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Home | Articles | General Surgery | Gallstone Disease

Gallstone Disease

Last updated 14th May 2021

Spectrum of Gallstone Disease

  1. Asymptomatic gallstones
    • Only 20-30% of patients with asymptomatic gallstones will develop symptoms within 20 years. No interventions are advised if diagnosed incidentally
  2. Biliary colic
  3. Acute cholecystitis
  4. Acute gallstone pancreatitis (link to acute pancreatitis)
  5. Choledocholithiasis
  6. Gallstone ileum (link to small bowel obstruction)

Biliary Colic

  1. 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
  2. Diagnosed using USS Liver
  3. Treatment
    1. Mild symptoms can be managed conservatively with dietary changes and analgesics .
    2. In those with severe or recurrent symptoms – elective laparoscopic cholecystectomy

Acute Cholecystitis/ Cholangitis

Presentation

  1. RUQ/epigastric pain – colicky in nature, radiating to tip of right shoulder
  2. Pyrexia
  3. Nausea & vomiting
  4. Obstructive jaundice may occur in cholangitis, obstruction of common bile duct or Mirizzi syndrome 

Investigations 

  1. 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
  2. Urine dip
  3. Urine pregnancy test/ serum HCG – for every female of reproductive age
  4. Erect CXR 
  5. US Liver – presence of gallstones, gallbladder thickening, pericholecystic fluid, gallbladder sludge, dilated CBD (>7-10mm), acute pancreatitis
  6. MRCP – if dilated CBD on USS or deranged LFTs

Management

  1. IV Antibiotics
  2. IV Fluids
  3. Definite management – cholecystectomy

Choledocholithiasis (CBD stones)

This can be primary or secondary to gallbladder stones (more common)

Presentation

  1. Obstructive jaundice – Dark urine, icterus, clay coloured stools
  2. 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)
  3. Silent – identified on imaging/cholangiography

Investigations

  1. As above for acute cholecystitis
  2. US Liver – may show biliary ductal dilatation or choledocholithiasis. Biliary ductal dilatation in the presence of gallstones suggests choledocholithiasis.
  3. MRCP

Treatment

  1. Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by elective laparoscopic cholecystectomy (common approach)
  2. Laparoscopic common bile duct exploration, single sitting ERCP with laparoscopic cholecystectomy

Acalculous Cholecystitis

  1. The exact pathophysiologic mechanism is poorly understood, but concentration of biliary solutes and stasis in the gallbladder play important roles.
  2. Risk factors – older age, critical illness, burns, trauma, prolonged use of total parenteral nutrition, diabetes and immunosuppression.
  3. Generally more fulminant than calculous cholecystitis and may progress to gangrene and perforation of GB.
  4. 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)
  5. 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