surgery 101 gallstones

Copyright The Surgery 101 team (www. surgery101.org) 2012

4. Gallstones

In this episode, Dr. Parveen Boora discusses gallstones. Topics covered include:

• epidemiology of gallstone disease • pathogenesis of gallstones • pathiophysiology and treatment of biliary colic, cholecystitis,

choledocholithasis and cholangitis • history and physical exam findings • investigations • laparoscopic cholecystectomy procedure

Terms

• cholelithiasis = presence of gallstones in gallbladder • biliary colic = pain caused by gallbladder contracting against an

obstructed cystic duct • cholecystitis = inflammation of gallbladder • choledocholithiasis = inflammation and infection of common bile duct

Introduction

• common condition • approximately 20% of women and 5-10% of men will have

cholelithiasis by age 50 • rule of thumb is 20% of people have gallstones, 20% of those will

have symptoms and 20% of those will have cholecystitis or a more serious complication


Types of Gallstones

• cholesterol stones • pigment stones • mixed stones most common • best way to determine type is U/S imaging

Risk Factors

• female • obesity • over age 40 • multiparty • aboriginal people have high incidence

Gallstone Symptoms

• bilary colic most common condition occurs when stones obstruct normal flow of bile usually associated with URQ pain that radiates to back or

right scapula pain usually occurs after high fat meal pain typically lasts few hours before subsiding physical exam is afebrile and stable vital signs with

tenderness on abdominal palpation labs will typically be normal if bilary colic is suspected, order U/S urgent surgical consult not required but out-patient

discussion of cholecystectomy should be arranged pain management required, Buscopan most commonly

prescribed only resolution is eventual removal of gallbladder


• cholecystitis inflammation of gallbladder due to obstruction of cystic

duct by gallstones gallbladder becomes swollen and edematous; if

prolonged, gallbladder necrosis can result pain typically lasts in excess of 6 hours presence of fever and Murphy’s sign are typical findings labs may or may not show elevated WBC, ALT, ALP,

bilirubin U/S will show thick-walled gallbladder with possible fluid if symptoms less than 48-72 hours, best treatment is early

cholecystectomy if symptoms greater than 72 hours, antibiotics and pain

control first course of action followed by eventual cholecystectomy

• exceptional situations patients who present with severe

cholecystitis – high fever and greatly elevated WBC count; should be operated on immediately

if emphasematous cholecystitis is present, urgent surgery is warranted

if patient diagnosed with acalculous cholecystitis, emergency surgery is preferred treatment

Cholecystectomy

• indicated in any individual with symptomatic gallstone disease • majority done by laparoscopy; 5% of elective cases and 30% of

emergency cases converted to open procedure • converted to open procedure when anatomy unclear, or there is

uncontrolled bleeding or contamination


• choledolithiasis when gallstone makes way through cystic duct and is in

the common bile duct two serious complications can occur, cholangitis and

pancreatitis • cholangitis

findings include fever, jaundice, RUQ pain, hypotension, decreased level of consciousness

lab findings will show elevated WBC, ALT, ALP, bilirubin

U/S can confirm diagnosis immediate treatment with antibiotics

required with eventual cholecystectomy

Summary

• Gallstones are very common, but only a minority ever produce symptoms.

• Gallstones are formed as a result of an imbalance in the usual concentrations of bile salts, lecithin and cholesterol in bile.

• Biliary colic is right upper quadrant pain resulting from the gallbladder contracting against a cystic duct obstructed by gallstones. Fever and jaundice are absent and the pain subsides within 6 hours.

• Cholecystitis is the result of obstruction of the outflow of bile from the gallbladder, usually by a gallstone, that is prolonged, resulting in inflammation and infection. The pain persists beyond 6 hours and is typically accompanied by fever and leukocytosis. Antibiotic treatment and cholecystectomy is the preferred treatment.

• Cholangitis is the infection of the common bile duct, usually caused by an obstructing gallstone. Charcot’s triad (fever, jaundice and right upper quadrant pain) are the classic findings. Cholangitis can be life threatening and antibiotics, resuscitation and emergent decompression of the common bile duct, usually by ERCP, are the treatment.

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