Gall stones

Introduction 

·         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 mixed composition (50%) with pure cholesterol stones accounting for 20% of cases. The etiology 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 arises 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

·         function tests Of In almost all suspected cases the standard diagnostic workup consists of abdominal ultrasound and liver patients who have stones within the bile duct, 60% will have at least one abnormal result on LFTs. 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

 

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, subtotal cholecystectomy maybe

needed if the Calots triangle is hostile

In unfit patients, percutaneous drainage maybe

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 a 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 the absence of

stones

• High fever

If the patient fits then cholecystectomy, if unfit then

percutaneous cholecystostomy

 

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 selective use of ultrasound-guided cholecystostomy. During the procedure, some surgeons will routinely perform either intraoperative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by the 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 trans-cystic exploration fails the alternative strategy is that of formal choledocholithotomy. 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.