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Gallstones - Pathology and Clinical Guideline PDF
Gallstones - Pathology and Clinical Guideline PDF
2. The Guidance
The following pathway should be followed.
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Suspected Gallstones
Y
Ultrasound + LFTs + Amylase
Y YES
Amylase ≥3 x normal See PANCREATITIS guidelines
N
YES
See SUSPECTED BILE DUCT STONE
Bile duct dilated AND/OR
management pathway
LFTs deranged
N AND Fevers (Temp>38°C) See ACUTE CHOLANGITIS guidelines
YES
Pain >24 hours AND/OR
See ACUTE CHOLECYSTITIS
raised inflammatory markers
guidelines
N
See BILIARY COLIC
management pathway
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A) SUSPECTED BILE DUCT STONE – Management Pathway
Normal LFTs Normal LFTs History of abnormal LFTs Abnormal LFTs
Non-dilated bile ducts Dilated bile ducts Non‐dilated bile ducts Dilated bile ducts
MINIMAL risk of CBD stones LOW risk of CBD stones If fevers/rigors see
CHOLANGITIS guidelines
HIGH risk of CBD stones
Laparoscopic cholecystectomy
(+/-OTC) Laparoscopic cholecystectomy & OTC MRCP if not fit for surgery
or OTC not available
(MRCP - see indications below in section 2)
CBD stone(s) No CBD stone(s)
CBD stone(s)
Post-op ERCP
Key
LFT Liver function tests
CBD Common bile duct
OTC Intraoperative On-Table Cholangiogram
USS Ultrasound Scan
ERCP Endoscopic Retrograde Cholangio-Pancreatography
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B) BILIARY COLIC – Management Pathway
Diagnosis
RUQ pain +/- sweating, vomiting
Night time pain
Precipitated by fatty meals
+/- Jaundice
Detailed History & Examination
History of gallstones
Medication and drug intake
Recent intervention (e.g. ERCP / stent)
History of biliary stricture / malignancy
Co-morbidities (respiratory, cardiac, diabetes, high BMI
Investigations
A) FBC, U+Es, LFTs, amylase, CRP
B) Upper abdominal ultrasound – inpatient or outpatient
Management
- Patient should be discharged with simple analgesia
- Advise a low fat diet
- Offer laparoscopic cholecystectomy or upper GI surgery outpatient review pending patient or
surgeon decision to operate
- If surgery declined or not appropriate, refer back to GP with advice on low fat diet.
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o MRCP indications:-
As above where surgery not being considered or patient not fit for surgery.
o Indications include:-
Common bile duct stone with jaundice where surgery not suitable
Common bile duct stone without jaundice where surgery not suitable
Suspected or definite acute cholangitis
Previous cholecystectomy with retained stone
o Indications include:
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3.6 Laparoscopic Cholecystectomy for Biliary Colic
3.7 References
o AUGIS. Pathway for the management of acute gallstone diseases. AUGIS 2015
o NICE. Gallstone disease: diagnosis and initial management. 2014 (CG188)
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Michael Clarke –
01 09 15 V1.0 Draft for consultation Consultant Upper GI
and Bariatric Surgeon
Michael Clarke –
23 Feb 16 V2.0 Approved for implementation Consultant Upper GI
and Bariatric Surgeon
All or part of this document can be released under the Freedom of Information Act
2000
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the express
permission of the author or their Line Manager.
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C). Please list any General surgery team (Audit meeting). Consultants (Radiology,
groups who have been Gastroenterology, Microbiology, Intensive care)
consulted about this
procedure.
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7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age x
Sex (male, female, trans- x
gender / gender
reassignment)
Race / Ethnic x
communities /groups
Disability - x
Learning disability,
physical disability, sensory
impairment and mental
health problems
Religion / x
other beliefs
Marriage and civil x
partnership
Pregnancy and maternity x
Sexual Orientation, x
Bisexual, Gay,
heterosexual, Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been highlighted:
You have ticked “Yes” in any column above and
No consultation or evidence of there being consultation- this excludes any policies which have
been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended. No
9. If you are not recommending a Full Impact assessment please explain why.
Signature of policy developer / lead manager / director Date of completion and submission
Michael Clarke, Consultant Upper GI and Bariatric Surgeon 23rd February 2016
Signed _______________
Date ________________
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