Biliary EmergenciesWhen the text books don’t help

T R Wilson

CASE 1 – Part 1

• 49 year old female• PMHx: BMI 32, Depression• 24 hours of RUQ pain• Tender, Guarding RUQ• USS: Thick wall GB with multiple stones, CBD

8mm• WCC 14.0, CRP 132, AST 102, ALP 140, BR 28

CASE 1 – Issues to discuss

• To operate or manage with antibiotics• Further imaging• What considerations when deciding to

operate• What NICE guidance ?

Risk of duct stones

CASE 1 – part 2

• Operation– Thick distended GB wrapped in omentum and can’t

grasp wall– Callot’s very stuck with no discernible planes

• How to proceed

• “It is better to remove 95% of the gall bladder than 101%”

Learning points

• AC should be managed like appendicitis– Operate as soon as possible– Logistical barriers common problem

• Minimal LFT derangements common due to periportal inflammation– MRCP desirable to exclude duct stones– On table cholangiogram if expertise to intervene

• Safe surgery– Open surgery is not a failure of care – easier than you think– Consider subtotal cholecystectomy

CASE 2

• 82 year old lady• PMHx stable IHD, HT, DM• Admitted with 48 hours of RUQ Pain• USS: Thick walled distended GB with stone in

neck and trace pericholecystic fluid• Been on 48 hours of Cef and Met• Temp 38.5, P 110, BP 102/68, RR 24, Sats 92%• CRP 320 (↑ from 280); WCC 16; Biochem NAD

CASE 2 - Issues

• Further investigation• Consider cholecystostomy vs surgery• Post recovery management of

cholecystostomy• Offer further surgery

Learning Points

• If clinical deterioration consider reimaging– CT can often be useful for collections/perforation

• If GB obstructed in frail patient– Radiological cholecystostomy if not improving– Remove after clamping or cholecystogram• If clamping/imaging fails then will need to consider Sx

– Once better re-consider surgery - Recommended

CASE 3

• 76 year old lady• PMHx: Pacemaker• Admitted with jaundice and sepsis• Temp 39, P 130, BP 80/40• BR 120, ALP 1200, ALT 400, CRP 210, WCC 19• USS: Multiple stones in thin wall GB. 9mm CBD

with no intrahepatic duct dilatation, but stone in distal CBD.

Case 3 - issues

• Resuscitation• Antibiotics• Critical care input• When to get drainage• Clotting

CASE 3 ctd

• Responds to antibiotics over next 3 days• BR ↓to 80, ALP ↓ to 900

• ERCP: Cannot canulate due to diverticulum

Case 3 - issues

• Further management– MRCP vs– ERCP

• Can she go home?

NICE Summary 188 – Oct 2014

• Asymptomatic – Do not treat• If acute cholecystitis – surgery within 1 week• If empyema and surgery contraindicated– Cholecystostomy if medical treatment fails– Re-consider surgery once better

• Clear bile duct stones– Operatively at time of surgery– ERCP before or at surgery

• If ERCP fails to remove stones – use temporary stent to achieve drainage prior to definitive Mx