Gallbladder Disease
Surgical Students Society of Melbourne, 2011
J. Bridie Mee
RMH intern
www.jacksonregionalsurgery.com
Gallstone Disease
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Cholelithiasis
Choledocolithiasis
Biliary Colic
Cholecystitis
Gallstone Types
• Cholesterol stones
• Pigment stones
Risk Factors
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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
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Site
Onset
Timing
Character
Radiation
Severity
Assoc sympt
Aggrav/reliev
Biliary Colic - Symptoms
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Site
Onset
Timing
Character
Radiation
Severity
Assoc sympt
Aggrav/reliev
RUQ
sudden
30 min – 6 hrs
dull
+/- to epigastrium, back
very
nausea & vomiting
fatty foods, analgesics
Biliary Colic - Examination
• General:
• Obs:
• Abdo:
Restless, +/- jaundice
tachy
RUQ tenderness, guarding
Biliary Colic - Investigations
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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
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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
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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
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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!