Gallbladder Disease Surgical Students Society of Melbourne, 2011 J. Bridie Mee RMH intern

Gallstone Disease Cholelithiasis Choledocolithiasis Biliary Colic Cholecystitis

Gallstone Types Cholesterol stones Pigment stones

Risk Factors Fair Female Fat Forties Fertile also DM, family Hx

Epidemiology Why do you need to know about it? 2 nd most common abdo organ requiring surgery Population prevalence 5-20% of which majority (70-80%) remain asymptomatic 1-4% develop symptoms each year

Biliary Colic - Symptoms Site Onset Timing Character Radiation Severity Assoc sympt Aggrav/reliev

Biliary Colic - Symptoms SiteRUQ Onsetsudden Timing30 min – 6 hrs Characterdull Radiation +/- to epigastrium, back Severityvery Assoc symptnausea & vomiting Aggrav/reliev fatty foods, analgesics

Biliary Colic - Examination General: Restless, +/- jaundice Obs: tachy Abdo: RUQ tenderness, guarding

Biliary Colic - Investigations FBE LFT UEC Amylase/lipase CXR/AXR Upper abdo ultrasound

Differentials Abdo: – Acute cholecystitis – Pancreatitis – GORD – Perforate PUD – Appendicits (atypical) – pyelonephritis Thoracic: – Pneumonia – angina

Biliary Colic - Management Analgesia Exclude complications/differentials Elective cholecystectomy

Acute Cholecystitis Acute inflammation of GB following impactions of stone, +/- infective Symptoms: – RUQ/epigastric pain – Nausea, vomiting – Fever – Aggravated by movement, deep breathing

Acute Cholecystitis - Examination General distressed, still, shallow breathing, +/- jaundice (scleral) Obs febrile, tachycardia Abdo RUQ tenderness, guarding +/- Murphy’s sign/peritonism

Acute Cholecystitis - investigations FBE, UEC, LFT, CRP Amylase/lipase ECG CXR/AXR Upper abdo US

Acute Cholecystitis - Ultrasound

90-95% sensitive What are the ultrasound findings?

Acute Cholecystitis - Management Call surg admit! Analgesia opiods NBM IVFT Antibiotics

Cholecystectomy: Indications & Timing Not indicated for incidental findings of cholelithiasis that are asymptomatic Elective for biliary colic During admission elective or urgent for acute cholecystitis Alternatives if unfit for surgery – Abx and percutaneous drainage

Laparotomy vs Laparoscopy

Complications Gangrenous cholecystitis Obstructive jaundice Cholangitis Gallstone ileus Pancreatitis Death!

Choledocolithiasis causing Obstructive Jaundice Post-hepatic jaundice (GGT, ALP) Symptoms – Hx of previous gallbladder disease – Jaundice – Pale stools, dark urine

Obstructive Jaundice – Ix LFT, FBE, UEC, CRP USS – GB, CBD, stones MRCP

Treatment obstructive jaundice ERCP Laparoscopic/open cholecystectomy with IOC

ERCP

Cholangitis When obstructed CBD becomes infected Charcot’s triad of signs – RUQ pain – jaundice – High fever/rigors Can be life threatening, early treament essential

Gallstone Ileus When stone perforates GB wall and erodes into duodenum, obstructing small bowel Treatment - laparotomy

Pancreatitis When gallstone irritates pancreas causing inflammation, or distal CBD blockage causing intrapancreatic release of enzymes 30-50% pancreatitis caused by gallstones Can be life threatening

Take home messages Gall stone disease very common, worth knowing about, understanding anatomy helps Feel lots of bellies Complications can be life threatening Get scrubbed for a cholecystectomy!