Australian Doctor 8th Dec 2023 8th Dec 23 | Page 20

20 HOW TO TREAT : GALLSTONES

20 HOW TO TREAT : GALLSTONES

8 DECEMBER 2023 ausdoc . com . au liver function test abnormality 1.5x the upper limit of normal , white cell count less than 4000 or greater than 10,000 ( see table 1 ). 6
PANCREATITIS Biliary pancreatitis is commonly associated with the presence of gallstones . It is thought to occur because of the passage of debris or stone through the CBD , either causing pressure on the pancreatic duct or retrograde passage of bacteria into the pancreatic duct . There is a high risk of early recurrent pancreatitis if the gallstones are not treated expeditiously , which is usually done on the same hospital admission . Subacute disease may also present with pancreatic-like pain , weight loss and steatorrhea ( unusually ), necessitating the exclusion of pancreatic carcinoma .
GALLBLADDER POLYPS Multiple so-called gallbladder polyps are usually small concretions of bile rather than true fleshy polyps ( see figures 5 and 6 ). They constitute the same risk as gallstones and are a predictor of biliary colic . In patients with biliary colic , removal of the gallbladder is most likely to resolve pain attacks .
GALLBLADDER CARCINOMA The presence of long-standing gallstones within the gallbladder are thought to be associated with a higher risk of developing gallbladder cancer in the long term . 7 This is thought to relate to chronic low-grade inflammation of the gallbladder mucosa . 8
Figure 1 . The biliary tree .
Examination
During clinical intervals when there is
no pain , abdominal examination may
be normal . Following a recent attack
of biliary colic , there may be epigastric
or right upper quadrant tenderness
, while in acute disease there may
be significant focal right upper quadrant
tenderness and focal peritonism .
In the presence of pancreatitis , the
patient may have severe epigastric
tenderness or indeed an acute abdomen
. In the presence of cholangitis ,
there may be pain , fever , jaundice ,
dark urine , bilirubin on urinalysis , and
signs of septicaemia . There may be a
palpable gallbladder in the presence of
acute cholecystitis with empyema of
the gallbladder .
DIFFERENTIAL DIAGNOSES
THE differential diagnosis of pain
associated with gallstones appears
in box 1 . The most common of these
are peptic ulcer disease , pancreatic
inflammation , reflux disease , constipation
and chest wall pain .
INVESTIGATIONS
IN patients presenting with biliary
colic , perform haematology and biochemical
screening , including FBC ,
inflammatory markers ESR and CRP , LFTs , electrolytes , renal function , cal-
Figure 2 . Gallstones .
cium and magnesium , amylase / lipase .
Ultrasound remains the linch-
bile duct may predict the presence of
negative when performed at an inter-
neoplasia . The presence of an inflam-
inflammation , and is useful in avoid-
pin for diagnosis of gallstones . Order
stones , raising clinical suspicion .
val between acute attacks .
matory pseudocyst , pancreatic necro-
ing diagnostic endoscopic retrograde
an ultrasound as the primary imag-
CT scanning only detects 20 % of
CT scanning of the pancreas may
sis , or peripancreatic collection may
cholangiopancreatography ( ERCP ),
ing modality in all patients presenting
gallstones and is not a sensitive test
be performed if there is clinical suspi-
be identified .
which has a risk of pancreatitis .
with upper abdominal pain . An ultrasound may show the presence of gallstones , gallbladder inflammation or
for biliary colic . 9 Biochemical analysis may indicate an abnormality of LFTs , suggesting
cion of low-grade pancreatic inflammation . More severe cases are usually investigated in hospital . CT scanning
Clinical suspicion of the presence of CBD stones can be confirmed on MRI with magnetic resonance chol-
MANAGEMENT
LAPAROSCOPIC cholecystectomy
dilation of the CBD , which indicates
stones within the CBD , or may show
of the pancreas is highly accurate
angiopancreatography ( MRCP ). This
( LC ) remains the least morbid and
a risk of stone disease in the CBD and
elevation of amylase / lipase indicative
in identifying residual inflamma-
is a sensitive test for stones within
most acceptable gold standard treat-
a greater risk for the patient . Ultrasound is not an accurate test for stones
of pancreatic inflammation . Biochemical tests frequently fluctuate dur-
tion after a previous attack , suggestive of pancreatitis or excluding the
the CBD and gallbladder . It evaluates the pancreas and pancreatic duct ,
ment for symptomatic gallstones . 10 Open surgery for more compli-
within the CBD , but distention of the
ing attacks of biliary colic and may be
alternative diagnosis of pancreatic
may demonstrate pancreatic cysts or
cated issues remains an
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