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Gallstone Disease
Last updated 14th May 2021
Spectrum of Gallstone Disease
- Asymptomatic gallstones
- Only 20-30% of patients with asymptomatic gallstones will develop symptoms within 20 years. No interventions are advised if diagnosed incidentally
- Biliary colic
- Acute cholecystitis
- Acute gallstone pancreatitis (link to acute pancreatitis)
- Choledocholithiasis
- Gallstone ileum (link to small bowel obstruction)
Biliary Colic
- Presents with several recurrent attacks of biliary colic. 50% patients have epigastric/ RUQ pain occurring after ingestion of fatty meal, radiating to scapula associated with bloating, nausea or vomiting
- Diagnosed using USS Liver
- Treatment
- Mild symptoms can be managed conservatively with dietary changes and analgesics .
- In those with severe or recurrent symptoms – elective laparoscopic cholecystectomy
Acute Cholecystitis/ Cholangitis
Presentation
- RUQ/epigastric pain – colicky in nature, radiating to tip of right shoulder
- Pyrexia
- Nausea & vomiting
- Obstructive jaundice may occur in cholangitis, obstruction of common bile duct or Mirizzi syndrome
Investigations
- IV access + Bloods
Routine – FBC, U&E, LFT (AST & Gamma GT needs to be added on), CRP, amylase
Venous blood gas – lactate (especially for acutely unwell patient, normal lactate is usually reassuring)
Blood cultures - Urine dip
- Urine pregnancy test/ serum HCG – for every female of reproductive age
- Erect CXR
- US Liver – presence of gallstones, gallbladder thickening, pericholecystic fluid, gallbladder sludge, dilated CBD (>7-10mm), acute pancreatitis
- MRCP – if dilated CBD on USS or deranged LFTs
Management
- IV Antibiotics
- IV Fluids
- Definite management – cholecystectomy
Choledocholithiasis (CBD stones)
This can be primary or secondary to gallbladder stones (more common)
Presentation
- Obstructive jaundice – Dark urine, icterus, clay coloured stools
- Cholangitis – Fever, RUQ pain and jaundice (Charcot’s triad); when associated with sepsis it is associated with hypotension and altered mental status (Reynold’s pentad)
- Silent – identified on imaging/cholangiography
Investigations
- As above for acute cholecystitis
- US Liver – may show biliary ductal dilatation or choledocholithiasis. Biliary ductal dilatation in the presence of gallstones suggests choledocholithiasis.
- MRCP
Treatment
- Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by elective laparoscopic cholecystectomy (common approach)
- Laparoscopic common bile duct exploration, single sitting ERCP with laparoscopic cholecystectomy
Acalculous Cholecystitis
- The exact pathophysiologic mechanism is poorly understood, but concentration of biliary solutes and stasis in the gallbladder play important roles.
- Risk factors – older age, critical illness, burns, trauma, prolonged use of total parenteral nutrition, diabetes and immunosuppression.
- Generally more fulminant than calculous cholecystitis and may progress to gangrene and perforation of GB.
- US – may show thickened gallbladder wall with pericholecystic fluid. (beware – similar US findings are in Congestive Cardiac Failure or anasarca without rise in inflammatory markers which does not require intervention)
- Treatment – similar to calculous cholecystitis. As many patients are critically ill and may not tolerate a laparotomy, percutaneous drainage is carried out in these cases. The cholecystostomy tube can eventually be removed and if follow up imaging demonstrates no stones, interval cholecystectomy is generally unnecessary