financial relationships
with any of the devices, drugs or organs that I
will be discussing.
• However, like many general surgeons, the
gallbladder is largely responsible for educating
my children, and so anything I say could be
skewed by that relationship.
Objectives
• Understand the many varied presentations of
gallstone disease and their management.
• Understand the workup and treatment of
acalculous gallbladder disease.
• Understand the management of gallbladder
disease in the critical care setting.
Introduction
• It hardly seems reasonable to have gallbladder disease
be part of “What’s New In My Specialty?”.
• Gallstones go back at least as far as ~1000 BC. An
Egyptian mummy—an apparent priestess—has been
found to have gallstones.
• First recognition of gallstones in life is credited to
Alexander of Tralles in the 6th century BC.
• John Stough Bobbs (1809-1870)—first cholecystotomy
in 1867.
• Carl Langenbuch (1846-1901)—first cholecystectomy in
1882—recognizing that horses, elephants and rats
don’t have gallbladders.
Introduction
• The last really big innovation for gallbladder
disease was laparoscopic cholecystectomy, first
performed in France in 1987.
• Perhaps MRCP, developed in 1991, could be
considered a major development, but that was 22
years ago.
• Single-port cholecystectomy
– No good evidence that it makes much difference
• NOTES—Natural Orifice Translumenal Endoscopic
Surgery
– Not likely to become common
Introduction
Introduction
Introduction
Sleisenger and Fordtran: Gastrointestinal and Liver Disease:
Pathophysiology/Diagnosis/Management , Ninth Edition
Mark Feldman, Lawrence S. Friedman, and Lawrence J. Brandt, 2010.
Introduction
Sleisenger and Fordtran: Gastrointestinal and Liver Disease:
Pathophysiology/Diagnosis/Management , Ninth Edition
Mark Feldman, Lawrence S. Friedman, and Lawrence J. Brandt, 2010.
Scope of Gallbladder Disease and
Cholecystectomy
• Among the most common surgical procedure performed—about
500,000 per year.
• Prevalence of gallstones estimated at 10-20% over a lifetime.
• A patient base of almost 7000 patients
– 1988—1.35 cholecystectomies per thousand
– 1992—2.15 cholecystectomies per thousand
– 59% increase!
• JAMA. 1993;270:1429-1432
• Today—1.68 just in ambulatory surgery centers, perhaps up to 3.00
in all.
• Multiply 2.15 times 75 years of life and that is 160 gallbladders
removed per thousand over a lifetime. (16%)
• By Comparison—Northern Ireland—1.01 per thousand in 2009.
Scope of Gallbladder Disease and
Cholecystectomy
• Local data
• January 2013: 80 cholecystectomies in Ogden
– Approximately 1000 cholecystectomies/year
– 9291 births in Ogden in 2012
• Approximately 10% of people in Northern
Utah will lose their gallbladders before they
die.
Scope of Gallbladder Disease and
Cholecystectomy
• Description of old Boitnott study.
• Taken together we can conclude that in the
laparoscopic era we are taking out more
gallbladders and less sick gallbladders.
• Data from 2013—11/40 consecutive
gallbladders at both hospitals did not have
stones. (28%)
Implications of Increasing
Cholecystectomy
• Are we reducing complications of gallbladder
disease?
• Maybe??
– A nationwide study of multiple databases concluded
that Acute Cholecystitis as a reason for hospital
admission declined 14% from 2000-2009.
– Is this related to more management of acute
cholecystitis as an outpatient?
– Peery, AF, et al. Burden of Gastrointestinal Disease in
the United States: 2012 Update.
Gastroenterology. 2012;143(5):1179-1187.
Implications of Increasing
Cholecystectomy
• Acute Pancreatitis
– 30% increase in admissions for acute pancreatitis
from 2000-2009.
– 40-50% would be “gallstone pancreatitis”
• Taken together, despite a decrease in acute
cholecystitis, with the increase in pancreatitis,
complications from gallstones are probably
not decreasing despite increasing
cholecystectomy.
Implications of Increasing
Cholecystectomy
• Bile Duct Injury
– Rate of bile duct injury is at a fairly constant 0.1-0.2%
– If 28% of 1000 gallbladders per year are not “that sick”, then every 2-4
years we are causing an additional bile duct injury in Weber County .
• Colon Cancer
– Several studies show an increased risk of colorectal cancer after
cholecystectomy in the 10-40% range.
– If cholecystectomy increases risk of colon cancer from 5-6% (a 20%
increase), then about 2 patients a year with gallbladders that are “not
that sick” are getting needless colorectal cancer in Weber County.
• Overall, increasing rates of cholecystectomy are not necessarily
beneficial to the population as a whole, which could become fairly
important as we move in the direction of accountable and/or
bundled care models for a population instead of individual patients.
Manifestations of Gallstone Disease
Sleisenger and Fordtran: Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management , Ninth Edition
Mark Feldman, Lawrence S. Friedman, and Lawrence J. Brandt, 2010.
Manifestations of Gallstone Disease
•
•
•
•
Biliary Colic and Chronic Cholecystitis
Most common indication for cholecystectomy
Intermittent cystic duct obstruction
Presence of stones on ultrasound and
symptoms are appropriate for
cholecystectomy without any further workup.
• Eventually symptoms tend to escalate.
• Atypical presentation in the elderly
Manifestations of Gallstone Disease
• Acute Cholecystitis
– 226,000 admissions and 959 deaths in 2009
•
•
•
•
•
Persistent Cystic Duct Obstruction
Charcot’s triad
Ultrasound for diagnosis
HIDAscan in difficult cases
Expeditious cholecystectomy
Manifestations of Gallstone Disease
• Choledocholithiasis and Cholangitis
– It is estimated that 5-10% of patients will have CBD
stones at time of cholecystectomy.
– Probably 90% of these pass without intervention.
– Nevertheless, approximately 50,000 admissions
• Painful Jaundice +/- Fever
• Reynold’s Pentad
• Expeditious Therapeutic Cholangiogram—
Cholecystectomy is actually optional. 5% per
year will have further trouble.
• Note Gastric Bypass Population
Manifestations of Gallstone Disease
• Gallstone Pancreatitis
– Perhaps 120,000 admissions per year.
– Perhaps 1200 deaths.
• Since the gallbladder has no Constitutional
rights, it is often appropriately removed in the
absence of another cause of acute
pancreatitis.
Manifestations of Gallstone Disease
• Gallstone Ileus
• Gallbladder Cancer
– Fortunately, only 3300 cases in 2008
– Many are incidental, but 2000 deaths per year.
Manifestations of Gallstone Disease
• Asymptomatic Gallstones
– 10% will have symptoms after 5 years.
– 20% after 20 years.
• Cholecystectomy for:
–
–
–
–
–
–
–
Pediatric population
Pigmented stones (Hemolytic anemia)
“Already there”
Stones greater than 3 cms
Extended time away from reliable medical care
Bariatric surgery—30% develop stones
? Diabetes
Gallbladder Disease in Critically Ill
Patients
• 2 Scenarios
• Presentation with acute cholecystitis and
becoming critically ill.
– Fortunately rare.
– Expeditious cholecystectomy usually definitive.
Gallbladder Disease in Critically Ill
Patients
• Presentation with critical illness and
developing acute calculous or acalculous
cholecystitis.
• 5-10% of cholecystectomies
• Seen in trauma, burn, and other critically ill
patients.
• Tend to be men and older
• Treatment can be surgical or percutaneous
drainage.
Gallbladder Polyps
• A somewhat common incidental finding.
• The standard of care is cholecystectomy at
10mm.
• The question is what to do in the symptomatic
patient.
Cholesterolosis
• An acquired histologic abnormality of the gallbladder
epithelium characterized by excessive accumulation of
cholesterol esters and triglyceride within epithelial
macrophages.
• Present on 12% of autopsy specimens and 18% of
cholecystectomy specimens.
• It does not clearly cause symptoms but has been
implicated in acalculous biliary pain in which patients
seem to have better results when this is found.
• Also implicated in idiopathic recurrent pancreatitis.
Cholesterolosis
Chronic Acalculous Cholecystitis AKA
Biliary Dyskinesia
• Different than acutely ill discussed above.
• Ultrasound accuracy exceeds 95% and rarely
misses stones larger than 2mm.
• “Microlithiasis” or presence of cholesterol
crystals in bile does exist.
Work up of Gallstone-negative “Biliary
Symptoms”
• HIDAscan
– In healthy volunteers, the average ejection fraction is 75%
and virtually all exceed 35%, which is generally the
threshold for normal on these scans.
– This has become very popular and is often done
immediately after a negative ultrasound which makes the
test less predictive.
– With an abnormal test, cholecystectomy will show some
gallbladder inflammation in 90% and cholesterolosis in
30%.
– 65-80% will have improvement in symptoms, however up
to 50% will eventually have pain relief without surgery.
– Comment about “Hyperkinetic Gallbladder”.
Work up of gallstone negative “biliary
symptoms”
• CT Scan
• Very good at excluding other causes of
abdominal pain
• Rarely adds much to gallbladder diagnosis
unless a thickened wall is seen.
Work up of gallstone negative “biliary
symptoms”
• MRCP
• Another way to look for gallstones
• Very good non-invasive way to look for biliary
and pancreatic ductal anomalies including
pancreas divisum and common bile duct cysts.
Work up of gallstone negative “biliary
symptoms”
• ERCP
• Although invasive, a very good look at ductal
anatomy.
• Can allow for stenting.
• Can do manometry, but difficult.
Algorithm for patient with mystery
“biliary” symptoms
Biliary
Symptoms
Ultrasound
Negative
Normal
Time
Do Nothing
Surgery
Time and
Counseling
Low EF
HIDAscan
CT Scan
Resolution
Positive
Negative
Negative
Time
Positive Resolution
Appropriate
Treatment
Find Something
To Treat
Consider
GI Consult
Endoscopy
MRCP
Conclusions
• Gallbladder Disease is common and highly
variable in its presentation and treatment.
• A thoughtful understanding and approach to
the various complications of gallbladder
disease can streamline diagnosis and therapy.
• We probably take out too many gallbladders.