Table 1 . Thresholds for cholangitis in a patient with pain , fever and jaundice , according to Tokyo guidelines 2018 |
Box 1 . Differential diagnoses of pain associated with gallstones |
||||
|
Measure
Fever
Threshold
PAGE 20 acceptable definitive management approach . 10 There is no support for medical therapy of gallstones , including dissolution or lithotripsy , which are of historical interest but no clinical value . 11-14
Cholecystitis
Acute cholecystitis is best managed within the first 2-3 days of symptom onset with acute laparoscopic cholecystectomy ; this limits the risks associated with the disease and is the least inconvenient for the patient . Later surgery , that is , after 3-4 days when the inflammatory process has progressed , often obscures the junction between the gallbladder and CBD , making the surgery more hazardous . Patients treated with the older , interval approach to cholecystectomy were more likely to experience failure of management , delayed treatment , septicaemic complications , and spend more time in hospital and away from work . Acute management has become preferable .
Body temperature greater than 38 ° C
WCC ( x 1000 / μL ) Less than 4 or greater than 10
Jaundice
Liver function tests : ALP , GGT , AST , ALT ( IU )
Source : Yokoe M et al 2018 6
Total bilirubin 2mg / dL or greater
Greater than 1.5 x STD ( upper limit of normal value )
of the gallbladder often resolves the acute inflammation and allows the egress of pus ( cholecystostomy ), allowing safer interval surgery , or occasionally no surgery at all .
Acute CBD stones / cholangitis / jaundice
The presence of stones in the CBD
may be associated with infection ( cholangitis ), or bile duct obstruction , leading to marked LFT abnormalities and jaundice . There is frequently marked upper abdominal pain , more to the midline than in the right upper quadrant and radiating to the back .
Acute cholangitis is particularly dangerous . In the acute situation , an initial 12-hour trial of IV antibiotics in hospital is undertaken , provided the patient ’ s condition is stable . If matters settle , semi-urgent ( within 24-48 hours ) surgical treatment is performed with either laparoscopic cholecystectomy and exploration of the CBD , or ERCP followed by LC . 15
|
• Gastrointestinal :
• Gastro-oesophageal reflux disease .
• Peptic ulcer disease .
• Acute pancreatitis .
• Inflammatory bowel disease .
• Acute hepatitis .
• Bowel perforation .
• Hepatic abscess .
• Right-sided diverticulitis .
• Fitz-Hugh-Curtis syndrome .
• Gastric motility disorders .
• Appendicitis .
• Bile duct disorders such as strictures or tumours .
• Gastroenteritis .
• Constipation .
• Malignancy of the pancreas or gallbladder .
• Irritable bowel syndrome .
• Cardiovascular :
• Acute coronary syndrome .
• Mesenteric ischaemia .
• Aortic catastrophe .
• Portal vein thrombosis .
• Pulmonary : — Pneumonia . — Pulmonary embolism .
• Metabolic : — Diabetic ketoacidosis .
• Renal : — Calculi .
• Musculoskeletal : — Chest wall pain .
|
Bile duct stones : dense opacity with acoustic shadow .
Figure 4 . Dilated intrahepatic ducts with bile duct stones .
|
|||
If there is a delayed presenta- |
If the patient is high risk because |
|||
tion , acute surgery is less feasible , |
of disease severity , unstable , and |
stabilises , gallbladder stones are gen- |
cholangiogram is performed ( see fig- |
laparoscopic bile duct clearance |
and interval cholecystectomy , after |
initial therapy with antibiotics is |
erally treated definitively with LC . |
ure 7 ); these stones may be treated |
does not . |
a course of antibiotics and hospital |
not effective , then urgent decom- |
This is because there is a high risk of |
at the initial laparoscopic oper- |
Interval identification of stones |
admission , is required . When there |
pression of the bile duct by ERCP is |
recurrent disease if the gallbladder |
ation in expert hands , or subse- |
in the CBD in patients who have had |
is failure of interval treatment or in patients who are medically very unsuitable , percutaneous drainage |
recommended as the safest management . 16 ERCP is carried out the same day , and once the patient ’ s condition |
remains in situ . Stones in the CBD are frequently identified at LC when an operative |
quently by ERCP . ERCP carries the risk of sphincterotomy ( bleeding , perforation , pancreatitis ), which |
a previous cholecystectomy are usually referred for treatment because of the risk of significant complications |