Biliary Emergencies When 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