Gallstones - Nicola Tanner

COMPLICATIONS OF GALLSTONES & THEIR

MANAGEMENT

Anatomy revision

10 complications Pathogenesis Symptoms Signs Management

Anatomy

1) Acute cholecystitis2) Chronic cholecystitis3) Obstructive jaundice4) Cholangitis5) Acute pancreatitis6) Mucocele7) Empyema8) Gallstone ileus9) Gallbladder perforation10) Gallbladder carcinoma

Acute Cholecystitis Cholecyst- Gallbladder -itis Inflammation -ectomy Removal

Acalculus vs calculus Inflammation of GB wall Obstruction of cystic duct Oedema, mucosal ulceration, fibro

purulent exudate

Acute Cholecystitis

Acute Cholecystitis Symptoms

RUQ/epigastric pain Fever Nausea & vomiting, anorexia

Signs Tender RUQ, guarding, rebound Murphy’s positive ↑WCC, ↑CRP, mildly ↑LFTs

Acute Cholecystitis Imaging

USS/CT – thickened GB wall, pericholecystic fluid, stones, distended GB

Management Admission

IV rehydration & NBM/clear fluids Analgesia Antibiotics

Cholecystectomy

Chronic Cholecystitis Gallstones invariably Repeated attacks fibrosis Insidious onset vs several attacks Common histological finding after

cholecystectomy

Asymptomatic vs pain

Management = conservative vs surgical

Obstructive Jaundice Blockage of biliary tree (CBD or hepatic duct) Intra-luminal vs extra-luminal Mirizzi Syndrome Local oedema

Courvoisier’s Law – jaundice, pain, non-palpable gallbladder

Management USS +/- MRCP ERCP Cholecystectomy

Obstructive Jaundice

Mirizzi’s Syndrome

Ascending Cholangitis Cholang- Bile ducts -itis Inflammation/infection

Biliary tree infection in presence of obstruction (stones, stricture)

Signs & Symptoms Unwell jaundiced patient! Charcot’s Triad = fever, pain, jaundice

Ascending Cholangitis Management

Resuscitation IV antibiotics

Biliary tree decompression ERCP, radiological or surgical

intervention

Definitive management of cause of obstruction

Acute Pancreatitis Inflammatory process due to local

enzymatic effects Causes:

GET SMASHED Gallstones Ethanol Trauma (ERCP)

Acute Pancreatitis

Acute Pancreatitis Signs & Symptoms

Epigastric pain radiating to back Tender, rigid abdomen, vomiting,

dehydrated Raised amylase, history of jaundice or

recent ERCP, or previous RUQ pains

Management Resuscitation, analgesia, removal of

cause & prevention of future episodes

ERCP Endoscopic Retrograde Cholangio-

Pancreatography

Imaging of biliary tree +/- therapeutic removal of stones +/- stent insertion +/- sphincterotomy

Mucocele Impaction of stone in GB neck or cystic

duct when GB empty of bile

Mucous is secreted into GB from epithelium

No inflammation so GB swells to many times its normal size

Signs & Symptoms Pain Tender RUQ mass

Mucocele

Empyema Impaction of stone in GB neck or cystic

duct with superadded infection of bile Water absorbed so bile concentrated Pus present

Due to: Acute cholecystitis Infection of mucocele

Empyema Signs

Palpable tender gallbladder Septic patient

Management Early cholecystectomy (prevents

perforation) Radiologically-guided percutaneous

drainage (temporary measure)

Gallstone Ileus Fistula between gallbladder & bowel Stone travels through bowel & embedded in

narrow point of bowel causing bowel obstruction Usually ileo-caecal valve (small bowel) Signs & Symptoms

Previous RUQ pain, small bowel obstruction X-ray – distended small bowel loops (opacity in

RIF), air in biliary tree Rigler’s triad: SBO; pneumobilia; GS in RIF

Management Laparotomy, resuscitation, milk stone back

and remove via cut into healthy section of bowel

Gallstone Ileus

Gallbladder Perforation Inflammation causes necrosis of GB wall

causing perforation Following empyema or acute cholecystitis

Biliary peritonitis Significant mortality (60%)

Carcinoma of the Gallbladder

Rare 4 Female:1 Male 95% of cases associated with gallstones

Incidental finding during cholecystectomy, or presents with similar picture to chronic cholecystitis.

Management Radical resection including liver

segments

THANK YOU!Questions?