Gallstones
Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery, 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases.
The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East, a far higher proportion arise in the CBD de novo.
The classical symptoms are of colicky right upper quadrant pain that occurs postprandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
In almost all suspected cases the standard diagnostic workup consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT's. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intraoperative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances, preoperative MRCP is probably a better option.
Specific gallstone and gallbladder related disease
Treatment
Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may, therefore, be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient, there is sometimes a role for the selective use of ultrasound guided cholecystostomy.
During the course of the procedure, some surgeons will routinely perform either intraoperative cholangiography to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.
Risks of ERCP(1)
References
1. Williams E et al. Guidelines on the management of common bile duct stones (CBDS)Gut 2008;57:10041021
2. Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005440.
The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East, a far higher proportion arise in the CBD de novo.
The classical symptoms are of colicky right upper quadrant pain that occurs postprandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Investigation
In almost all suspected cases the standard diagnostic workup consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT's. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intraoperative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances, preoperative MRCP is probably a better option.
Specific gallstone and gallbladder related disease
| Disease | Features | Management |
|---|---|---|
| Biliary colic | Colicky abdominal pain, worse postprandially, worse after fatty foods | If imaging shows gallstones and history compatible then laparoscopic cholecystectomy |
| Acute cholecystitis | Right upper quadrant pain Fever Murphys sign on examination Occasionally mildly deranged LFT's (especially if Mirizzi syndrome) | Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2) |
| Gallbladder abscess | Usually prodromal illness and right upper quadrant pain Swinging pyrexia Patient may be systemically unwell Generalised peritonism not present | Imaging with USS +/- CT Scanning Ideally, surgery although subtotal cholecystectomy may be needed if Calot's triangle is hostile In unfit patients, percutaneous drainage may be considered |
| Cholangitis | Patient severely septic and unwell Jaundice Right upper quadrant pain | Fluid resuscitation Broad-spectrum intravenous antibiotics Correct any coagulopathy Early ERCP |
| Gallstone ileus | Patients may have a history of previous cholecystitis and known gallstones Small bowel obstruction (may be intermittent) | Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with. |
| Acalculous cholecystitis | Patients with intercurrent illness (e.g. diabetes, organ failure) Patient of systemically unwell Gallbladder inflammation in absence of stones High fever | If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy |
Treatment
Asymptomatic gallstones which are located in the gallbladder are common and do not require treatment. However, if stones are present in the common bile duct there is an increased risk of complications such as cholangitis or pancreatitis and surgical management should be considered.
Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may, therefore, be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient, there is sometimes a role for the selective use of ultrasound guided cholecystostomy.
During the course of the procedure, some surgeons will routinely perform either intraoperative cholangiography to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.
Risks of ERCP(1)
- Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
- Duodenal perforation 0.4%
- Cholangitis 1.1%
- Pancreatitis 1.5%
References
1. Williams E et al. Guidelines on the management of common bile duct stones (CBDS)Gut 2008;57:10041021
2. Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005440.