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Gallstone Disease

Gallstone Disease. Objectives. Basic biliary anatomy and physiology Pathophysiology of gallstone disease Clinical manifestations of gallstone disease Complications of gallstone disease Investigation and management of gallstone disease. Gallbladder Surface Anatomy.

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Gallstone Disease

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  1. Gallstone Disease

  2. Objectives • Basic biliary anatomy and physiology • Pathophysiology of gallstone disease • Clinical manifestations of gallstone disease • Complications of gallstone disease • Investigation and management of gallstone disease

  3. Gallbladder Surface Anatomy • Lies in the right upper quadrant, under the costal margin at the level of the 9th costal cartilage • The level of the 9th costal cartilage can be palpated as a distinct notch

  4. Gallstones • Common (20% population) • Cholesterol stones in West • Female proponderance (3/1) • Risk factors • Obesity • Oestrogen • Hypercholesterolaemia • Increasing age • 5 F’s

  5. Clinical Manifestations • Asymptomatic • Cholecystitis • Biliary colic • Complications • Jaundice • Pancreatitis • Cholangitis • Gallstone ileus • Carcinoma of gallbladder

  6. Acute Cholecystitis • Acute inflammation of the gallbladder • Usually associated with calculi (stones) • Calculus causes obstruction at Hartmann's pouch or cystic duct • Less commonly with biliary sludge • A-calculus (no-stone) cholecystitis rare • Bacterial infection in 50% only • Recurrent attacks result in fibrosed thickened gallbladder (chronic cholecystitis)

  7. Acute Cholecystitis Clinical Features Pain • Sudden onset • Post-prandial • RUQ—around to back • Constant • Associated nausea and vomiting • May last several hours to days • Recurrent attacks common

  8. Acute Cholecystitis Signs • Pyrexia (37.5-38.5) • Associated jaundice signifies CBD blockage • CBD stone or Mirrizi’s Syndrome • Abdominal tenderness localized to RUQ • Murphys’ sign positive

  9. Murphys’ Sign • Inspiratory arrest with manual pressure below the gallbladder

  10. Murphy’s Sign

  11. Biliary Colic • Pain associated with passage of stone • Usually not colicky but constant (a misnomer) • As cholecystitis but notassociated with fever/ leucocytosis and positive Murphys’ sign • Usually resolves after minutes- few hours

  12. Complications • Empyema/ mucocele • Obstructive jaundice • Ascending cholangitis • Pancreatitis

  13. Charcots’ Triad- Ascending cholangitis • Pain • Fever • Jaundice

  14. Courvoisiers’ Law In the presence of jaundice a palpable gallbladder is most likely due to malignant obstruction of the bile duct • Based on presumption that patients with gallstones have chronically inflammed, fibrosed gallbladders incapable of distension • Does not always hold true e.g. • Empyema + CBD stone

  15. Acute Cholecystitis - Investigation • Bloods • FBC (WCC) • LFT’s (Bilirubin, GGT, Alk Phos) • Amylase • Imaging • CXR • Ultrasound • CT • Special tests

  16. Acute Cholcystitis – Special tests • Endoscopic Retrograde Cholecystogram (ERCP) • Diagnostic and therapeutic • Magnetic Resonance Imaging (MRC) • Other forms of Cholangiography • Intra-operative • Percutaneous Transhepatic (PTC) • Oral cholangiogram

  17. Acute Cholecystitis – Management • Restrict Oral intake (NPO) • Intravenous fluids • Ng tube aspiration (for vomiting) • Analgesia • Morphine • Intravenous antibiotics • Gram negative cover (co-amoxiclav—gentamicin—piperacillin) • Cholecystectomy after resolution

  18. Biliary Colic - Management • Acute attack usually resolves spontaneously • Analgesia • Investigations as for cholecystitis • Prolonged attacks treated as cholecystitis • Elective cholecystectomy

  19. Ascending Cholangitis • Charcots’ Triad • Investigations • FBC, LFT's, Amylase, US • Management • Resuscitation (IV fluids) • Antibiotics (G-negative cover) • Intensive monitoring (urometry)

  20. Ascending Cholangitis • Definitive management • ERCP and stone removal +/- stent • Cholecystectomy after resolution

  21. Gallstone Pancreatitis • Commonest cause of Pancreatitis • More severe than alcohol Pancreatitis • Due to CBD stones irritating pancreas • Obstruction at ampulla of Vater • Irritation in pancreatic portion of CBD

  22. Gallstone Pancreatitis • Supportive • Fluid resuscitation • Antibiotics • Analgesia • Definitive • ERCP & stone retrieval • Elective cholecystectomy

  23. Laparoscopic Cholecystectomy • Commonest elective surgical procedure • Standard treatment for gallstone disease • May be performed as daycase • Converted to open in small number

  24. Complications • Trauma • Common bile duct (CBD) • Intestine • Liver • Haemorrhage • Vessel injury • Liver injury • Cystic artery clips • Infection • Biliary peritonitis

  25. Late Complications • Post cholecystectomy syndrome • Rare • Pain • Occasionally due to stones in the biliary tree • Port site hernia • Umbilical • 10mm port sites

  26. ERCPEndoscopic Retrograde Cholangio Pancreato Graphy • Usually performed by gastroenterologists • Diagnostic and therapeutic • Indicated in jaundiced patients • Ampulla of Vater cannulated • Demonstrates ductal anatomy • Allows biopsy of malignant lesions • Therapeutic in relieving obstruction • Stone retrieval or Stenting

  27. Summary • Gallstones are common • Usually asymptomatic • Clinical manifestations • Cholecystitis • Biliary colic • Complications • Ascending cholangitis (Charcots' Triad) • Treatment • Laparoscopic cholecystectomy • ERCP

  28. Back to Department of Surgery

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