Gallstone Disease

Patients regularly present under the surgical take with gall stone disease. The aim of this article is to supplement the surgical webinar series session on gallstone disease that can be found on this website. The key learning points are to understand the background of gallstone disease, appreciate how they can present, and understand key concepts for investigation and management.

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Background

92% of patients with gallstone disease present with biliary colic or cholecystitis rather than cholangitis or other rarer presentations of gallstone disease. Note that about 15% of asymptomatic patients have gall stones. Thus identifying gall stones does not mean that’s the cause of a patient’s symptoms. Only up to 25% of those with gall stones will ever develop symptoms.

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From webmd.com

Understanding gallstone disease

Definitions
  • Cholelithiasis – formation of gallstones in the gallbladder
  • Choledocholithiasis – The presence of gallstones within the CBD
  • Cholecystitis – Inflammation of the GB
  • Cholangitis – Inflammation of the bile ducts
  • Cholestasis – failure of normal amounts of bile to reach the intestine
Types of gallstone
  1. Cholesterol (30%) = large, fewer
  2. Pigment = small, irregular, dark
  3. Mixed (50%)
  4. Sometimes de novo in CBD (more common in the Far East)
Biliary colic
  • The gall stone transiently blocks the cystic duct. Usually for a few hours but it can be anywhere from 15 minutes to up to 24h
  • This often occurs after eating (post-prandial) when the gall bladder contracts
  • Thus the usually asymptomatic stones, present with an intermittent colicky RUQ pain but are systemically well patient as there’s no infection
  • Discharge advice: low-fat diet, analgesia, exercise & obesity management, if recurrent can be followed up in outpatients for consideration of cholecystectomy
Cholecystitis
  • Inflammation +/- infection of the gall bladder causing patient to be systemically unwell with fever and malaise
  • Examination reveals constant RUQ pain, Murphy’s sign but no jaundice (as the common bile duct remains unobstructed)
  • Observe for sepsis (and treat accordingly), deranged LFTs/jaundice for cholangitis
  • The obstructed gall bladder may accumulate fluid (mucocele) which could be purulent (gall bladder empyema).
  • Manage with supportive care, antibiotics & analgesia and laparoscopic cholecystectomy
  • MRCP may be used to pre-operatively to confirm that there are no stones in the CBD – the last thing you want to do is take out the gallbladder when there is a stone in the CBD which will mean they could re-present with cholangitis!
Ascending cholangitis *obstructive jaundice until proven otherwise*
  • The stone has travelled further to where the cystic duct joins the hepatic ducts to form the common bile duct.
  • This results in much more serious infection with jaundice (Charcot’s triad of RUQ pain, fever & jaundice)
  • Observe for sepsis & signs of peritonism as above
  • Hopefully, with IV antibiotics & supportive care, the sepsis will settle. The patient will need emergency decompression of the CBD via ERCP. MRCP may be used to confirm the issue & to guide the performing doctor where the stone is. If the ERCP fails (i.e. procedure not possible due to technical reasons) a percutaneous transhepatic cholangiogram (PTC) and stent may be used.

Discharge advice as above, including that they will be referred for cholecystectomy which usually the surgeon does electively once the inflammation has settled and it is safer.

Further Complications of Gallstone Disease
  • Pancreatitis
  • Gallstone Ileus causing bowel obstrution (this is rare)

Risk factors 

  1. 5Fs – female, forty, fat, fertile, fair
  2. Rapid weight loss
  3. Pregnancy (bile stasis)
  4. Inlammation/infection
  5. Problem with enterohepatic circulation (e.g. Crohn’s or terminal ileal resection)
  6. Haematological conditions – HS, G6PD, sickle (risk factors for pigmented gallstones)

Clinical presentation

  • Anyone presenting with RUQ abdominal pain should have gallstone related biliary disease in their differentials. Other features may include fevers, jaundice and being systemically unwell.
  • Charcot triad for cholangitis = fever + RUQ pain + jaundice
    Reynold’s pentad for severe cholangitis = Charcot’s + confusion + hypotension (shock)

History

  • SOCRATES for abdominal pain (intermittent/ episodic RUQ pain, radiating to back, onset after eating (especially fatty foods))
  • Any systemic upset?
  • Any jaundice? Stool or urine colour change?
  • Any weight loss? (Sudden weight loss is a risk factor)
  • Known gallstones or high cholesterol?
  • Other risk factors: diabetes, previous ileal disease or surgery
  • Alcohol/ dietary hx
  • Drug hx
  • FHx
  • PMHx
  • PSHx – note that patients can form stones in the CBD even when they’ve had a cholecystectomy. Specifically, ask if they’ve had episodes like this before.
  • Analgesia

Examination

  • End of the bed jaundice? High BMI? Looks unwell? Looks in pain?
  • ABCDE
  • ?Murphy sign i.e. local peritonism (palpate subcostally in the RUQ region and then ask the patient to breathe in & look for worsening pain/wincing. Repeat for the LUQ and confirm this is isn’t just as deep breathing is painful)
  • Boas’ sign – hyperalgesia to light touch of the skin over the low right scapula region

Investigations

  • Bloods: FBC/U&E/LFTs/CRP/amylase (coagulation if patient for ERCP)
  • Blood cultures
  • Urinalysis – ?bilirubin/urobilinogen
Imaging
  • Abdominal ultrasound – evidence of stones/ dilated CBD or intrahepatic ducts. Note the patient ideally needs to have fasted for this.
  • MRCP – if evidence of stones obstructing the CBD with very deranged LFTs may go straight to ERCP. However if high clinical suspicion (deranged LFTs/jaundice) & if no stones seen on ultrasound scan consider discussing whether MRCP is indicated with your seniors (take note of contraindications to MRI and assess the patient prior)

Management

  • Ensure patients have adequate analgesia & antibiotics if they are indicated (see below)
  • Don’t forget VTE prophylaxis
  • ERCP is a form of investigation and management – used to visualise obstructions in the CBD and then fish them out
  • Laparoscopic cholecystectomy has better operative outcomes than open surgery. ‘Hot’ gallbladder surgery is when the surgery is performed during the acute phase of cholecystitis illness (in the first couple days) and is preferable. If this window is missed, the operative field will be hostile with adhesions and in that case is best left until a few weeks after the acute phase of illness (i.e. elective).

Further Reading

Written by Dr Rachael Boardley. Edited by Dr Akash Doshi (CT2) and Dr Marc Huttman (FY2)

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