1. Gallstone Disease

2. Objectives Basic biliary anatomy and physiology
Pathophysiology of gallstone disease
Clinical manifestations of gallstone disease
Complications of gallstone disease
Investigation and management of gallstone disease

3. Gallbladder Surface Anatomy
Lies in the right upper quadrant, under the costal margin at the level of the 9th costal cartilage
The level of the 9th costal cartilage can be palpated as a distinct notch

10. Gallstones Common (20% population) Cholesterol stones in West
Female proponderance (3/1)
Risk factors
Obesity
Oestrogen
Hypercholesterolaemia
Increasing age
5 F’s

11. Clinical Manifestations
Asymptomatic
Cholecystitis
Biliary colic
Complications
Jaundice
Pancreatitis
Cholangitis
Gallstone ileus
Carcinoma of gallbladder

12. Acute Cholecystitis Acute inflammation of the gallbladder
Usually associated with calculi (stones)
Calculus causes obstruction at Hartmann's pouch or cystic duct
Less commonly with biliary sludge
A-calculus (no-stone) cholecystitis rare
Bacterial infection in 50% only
Recurrent attacks result in fibrosed thickened gallbladder (chronic cholecystitis)

13. Acute Cholecystitis Clinical Features
Pain
Sudden onset
Post-prandial
RUQ—around to back
Constant
Associated nausea and vomiting
May last several hours to days
Recurrent attacks common

14. Acute Cholecystitis Signs Pyrexia (37.5-38.5)
Associated jaundice signifies CBD blockage
CBD stone or Mirrizi’s Syndrome
Abdominal tenderness localized to RUQ
Murphys’ sign positive

15. Murphys’ Sign
Inspiratory arrest with manual pressure below the gallbladder

16. Murphy’s Sign

17. Biliary Colic Pain associated with passage of stone
Usually not colicky but constant (a misnomer)
As cholecystitis but not associated with fever/ leucocytosis and positive Murphys’ sign
Usually resolves after minutes- few hours

18. Complications Empyema/ mucocele Obstructive jaundice
Ascending cholangitis
Pancreatitis

19. Charcots’ Triad- Ascending cholangitis
Pain
Fever
Jaundice

20. Courvoisiers’ Law
In the presence of jaundice a palpable gallbladder is most likely due to malignant obstruction of the bile duct
Based on presumption that patients with gallstones have chronically inflammed, fibrosed gallbladders incapable of distension
Does not always hold true e.g.
Empyema + CBD stone

21. Acute Cholecystitis - Investigation
Bloods
FBC (WCC)
LFT’s (Bilirubin, GGT, Alk Phos)
Amylase
Imaging
CXR
Ultrasound CT
Special tests

22. Acute Cholcystitis – Special tests
Endoscopic Retrograde Cholecystogram (ERCP)
Diagnostic and therapeutic
Magnetic Resonance Imaging (MRC)
Other forms of Cholangiography
Intra-operative
Percutaneous Transhepatic (PTC)
Oral cholangiogram

23. Acute Cholecystitis – Management
Restrict Oral intake (NPO)
Intravenous fluids
Ng tube aspiration (for vomiting)
Analgesia
Morphine
Intravenous antibiotics
Gram negative cover
(co-amoxiclav—gentamicin—piperacillin)
Cholecystectomy after resolution

24. Biliary Colic - Management
Acute attack usually resolves spontaneously
Analgesia
Investigations as for cholecystitis
Prolonged attacks treated as cholecystitis
Elective cholecystectomy

25. Ascending Cholangitis
Charcots’ Triad
Investigations
FBC, LFT's, Amylase, US
Management
Resuscitation (IV fluids)
Antibiotics (G-negative cover)
Intensive monitoring (urometry)

26. Ascending Cholangitis
Definitive management
ERCP and stone removal +/- stent
Cholecystectomy after resolution

27. Gallstone Pancreatitis
Commonest cause of Pancreatitis
More severe than alcohol Pancreatitis
Due to CBD stones irritating pancreas
Obstruction at ampulla of Vater
Irritation in pancreatic portion of CBD

28. Gallstone Pancreatitis
Supportive
Fluid resuscitation
Antibiotics
Analgesia
Definitive
ERCP & stone retrieval
Elective cholecystectomy

29. Laparoscopic Cholecystectomy
Commonest elective surgical procedure
Standard treatment for gallstone disease
May be performed as daycase
Converted to open in small number

35. Complications Trauma Common bile duct (CBD) Intestine Liver
Haemorrhage
Vessel injury
Liver injury
Cystic artery clips
Infection
Biliary peritonitis

36. Late Complications Post cholecystectomy syndrome Rare Pain
Occasionally due to stones in the biliary tree
Port site hernia
Umbilical
10mm port sites

37. ERCP Endoscopic Retrograde Cholangio Pancreato Graphy
Usually performed by gastroenterologists
Diagnostic and therapeutic
Indicated in jaundiced patients
Ampulla of Vater cannulated
Demonstrates ductal anatomy
Allows biopsy of malignant lesions
Therapeutic in relieving obstruction
Stone retrieval or Stenting

39. Summary Gallstones are common Usually asymptomatic
Clinical manifestations
Cholecystitis
Biliary colic
Complications
Ascending cholangitis (Charcots' Triad)
Treatment
Laparoscopic cholecystectomy
ERCP

40. Back to Department of Surgery