1. Grand Round Presentation – 21/11/06

2. Prologue: Journey Of The Stone  Overview of the biliary system & related organs  Presentation of 2 patients with gallstones  Pathology & aetiology of gallstones  Problems associated with gallstones  Investigation & management of gallstones

3. Fig 1: The Biliary System

4. Fig 2: ERCP - Contrast

5. Fig 3: ERCP - Sphincterotomy

6. Fig 4: ERCP - Endoscope

7. Fig 5: Double Pig-Tail Stent

8. Fig 5: MRCP

9. Fig 6: Gallstone Pancreatitis

10. Chapter 3: The Birth Of A Gallstone  Risks: 4 F’s: Fat, Fertile Females of Forty.  Also diet, rapid weight loss, drugs (OCP), diabetes  80% cholesterol-based, 20% pigment (Ca-bilirubinate):  Cholesterol & bile salts secreted from hepatocytes & stored in gallbladder  Stones form on a nidus (mucins) often when motility is ↡

11. 3.1: Heart Of Stones  Cholesterol: super-saturation with relation to bile salts. Predisposes as cholesterol can precipitate on nidus  Pigment: black (Ca-salts & glycoproteins) which are associated with haemolysis  Pigment: brown (Ca-salts & fatty acids); occur during stasis. Can cause recurrent stones post-cholecystectomy  Cholesterol stones missed on radiographs as radiolucent

12. Chapter 4: Struggles With The Stones  Most are asymptomatic (80%), discovered incidentally  Biliary Colic +/- nausea, vomiting & jaundice  Aggravated by food (especially fatty), relieved by opiates  2ndry complications associated with pyrexia & ↟ pain  Cholecystitis (acute or chronic), empyema, mucocele, pancreatitis, cholangitis, perforation, fistulae & gallstone ileus

13. 4.1: Judging The Jaundice  Unconjugated (haemolytic) or conjugated (congenital or cholestatic)  Biliary Obstruction: Intra-hepatic or Extra-hepatic: Extra- ductal or Intra-ductal  Intra-hepatic: Hepatitis, Cirrhosis, Drugs, Pregnancy. Associated with ↟ AST & ALT  Extra-hepatic: Carcinoma, strictures, inflammation, gallstones. Associated with ↟ ALP &  GT

14. 4.2: Problems With The Pancreas  GET SMASHED! Gallstones Ethanol Trauma Steroids Mumps Autoimmune (PAN) Scorpion Sting Hyper -lipidaemia -Ca 2+, Hypothermia ERCP, Emboli Drugs

15. 4.2: Problems With The Pancreas (…cont’) Age> 55 years pO 2 < 8 mmHg Glucose> 10 mmol/l Blood Urea Nitrogen> 46 mg/dl Calcium< 2 mmol/l LDH> 600 u/l WBC> 15 x10 9 /l Albumin< 32 g/l  Glasgow Modified Severity Scale (>3 = Severe)  Also APACHE-II, Ranson & Multi-Organ System Failure

16. Chapter 5: Chasing The Calculi  Clinical: History & Examination (jaundice, pain)  Bloods: ↟ ALP +/- amylase & bilirubin if obstructed  Radiograph / CT not useful without contrast  USS: imaging investigation of choice: non-invasive, accurate, cheap, sensitive (95%). Can be endoscopic  MRCP: T2, better for visualising ducts & level of calculi but not as sensitive in early dilatation

17. 5.1: Removing The Rock  ERCP: Uses contrast to visualise biliary tree. Can be used to remove stones from CBD, insert stents and perform sphincterotomies. Can cause pancreatitis (5%)  Percutaneous transhepatic cholangiogram (PTC) sometimes used if close to the liver  If asymptomatic manage conservatively  Medical interventions include: shockwave lithotripsy, ursodeoxycholic acid ( ↡ cholesterol secretion) & bile salts

18. 5.1: Removing The Rock  Surgical includes laparoscopic & open cholescystectomy  Most laparoscopic. Incision in umbilicus, fill peritoneum with gas, insert light. 3 more incisions in RUQ for instruments. CD clipped & gallbladder removed in bag  5% need to convert to open: midline scar  Complications if wrong duct clipped, infection, perforation and if stones spilled into peritoneum or ducts (…cont’)

19. Epilogue: Legacy Of The Stone  Gallstones are a common problem in the middle-aged and elderly population but are often asymptomatic  Diagnosis often made on history & examination +/- USS  Obstruction may present with jaundice & complications  MRCP & ERCP often used in cases of obstruction  Medical treatment may be used but most often laparoscopic cholecystectomy is performed

20. References: Writings On The Stone  Burroughs AK, Westaby D: Liver, biliary tract and pancreatic disease, In Kumar P, Clark M: Clinical Medicine (5 th Edition). WB Saunders, 2002  Longmore M, Wilkinson I, Török E: Oxford Handbook Of Clinical Medicine. Oxford University Press, 2001  Adamek HE, Albert J, Weitz M: A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut, 1998; 43(5): 680-683  Ahmed A, Cheung RC, Keeffe EB: Management of gallstones and their complications. Am Fam Physician, 2000; 61(6): 1673-1688  Werner J, Feuerbach S, Uhl W, Buchler MW: Management of acute pancreatitis: from surgery to interventional intensive care. Gut, 2005; 54(3): 426-436