37 Gallstones and Surgical Jaundice.pdf

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Gallstones & Surgical Jaundice Prof TN Walsh Class Year 2 Course Surgery Year 2023/2024 LEARNING OUTCOMES Understand Biliary anatomy Understand the risk factors for...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Gallstones & Surgical Jaundice Prof TN Walsh Class Year 2 Course Surgery Year 2023/2024 LEARNING OUTCOMES Understand Biliary anatomy Understand the risk factors for developing gallstones Understand the symptoms & signs of gallbladder disease Discuss the potential complications of gallstones Outline the management options of patients with gallstone complications GALLSTONE DISEASE(S) Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Why these changes in bile occur - not fully understood. Gallstones also may form if the gallbladder does not empty completely or often enough. 10 % of the adult population have gallstones Female : Male 2:1 10% approximately become symptomatic RISK FACTORS FOR GALLSTONES 1. Gender 2. Obesity (bile supersaturated with cholesterol) 3. Haemolytic disorders 4. Diet….higher prevalence in Western world 5. Medications (clofibrate) 6. Age 7. Fertility 8. Family History “The 5 Fs” RISK FACTORS - FIVE “FS” Female Fertile Forty Fat Family history SOME TERMS TO UNDERSTAND Biliary colic: RUQ/epigastric pain associated with stones in the bile ducts. Chole-lithiasis: Stones in the gallbladder Chole-cyst-itis: Inflammation of the gallbladder Chole-docho-lithiasis: A stone within the common bile ducts. Ascending chol-angitis: Infection of the common bile duct Gallstone ileus: Intestinal obstruction due to a gallstone  THE PRESENTATION OF GALLSTONES DEPENDS ON WHERE THEY ARE AND WHAT THEY DO! Empyema Ascending Mucoceole cholangitis Obstructive jaundice Asymptomatic Biliary colic Pancreatitis Cholecystitis Gangrene Perforation Gallstone ileus  COMPLICATIONS OF GALLSTONES Gallstone in the Gallbladder or Cystic Duct: Asymptomatic – majority – But can distract from another diagnosis Biliary colic – pain - no inflammation Cholecystitis - infection in the GB – 80% - obstruction of cystic duct by gallstone Can progress to: – empyema, - pus in the gallbladder – gangrene, - necrosis of the wall – perforation Or it may settle down to: - Chronic Cholecystitis or mucoceole (stone impacted in cystic duct) Stone can erode into duodenum - small bowel ileus COMPLICATIONS OF GALLSTONES - CTD Gallstone in the Common Bile Duct – Ascending cholangitis - infection – Pancreatitis -inflammation – Jaundice - obstruction  COMPLICATIONS 1 BILIARY COLIC Stone in gallbladder or GB neck Pain (RUQ +/- epigastric) Waxing and waning Radiates to scapula (Collins sign – patient points to scapula) Usually within an hour of eating - food stimulates CCK secretion from duodenum – GB contractions Few abdominal signs COMPLICATIONS 2 ACUTE CHOLECYST “ITIS” Stone blocking GB neck Constant pain (RUQ) may radiate to right scapula - Collin’s sign Worse on deep breathing Fever Nausea and anorexia Tenderness, guarding & Rebound RUQ Murphys sign + COMPLICATIONS 3 ASCENDING CHOLANGITIS Stone in Common Bile Duct Charcot’s triad – Intermittent RUQ pain – Intermittent Fever – Intermittent Jaundice May have dark urine and pruritis RUQ tenderness Risk factors: >50y/o, cholelithiasis, injury or stricture of bile ducts COMPLICATION 4 SURGICAL JAUNDICE Definition: Jaundice due to intra- or extra-hepatic obstruction to bile. Biliary obstruction - blockage of any duct carrying bile from liver to duodenum. Many non-surgical causes of Jaundice [revise pre-hepatic, hepatic and post- hepatic causes]. Most surgical causes are hepatic and post-hepatic!  COMPLICATION 4 SURGICAL JAUNDICE Gallstones - the commonest cause of extra-hepatic obstruction Other causes include: – Malignancy – Inflammation ( pancreatitis) – Primary Sclerosing Cholangitis (PSC) – [Merrizi’s syndrome] COMPLICATION 5 PANCREATITIS Stone blocking the Ampulla of Vater Bile forced up the pancreatic duct This causes inflammation and injury to pancreas Release of digestive enzymes locally and into blood stream Massive release of cytokines “Cytokine storm” a possible consequence Every organ of the body can be affected – Lungs – Blood oxygen falls – Kidneys – Urea level rises – Pancreatic islets - Blood sugar rises etc  COMPLICATION 6 GALLSTONE ILEUS Stone erodes into duodenum Fistula between gallbladder and duodenum Uncommon! Elderly women Small bowel obstruction Air in biliary tree on plain x-ray PATIENTS PRESENTING WITH GALLSTONES History Site and nature of pain essential (usually RUQ) Associated symptoms (nausea and vomiting) Jaundice Pale stools, dark urine & pruritus Rigors Risk factors PATIENTS PRESENTING WITH GALLSTONES Physical examination. Look for: Jaundice Pyrexia Scratch marks Murphy’s Sign (acute cholecystitis) - https://www.youtube.com/watch?v=2T0XUQ1M-x0 https://www.youtube.com/watch?v=9L7N89sOSuc WORKUP Bedside Investigations Laboratory Investigations Imaging Physical Examination Full Blood Count (FBC Erect CXR (including vitals) ECG Liver function tests (LFTs) US abdomen - bilirubin, AST/ALT, alkaline phosphatase Urine dipstick & Beta- C-reactive protein (CRP) MRCP hCG Amylase Coagulation Screen ABG/VBG Lactate Glucose check ERCP Endoscopic ultrasound MANAGEMENT OF GALLSTONE DISEASE If asymptomatic gallstones may be discovered incidently: – Patient must be fully informed of potential complications of gallstones and of surgery If symptomatic…. …..management will depend on the presentation BILIARY COLIC Analgesia Anti-emetics IV fluids ± Elective laparoscopic cholecystectomy Ultrasound of the gallbladder Acoustic shadow Wall not thickened Check for dilated CBD VIDEO OF A GALLBLADDER ULTRASOUND LAPAROSCOPIC CHOLECYSTECTOMY – NO INFLAMMATION ACUTE CHOLECYSTITIS ABCDE principals ± US in Acute Cholecystitis sepsis protocol Gallstones Acoustic shadow IV fluids Gallbladder wall thickened Antibiotics IV Fluid in GB wall – double wall Analgesia Anti-emetics Laparoscopic Cholecystectomy (early vs. late) - Early: hot gallbladder (