Professional Documents
Culture Documents
Gallstone
Gallstone
Epidemiology
Fat, Fair, Female, Fertile, Fourty inaccurate, but
reminder of the typical patient
F:M = 2:1
10% of British women in their 40s have gallstones
Genetic predisposition – ask about family history
Composition of bile:
Bilirubin (by-product of haem degradation)
Cholesterol (kept soluble by bile salts and lecithin)
Bile salts/acids (cholic acid/chenodeoxycholic acid):
mostly reabsorbed in terminal ileum(entero-hepatic
circulation).
Lecithin (increases solubility of cholesterol)
Inorganic salts (sodium bicarbonate to keep bile
alkaline to neutralise gastric acid in duodenum)
Water (makes up 97% of bile)
Cholesterol
Imbalance between bile salts/lecithin and cholesterol allows
cholesterol to precipitate out of solution and form stones
Pigment
Occur due to excess of circulating bile pigment (e.g.
Heamolytic anaemia)
Mixed
Same pathophysiology as cholesterol stones
Other Factors
Stasis (e.g. Pregnancy)
Ileal dysfunction (prevents re-absorption of bile salts)
Obesity and hypercholesterolaemia
80% Asymptomatic
20% develop complications and do so on
recurrent basis
Biliary Colic
Acute Cholecystitis
Gallbladder Empyema
Gallbladder gangrene
Gallbladder perforation
Obstructive Jaundice
Ascending Cholangitis
Pancreatitis
Gallstone Ileus (rare)
Gallstone disease (and its related complications)
Gastritis/duodenitis
Peptic ulcer disease/perforated peptic ulcer
Acute pancreatitis
Right lower lobe pneumonia
MI
Treatment
Analgesia
Fluid resuscitation if vomiting
If pain and vomiting subside does not need
admitting
Pathogenesis:
Due to obstruction of cystic duct by gallstone:
Cystic duct blockage by gallstone
Obstruction to secretion of bile from gallbladder
Bile becomes concentrated
Chemical inflammation initially
Secondarily infected by organisms released by liver into bile stream
Treatment
Admit for monitoring
Analgesia
Clear fluids initially, then build up oral intake as cholecystitis settles
IVF
Antibiotics
95% settle with above management
If do not settle then for CT scan
Empyema percutaneous drainage
Gangrene/perforation with generalised peritonitis emergency surgery
Pathogenesis:
Stone obstructing CBD (bear in mind there are other causes for obstructive
jaundice) – danger is progression to ascending cholangitis.
USS
Will confirm gallstones in the gallbladder
CBD dilatation i.e. >8mm (not always!)
May visualise stone in CBD (most often does not)
MRCP
In cases where suspect stone in CBD but USS indeterminate
E.g.1 obstructive LFTs but USS shows no biliary dilatation and no stone in CBD
E.g. 2 normal LFTS but USS shows biliary dilatation
ERCP
If confirmed stone in CBD on USS or MRCP proceed to ERCP which will confirm this (diagnostic)
and allow extraction of stones and sphincterotomy (therepeutic)
Treatment
Must unobstruct biliary tree with ERCP to prevent progression to ascending
cholangitis
Whilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis
Pathogenesis:
Stone obstructing CBD with infection/pus
proximal to the blockage
Treatment
ABC
Fluid resuscitation (clear fuids and IVF, catheter)
Antibiotics (Augmentin)
HDU/ITU if unwell/septic shock
Pus must be drained* - this is done by
decompressing the biliary tree
Urgent ERCP
Urgent PTC – if ERCP unavailable or unsuccesful
Pathogenesis
Obstruction of pancreatic outflow
Pancreatic enzymes activated within pancreas
Pancreatic auto-digestion
Treatment
Analgesia
Fluid resuscitation
Pancreatic rest – clear fluids initially
Identify underlying cause of pancreatitis
Treatment
NBM
Fluid resuscitation + catheter
NG tube
Analgesia
Surgery (will not settle with conservative management) – enterotomy +
removal of stone
Indications
A single complication of gallstones is an indication for
cholecystectomy (this includes biliary colic)
After a single complication risk of recurrent complications
is high (and some of these can be life threatening e.g.
cholangitis, pancreatitis)
Advantages:
Less post-op pain
Shorter hospital stay
Quicker return to normal activities
Disadvantages:
Learning curve
Inexperience at performing open cholecystectomies
After acute cholecystitis, cholecystectomy traditionally performed
after 6 weeks