Gallbladder Disease

1. Gallbladder Disease Surgical Students Society of Melbourne, 2011 J. Bridie Mee RMH intern

2. www.jacksonregionalsurgery.com

3. Gallstone Disease • Cholelithiasis • Choledocolithiasis • Biliary Colic • Cholecystitis

4. Gallstone Types • Cholesterol stones • Pigment stones

5. Risk Factors • Fair • Female • Fat • Forties • Fertile • also DM, family Hx

6. Epidemiology • Why do you need to know about it? • 2nd most common abdo organ requiring surgery • Population prevalence 5-20% of which majority (70-80%) remain asymptomatic • 1-4% develop symptoms each year

7. Biliary Colic - Symptoms • Site • Onset • Timing • Character • Radiation • Severity • Assoc sympt • Aggrav/reliev

8. Biliary Colic - Symptoms • Site RUQ • Onset sudden • Timing 30 min – 6 hrs • Character dull • Radiation +/- to epigastrium, back • Severity very • Assoc sympt nausea & vomiting • Aggrav/reliev fatty foods, analgesics

9. Biliary Colic - Examination • General: Restless, +/- jaundice • Obs: tachy • Abdo: RUQ tenderness, guarding

10. Biliary Colic - Investigations • FBE • LFT • UEC • Amylase/lipase • CXR/AXR • Upper abdo ultrasound

12. Differentials • Abdo: • Acute cholecystitis • Pancreatitis • GORD • Perforate PUD • Appendicits (atypical) • pyelonephritis • Thoracic: • Pneumonia • angina

13. Biliary Colic - Management • Analgesia • Exclude complications/differentials • Elective cholecystectomy

14. Acute Cholecystitis • Acute inflammation of GB following impactions of stone, +/- infective • Symptoms: • RUQ/epigastric pain • Nausea, vomiting • Fever • Aggravated by movement, deep breathing

15. Acute Cholecystitis - Examination • General distressed, still, shallow breathing, +/- jaundice (scleral) • Obs febrile, tachycardia • Abdo RUQ tenderness, guarding +/- Murphy’s sign/peritonism

16. Acute Cholecystitis - investigations • FBE, UEC, LFT, CRP • Amylase/lipase • ECG • CXR/AXR • Upper abdo US

17. Acute Cholecystitis - Ultrasound

18. Acute Cholecystitis - Ultrasound • 90-95% sensitive • What are the ultrasound findings?

19. Acute Cholecystitis - Management • Call surg admit! • Analgesia opiods • NBM • IVFT • Antibiotics

20. Cholecystectomy:Indications & Timing • Not indicated for incidental findings of cholelithiasis that are asymptomatic • Elective for biliary colic • During admission elective or urgent for acute cholecystitis • Alternatives if unfit for surgery – Abx and percutaneous drainage

21. Laparotomy vs Laparoscopy

22. http://www.laparoscopy.com/pictures/lap_chol.html

23. Complications • Gangrenous cholecystitis • Obstructive jaundice • Cholangitis • Gallstone ileus • Pancreatitis • Death!

24. Choledocolithiasis causing Obstructive Jaundice • Post-hepatic jaundice (GGT, ALP) • Symptoms • Hx of previous gallbladder disease • Jaundice • Pale stools, dark urine

25. Obstructive Jaundice – Ix • LFT, FBE, UEC, CRP • USS – GB, CBD, stones • MRCP

26. MRCP

27. Treatment obstructive jaundice • ERCP • Laparoscopic/open cholecystectomy with IOC

28. ERCP

29. Cholangitis • When obstructed CBD becomes infected • Charcot’s triad of signs • RUQ pain • jaundice • High fever/rigors • Can be life threatening, early treament essential

30. Gallstone Ileus • When stone perforates GB wall and erodes into duodenum, obstructing small bowel • Treatment - laparotomy

31. Pancreatitis • When gallstone irritates pancreas causing inflammation, or distal CBD blockage causing intrapancreatic release of enzymes • 30-50% pancreatitis caused by gallstones • Can be life threatening

32. Take home messages • Gall stone disease very common, worth knowing about, understanding anatomy helps • Feel lots of bellies • Complications can be life threatening • Get scrubbed for a cholecystectomy!