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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!