gallstones - nicola tanner
TRANSCRIPT
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COMPLICATIONS OF GALLSTONES & THEIR
MANAGEMENT
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Anatomy revision
10 complications Pathogenesis Symptoms Signs Management
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Anatomy
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1) Acute cholecystitis2) Chronic cholecystitis3) Obstructive jaundice4) Cholangitis5) Acute pancreatitis6) Mucocele7) Empyema8) Gallstone ileus9) Gallbladder perforation10) Gallbladder carcinoma
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Acute Cholecystitis Cholecyst- Gallbladder -itis Inflammation -ectomy Removal
Acalculus vs calculus Inflammation of GB wall Obstruction of cystic duct Oedema, mucosal ulceration, fibro
purulent exudate
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Acute Cholecystitis
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Acute Cholecystitis Symptoms
RUQ/epigastric pain Fever Nausea & vomiting, anorexia
Signs Tender RUQ, guarding, rebound Murphy’s positive ↑WCC, ↑CRP, mildly ↑LFTs
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Acute Cholecystitis Imaging
USS/CT – thickened GB wall, pericholecystic fluid, stones, distended GB
Management Admission
IV rehydration & NBM/clear fluids Analgesia Antibiotics
Cholecystectomy
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Chronic Cholecystitis Gallstones invariably Repeated attacks fibrosis Insidious onset vs several attacks Common histological finding after
cholecystectomy
Asymptomatic vs pain
Management = conservative vs surgical
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Obstructive Jaundice Blockage of biliary tree (CBD or hepatic duct) Intra-luminal vs extra-luminal Mirizzi Syndrome Local oedema
Courvoisier’s Law – jaundice, pain, non-palpable gallbladder
Management USS +/- MRCP ERCP Cholecystectomy
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Obstructive Jaundice
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Mirizzi’s Syndrome
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Ascending Cholangitis Cholang- Bile ducts -itis Inflammation/infection
Biliary tree infection in presence of obstruction (stones, stricture)
Signs & Symptoms Unwell jaundiced patient! Charcot’s Triad = fever, pain, jaundice
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Ascending Cholangitis Management
Resuscitation IV antibiotics
Biliary tree decompression ERCP, radiological or surgical
intervention
Definitive management of cause of obstruction
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Acute Pancreatitis Inflammatory process due to local
enzymatic effects Causes:
GET SMASHED Gallstones Ethanol Trauma (ERCP)
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Acute Pancreatitis
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Acute Pancreatitis Signs & Symptoms
Epigastric pain radiating to back Tender, rigid abdomen, vomiting,
dehydrated Raised amylase, history of jaundice or
recent ERCP, or previous RUQ pains
Management Resuscitation, analgesia, removal of
cause & prevention of future episodes
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ERCP Endoscopic Retrograde Cholangio-
Pancreatography
Imaging of biliary tree +/- therapeutic removal of stones +/- stent insertion +/- sphincterotomy
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Mucocele Impaction of stone in GB neck or cystic
duct when GB empty of bile
Mucous is secreted into GB from epithelium
No inflammation so GB swells to many times its normal size
Signs & Symptoms Pain Tender RUQ mass
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Mucocele
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Empyema Impaction of stone in GB neck or cystic
duct with superadded infection of bile Water absorbed so bile concentrated Pus present
Due to: Acute cholecystitis Infection of mucocele
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Empyema Signs
Palpable tender gallbladder Septic patient
Management Early cholecystectomy (prevents
perforation) Radiologically-guided percutaneous
drainage (temporary measure)
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Gallstone Ileus Fistula between gallbladder & bowel Stone travels through bowel & embedded in
narrow point of bowel causing bowel obstruction Usually ileo-caecal valve (small bowel) Signs & Symptoms
Previous RUQ pain, small bowel obstruction X-ray – distended small bowel loops (opacity in
RIF), air in biliary tree Rigler’s triad: SBO; pneumobilia; GS in RIF
Management Laparotomy, resuscitation, milk stone back
and remove via cut into healthy section of bowel
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Gallstone Ileus
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Gallbladder Perforation Inflammation causes necrosis of GB wall
causing perforation Following empyema or acute cholecystitis
Biliary peritonitis Significant mortality (60%)
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Carcinoma of the Gallbladder
Rare 4 Female:1 Male 95% of cases associated with gallstones
Incidental finding during cholecystectomy, or presents with similar picture to chronic cholecystitis.
Management Radical resection including liver
segments
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THANK YOU!Questions?