Gallbladder Disease Surgical Students Society of Melbourne, 2011 J. Bridie Mee RMH intern.
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Transcript of Gallbladder Disease Surgical Students Society of Melbourne, 2011 J. Bridie Mee RMH intern.
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Surgical Students Society of Melbourne, 2011J. Bridie MeeRMH intern
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www.jacksonregionalsurgery.com
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Gallstone Disease
• Cholelithiasis• Choledocolithiasis• Biliary Colic• Cholecystitis
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Gallstone Types
• Cholesterol stones • Pigment stones
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Risk Factors
• Fair• Female• Fat• Forties• Fertile • also DM, family Hx
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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
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Biliary Colic - Symptoms
• Site• Onset• Timing• Character• Radiation • Severity• Assoc sympt• Aggrav/reliev
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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
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Biliary Colic - Examination
• General: Restless, +/- jaundice• Obs: tachy• Abdo: RUQ tenderness, guarding
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Biliary Colic - Investigations
• FBE• LFT • UEC• Amylase/lipase• CXR/AXR• Upper abdo ultrasound
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Differentials• Abdo:– Acute cholecystitis– Pancreatitis– GORD– Perforate PUD– Appendicits (atypical)– pyelonephritis
• Thoracic:– Pneumonia– angina
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Biliary Colic - Management
• Analgesia• Exclude complications/differentials• Elective cholecystectomy
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Acute Cholecystitis
• Acute inflammation of GB following impactions of stone, +/- infective
• Symptoms:– RUQ/epigastric pain – Nausea, vomiting– Fever– Aggravated by movement, deep breathing
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Acute Cholecystitis - Examination
• General distressed, still, shallow breathing,+/- jaundice (scleral)
• Obs febrile, tachycardia
• Abdo RUQ tenderness, guarding+/- Murphy’s sign/peritonism
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Acute Cholecystitis - investigations
• FBE, UEC, LFT, CRP• Amylase/lipase• ECG• CXR/AXR• Upper abdo US
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Acute Cholecystitis - Ultrasound
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Acute Cholecystitis - Ultrasound
• 90-95% sensitive• What are the ultrasound findings?
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Acute Cholecystitis - Management
• Call surg admit!• Analgesia opiods• NBM• IVFT• Antibiotics
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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
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Laparotomy vs Laparoscopy
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http://www.laparoscopy.com/pictures/lap_chol.html
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Complications
• Gangrenous cholecystitis • Obstructive jaundice• Cholangitis• Gallstone ileus• Pancreatitis• Death!
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Choledocolithiasis causing Obstructive Jaundice
• Post-hepatic jaundice (GGT, ALP)
• Symptoms– Hx of previous gallbladder disease– Jaundice– Pale stools, dark urine
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Obstructive Jaundice – Ix
• LFT, FBE, UEC, CRP• USS – GB, CBD, stones• MRCP
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MRCP
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Treatment obstructive jaundice
• ERCP• Laparoscopic/open cholecystectomy with IOC
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ERCP
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Cholangitis
• When obstructed CBD becomes infected• Charcot’s triad of signs– RUQ pain– jaundice– High fever/rigors
• Can be life threatening, early treament essential
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Gallstone Ileus
• When stone perforates GB wall and erodes into duodenum, obstructing small bowel
• Treatment - laparotomy
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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
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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!