Biliary colic /  Site: RHC pain (Severe right hypochondrium tenderness)

Cholelithiasis  Onset: gradual in onset

 Character: Not a true colic – Waxing-waning in character
 Radiating: inferior angle of the right scapula, or tip of right shoulder
 Aggravating fx: Pain aggravates by eating fatty food
 Relieving fx: Pain subsides over time or with analgesia and may recur some other time
 Timing: Pain occurs within hours of eating a meal often awakening the patient from sleep
 Severity: Pain is steady and intense
 Duration: pain comes in distinct attacks lasting 30mins to several hours, often resolves spontaneously (if >6hrs,
suspect complication i.e. cholecystitis)
 NO FEVER

Acute cholecystitis Symptoms:

 Fever (low grade)
 RUQ pain : aggravated by food intake , radiates to back (Radiates to the inferior angle of the scapula,
interscapular)
 Nausea, vomiting
 Anorexia

Signs:
 General inspection/examination:
o NO JAUNDICE

 Abdomen examination:
o RHC tenderness with guarding
o Positive Murphy’s sign positive (inspiratory arrest during deep palpation of the RUQ)
o Boas’s sign – hyperaesthesia below the right scapula (between 9-11th ribs posteriorly, location-phrenic nerve
innervation)
o Palpable GB (30%) – omentum wrapping around GB; worst case scenario is empyema

Choledocholithiasis  RUQ or epigastric pain (pain often more prolonged than seen with biliary colic)
 Nausea and/or Vomiting
 Obstructive Jaundice – tea-coloured urine, pale stools, pruritus
 Complications: obs jaundice& acute cholangitis & acute pancreatitis

Ascending cholangitis  Charcot’s triad: Right Upper Quadrant (RUQ) pain + intermittent fever with chills + jaundice
(only 50-70% of patients have the classic triad)

 Reynold’s pentad: Charcot’s triad + mental obtundation + hemodynamic instability

– seen in less than 10% of patients, more prevalent in the elderly
Pancreatic carcinoma
 Painless, progressive jaundice
 Dark tea colored urine
 Pale stool
 pruritus
 LOW, LOA
 Nausea and vomiting ( sec to gastric outlet obstx)
 Diabetes mellitus * sx: polyuria, polydipsia, nocturia, fatigue, peripheral numbness
 Bleeding upper GIT (haematemesis and/or melena)
 Mets sx: ascites, back pain, CNS symptoms, SOB
Signs
- jaundice with palpable GB (Courvoisier’s sign
Approach to gallstone disease Past Medical History

Personal identification data  DM/HTN/ *HPL

 past hx of gallstone before
Fat, forty, fertile, female
 hx of previous ercp/ refused lap.
Chief complaint cholecystectomy

History of presenting illness PSHx

RUQ Drug Hx

 Sudden Allergy Hx
 Intermittent Family Hx
 Colicky in nature
 aggravated by taking fatty meals Social Hx
 relieved intermittently by taking analgesic
Diet Hx
 lasting about 2-3 hours
 pain score was given 5 out of 10.  takes fatty and high cholesterol meals.

Associated with:
Physical Examination
 Nausea and vomiting
- content was undigested food, 2-3 cups in General inspection: The patient had generalized
amount, foul smelling, 2-3 times per day yellowish of skin and sclera.
 yellowish of skin and sclera of eyes
 generalised pruritus
 dark tea colored urine General examination
 pale stool
 fever  Hand: hands were dry, warm, yellowish. CRT
-intermittent, any recorded temperature at <2 seconds.
home, relieved by taking PCM, ass/w
 Eyes: sclera is yellowish indicates jaundice, no
chills/rigor?
pallor
TRO other ddx:

 vomiting of blood black tarry stool no

Abdomen Examination
epigastric pain, pain not related to taking food
(TRO PUD) Inspection: -
 loss of appetite or loss of weight (TRO ca)
 Chest pain, palpitation, SOB (TRO CAD, Palpation:
pneumonia)
o RHC tenderness
Due to concern seek tx
Acute cholecystitis:
 US – was told that stone in CBD/ gallbladder
o Positive Murphy’s sign positive (inspiratory arrest
 Xray, AXR? , blood sample
during deep palpation of the RUQ)
 Plan for – ercp, lap.cholecystectomy
o Boas’s sign – hyperaesthesia below the right
Systemic Review scapula (between 9-11th ribs posteriorly, location-
phrenic nerve innervation)

o Palpable GB (30%) – omentum wrapping around

GB = empyema of GB

Percussion: -

Auscultation: -
Courvoisier’s law  Mild jaundice + gallbladder is palpable (feel globular shape) but non tender, the cause is likely to be
malignancy rather than gallstone

- stoneinflammationfibrosis not distensible

- stone obstruction wall thickening not distensible

- 4 exceptions:

 Double impaction of stones ( 1 CBD+ 1 in cystic ducts)

 Stone converse ( if not palpable does not mean it is due to stone)
 Stone in cystic dust ( other thing compress CBD)
 Stones in CBD but normal distensible GB
Cholelithiasis

Definition Cholelithiasis refers to the presence of gallstones in the gallbladder

Types of stone Can be divided into 3 types :
 Cholesterol stones
 Pigment stones
 Mixed stones

Risk factor The main factors of gallstones formation are :

 Biliary stasis
 Infection
 Imbalance in the constituents of bile
4F: fat, female, forty, fertile (estrogenic influence – pregnancy and OCP use lead to increase uptake and
biosynthesis of cholesterol in the liver leading to increase biliary cholesterol excretion)

Clinical features
CLINICAL COURSE
Patients can be divided into 3 clinical stages  asymptomatic, symptomatic cholelithiasis and complicated
cholelithiasis

Asymptomatic Gallstones
 Detected on routine imaging studies or incidentally at laparotomy
 80-95% of patients will have asymptomatic gallstones
 Risk of symptom occurrence is 1 to 2% per year, of which
Thus the majority of patients do not require prophylactic cholecystectomy  expectant Management
 Symptomatic Gallstones = biliary colic
Initiated by impaction of a gallstone in the outlet of the gallbladder

Site: epigastric (70%) or RHC pain (Severe right hypochondrium tenderness)

Onset: gradual in onset
Character: Not a true colic – Waxing-waning in character but rarely have any painfree intervals between
waves of pain (unlike ureteric colic where pain resolves completely in between) – basal pain is due to
inflammation of ductal epithelium & proximal distension
Radiating: inferior angle of the right scapula, or tip of right shoulder
Aggravating fx: Pain aggravates by eating fatty food
Relieving fx: Pain subsides over time or with analgesia and may recur some other time
Timing: Pain occurs within hours of eating a meal often awakening the patient from sleep
Severity: Pain is steady and intense
Duration: pain comes in distinct attacks lasting 30mins to several hours, often resolves spontaneously (if
>6hrs, suspect complication i.e. cholecystitis)
Other Symptoms: back pain, LUQ pain, nausea and vomiting (patient gets better after vomiting) bloating,
abdominal distension. No fever ( distinguish it from Ac. Cholecystitis)
Complication
Acute cholecystitis

Definition Inflammation of gallbladder wall with infection

 Initiated by obstruction of the cystic duct by an impacted gallstone
 Persistence of stone impaction leads to inflammation of the gallbladder which may be acute, chronic or
acute on chronic

Pathophysiology  Gallstone gets stuck in the cystic duct causing obstruction of biliary flow
 Gallbladder becomes distended and inflamed
50% of cultures are sterile (infection occurs eventually. In elderly, DM  severe with gas forming
organisms causing emphysematous cholecystitis)
Symptoms 1. Fever (low grade)
2. RUQ pain : aggravated by food intake , radiates to back (Radiates to the inferior angle of the scapula,
interscapular)
3. Nausea, vomiting
4. Anorexia
Signs  General inspection/examination:
o NO JAUNDICE

 Abdomen examination:
o RHC tenderness with guarding
o Positive Murphy’s sign positive (inspiratory arrest during deep palpation of the RUQ)
o Boas’s sign – hyperaesthesia below the right scapula (between 9-11th ribs posteriorly, location-phrenic
nerve innervation)
o Palpable GB (30%) – omentum wrapping around GB; worst case scenario is empyema

Investigation
1. FBC: leucocytosis
2. BUSEC: increased urea = dehydration
3. LFT: increased AST, ALT
4. Serum amylase: can be raised mildly, if >1000, pancreatitis
5. Pre-op ix: coagulation profile, ECG
6. US HBS:
 Stones in gallbladder
 Thickened GB wall
 Pericholecystic fluid
 Sonographic Murphy’s positive
 Contracted GB (chronic)

7. CT HBS (maybe buat?)= exclude empyema, perforation

Management Definitive mx:

Open/laparoscopic cholecystectomy OR
Percutaneous cholecystectomy

 Assess the patient’s vitals sign/condition and resuscitate the patient if needed – IV fluid resuscitation
 Empirical intravenous antibiotics – IV ceftriaxone and metronidazole
 Careful monitoring for signs of failure (peritonism, non-resolving fever/pain)
 Septic workup
 If feverPCM
 Analgesia
 NBM – bowel rest
 Definitive treatment – open or laparoscopic cholecystectomy
 Alternative Treatment – percutaneous cholecystostomy
o Involves percutaneous catheter placement in the gallbladder lumen under imaging
guidance (alternative to surgical cholecystectomy)
o Indications: moribund patients who are not fit for surgery or when early surgery is
difficult due to extensive inflammation
o Drains the gallbladder and alleviates the inflammation (resolves acute episode)
o Followed by elective cholecystectomy 4-6 weeks later
Take note:

Physiological Effects of Cholecystectomy

 Reflux disease & biliary gastritis (20 to the loss of concentrating action of the GB leading to increased flow of bile)
 Abdominal pain & diarrhoea (20 to disturbed micelles formation leading to fat intolerance and malabsorption)

Timing of cholecystectomy

 Dependent on several factors:

o Severity of illness
o Response to resuscitation and antibiotic therapy
o Logistical considerations (availability of OT, surgeon etc.)

 Possibilities available:
o Emergency (immediate; in sick patients who are not responding to treatment)
o Early (within few days of onset)
o Delayed/Interval (after 6-8 weeks)
Choledocholithiasis

Definition Presence of gallstones in CBD (originated from the gallbladder and pass through the cystic duct into the
common bile duct)

Pathophysiology If stones in the gall bladder migrates and dislodge in the common bile duct
 Lead to obstructive jaundice, ascending cholangitis and acute pancreatitis

Symptoms  RUQ or epigastric pain (pain often more prolonged than seen with biliary colic)
 Nausea and/or Vomiting
 Obstructive Jaundice – tea-coloured urine, pale stools
 Complications: obs jaundice& acute cholangitis & acute pancreatitis

Signs  General inspection/examination:

o Jaundice

 Abdomen examination:
o RHC tenderness
Investigation
1. FBC: leucocytosis
2. BUSEC: increased urea = dehydration
3. LFT: increased ALP, increased CB (obstructive jaundice)
4. Serum amylase: can be raised mildly, if >1000, pancreatitis (tgk keadaan buat ke x)
5. Pre-op ix: coagulation profile, ECG
6. US HBS:
o gallstones in CBD
o CBD dilated : normal = 6-7 mm, dilated = >6 mm
o Acoustic shadow of stone

*other than US: MRCP, EUS

7. ERCP
o Identify presence of stone
o Sphincterotomy: Sphincterotomy is cutting the muscle that surrounds the opening of the
ducts, or the papilla. This cut is made to enlarge the opening. The cut is made while your
doctor looks through the ERCP scope at the papilla, or duct opening.
o Stenting to drain the bile
o Removal of stone

Management Definitive mx:

1. ERCP – to remove stone in CBD and stenting to drain bile
2. Followed by Interval Open/laparoscopic cholecystectomy + Laparoscopic CBD exploration (if stones
are seen)
o If Lap. CBD exploration fails to clear stone  open CBD exploration

**CBD exploration = a small incision (cut) in the abdomen, locates the bile duct and injects a dye into the duct.
The doctor then takes an X-ray, which shows where the stone or blockage is located. If stones are found, the
doctor makes a cut into the bile duct and removes stones.

 Assess the patient’s vitals sign/condition and resuscitate the patient if needed – IV fluid resuscitation
  Empirical intravenous antibiotics – IV ceftriaxone and metronidazole
 Careful monitoring for signs of failure (peritonism, non-resolving fever/pain)
 Septic workup
 If feverPCM
 Analgesia
 NBM – bowel rest
 Definitive treatment : plan for ERCP  interval lap.cholecystectomy

Ascending cholangitis
Definition Infection of biliary tract due to ascending bacterial infection from obstruction (gallstone)

 A life-threatening bacterial infection of the biliary tree associated with partial or complete obstruction
of the ductal system
 A delay in treatment can result in multi-organ failure secondary to septicaemia
Pathophysiology
 Usually results from obstruction to the biliary system with infection of stagnant bile
 Most common cause is choledocholithiasis (60%);

Aetiology  Most common cause is choledocholithiasis (60%);

 Consider benign strictures (instrumentation), malignancy (pancreatic, biliary), foreign body (previous
instrumentation), PSC, Choledochal cysts, Mirizzi’s, haemophilia, biliary enteric anastomosis

Organism:
 Common causative organisms are gram negative bacteria and anaerobes – Klebsiella, E. coli,
Enterobacter, Enterococcus
 Small proportion (elderly, prev biliary surgery) – anaerobes (bacteriodes, clostridium), developing world
– parasites (Clonorchis sinensis, Ascaris lumbricoides)

Symptoms  Charcot’s triad: Right Upper Quadrant (RUQ) pain + intermittent fever with chills + jaundice
(only 50-70% of patients have the classic triad)

 Reynold’s pentad: Charcot’s triad + mental obtundation + hemodynamic instability

– seen in less than 10% of patients, more prevalent in the elderly

Signs  General inspection/examination:

o Jaundice

 Abdomen examination:
o RHC tenderness

Complications
 Sepsis
 Electrolyte abnormality (dehydration)
 Infection
 Coagulopathy (Vit K)
Investigation
1. FBC: leucocytosis
2. BUSEC: increased urea = dehydration
3. LFT: increased ALP, increased CB (obstructive jaundice)
4. Serum amylase: can be raised mildly, if >1000, pancreatitis (tgk keadaan buat ke x)
5. Pre-op ix: coagulation profile, ECG
6. US HBS:
 gallstones in CBD
 CBD dilated : normal = 6-7 mm, dilated = >6 mm
 Acoustic shadow of stone

*other than US: MRCP, EUS

7. ERCP
 Identify presence of stone
 Sphincterotomy: Sphincterotomy is cutting the muscle that surrounds the opening of the
ducts, or the papilla. This cut is made to enlarge the opening. The cut is made while your
doctor looks through the ERCP scope at the papilla, or duct opening.
 Stenting to drain the bile
 Removal of stone

8. CT HBS: if stones cannot be seen

Management Definitive mx:

ERCP – to remove stone in CBD and stenting to drain bile
 Followed by Interval Open/laparoscopic cholecystectomy + Laparoscopic CBD exploration (if stones are seen)
o If Lap. CBD exploration fails to clear stone  open CBD exploration

**CBD exploration = a small incision (cut) in the abdomen, locates the bile duct and injects a dye into the duct.
The doctor then takes an X-ray, which shows where the stone or blockage is located. If stones are found, the
doctor makes a cut into the bile duct and removes stones.

 Assess the patient’s vitals sign/condition and resuscitate the patient if needed – IV fluid resuscitation
 Empirical intravenous antibiotics – IV ceftriaxone and metronidazole
 Careful monitoring for signs of failure (peritonism, non-resolving fever/pain)
 Septic workup
 If feverPCM
 Analgesia
 NBM – bowel rest
 Definitive treatment : plan for ERCP  interval lap.cholecystectomy

When to do operative removal of stones (i.e. not suitable for ERCP)

 Stone >25mm
 Intrahepatic stone
 Large number of stones
 Impacted stone
 Dual pathology
 Tortuous duct
 Previous Billroth II (unsuitable anatomy for ERCP)

Other methods to decompress: (if cannot do ERCP)

 percutaneous transhepatic biliary drainage = PTBD (esp. if neoplastic obstruction) = (PTBD) is a medical
procedure for diagnosis or treatment of a bile duct obstruction. The objective of the procedure is to locate the
obstruction and/or to insert a temporary catheter to drain the bile.
 operative decompression

CBD EXPLORATION

Cholangiogram or choledochoscopy is performed

 Cholangiogram involves injection of dye – can image higher ducts
 Choledochoscopy involves using a scope to visualise the large biliary ducts – cannot image higher ducts, thus not
as sensitive, but can be used to remove stones visualised in the duct
 Choice of imaging depends on site of obstruction and the cause

Removal of stones
 Manual removal with stone-grasping forceps
 Flushing out stones
 Dredging stones out using balloon catheter or Dormia basket
 Lithotripsy

Consider use of biliary stent or T-tube after removal of stone(s)

If there is a lot of instrumentation of the biliary system during the operation, one should anticipate swelling and oedema of
the biliary system resulting in post-operative obstruction and build-up of bile  higher risk of biliary leakage

(a) Stent – removed later by endoscopy

(b) T-tube (usually inserted after CBD-E)
 A T-shaped tube with its horizontal limb placed in the CBD and the vertical limb
leading out to drain bile
 Functions as a “pressure release valve” as most of the bile will flow through the horizontal limb of the tube into
the distal part of the CBD; only when there is obstruction to flow will bile be diverted out through the vertical
limb
 Allows for post-op cholangiogram to check for remaining stones (at POD 9-10) before removal – free flow of
contrast into duodenum, no residual stones, and no free leak of contrast into peritoneum
 If all normal  release anchoring stitch and exert gentle traction on the tube; the tube should slip out easily, if
not, call for help
 If stones are present  leave tube in for 4-6 weeks to form a fibrous tract  allows for instrumentation of tract
with a scope to remove the stones

BILIARY BYPASS (UNCOMMON)

- Consider biliary bypass if there are
i. Multiple stones,
ii. The CBD is more than 2cm in diameter, or
iii. There are strictures
- Since the CBD has been chronically dilated, quite unlikely that it will function normally even
after removal of the obstruction
- Mostly replaced by endoscopic stenting
- Cholecystojejunostomy preferred over Roux-en-Y choledochojejunostomy

Obstructive jaundice
Definition: Jaundice due to obstruction of bile flow to the duodenum

Causes of obstructive jaundice

1. Choledocholithiasis
2. Head of pancreas carcinoma
3. Peri-ampullary carcinoma = tumour arise within 2 cm of ampulla of Vater in duodenum
4. Iatrogenic biliary stricture
5. Tumour compressing bile duct
6. Choledochal cyst
7. Parasitic infestation in CBD