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HOW TO TREAT 23
ausdoc . com . au 1 DECEMBER 2023

HOW TO TREAT 23

developing . Treatment is removal of the CBD stone by ERCP .
Symptoms are probably only pres-
Table 2 . Factors associated with increased likelihood of gallstones
ent in 50 % of patients with stones in the CBD . 17
Factor
Causes
Pancreatitis
Biliary pancreatitis may be mild , very severe , and occasionally lethal . Pancreatitis is usually identified in hospital . Patients present with relatively severe episodes of upper abdominal pain , nausea and vomiting , neces-
GI dysmotility
Spinal cord injury Weight cycling Prolonged fasting Rapid weight loss Bariatric surgery Total parenteral nutrition Gastrectomy
sitating admission , usually through ED . Patients will occasionally present in general practice following a particularly unpleasant 24-48 hours
Diet
High calorie High carbohydrate High glycaemic load Low-fibre
self-managed at home . Early recurrence of pancreatitis occurs frequently if the gallstones are not expeditiously treated .
If the patient ’ s symptoms resolve to an adequate extent in hospital , early LC and operative cholangiogram are performed because there is a high rate of potential CBD stones and recurrent pancreatitis .
It is frequently noted clinically that patients with multiple small gallbladder calculi on ultrasound are more likely to have pancreatitis than patients with a single large stone . This is not , however , always the case .
Metabolic syndrome
Drugs
Increased enterohepatic bilirubin cycling
Insulin resistance Diabetes mellitus Lack of exercise Obesity Non-alcoholic fatty liver disease
Fibrates Octreotide Calcineurin inhibitors Hormone replacement therapy
Ileal resections Crohn ’ s disease Cirrhosis
Complications of severe pancreatitis
include pancreatic necrosis , severe
septicaemia , shock , renal failure and
may increase the risk of gallstones ( see
multiorgan failure . Patients may spend
table 2 ). Gallstones appear to have a
months in ICU , with associated signifi-
hereditary frequency , especially in
cant morbidity and mortality .
the Hispanic population and those of
Atypical gallbladder disease in the elderly
Elderly patients frequently present
in an atypical fashion , with only mild
indigenous American ancestry , as well
25 , 26 as in twins .
PATHOPHYSIOLOGY
THE formation of gallstones may be
abdominal pain , confusion , fever and malaise . Clinical diagnosis can be particularly difficult , and full investiga-
associated with the chemical imbalance of cholesterol solubility , promoting cholesterol crystallisation and
tion with ultrasound , biochemical and haematological screening , and inflammatory markers may ultimately reveal the diagnosis .
Gallbladder cancer
Gallbladder cancer is rare but may be
the formation of gallstones ( see figure 8 ). 27 Insulin resistance promotes biliary cholesterol secretion and oestrogen increases gallstone formation . Many patients form supersaturated bile with an increased rate of gallstone formation . 28
Figure 5 . Gallbladder polyps .
associated with the presence of gallstones . 18 There is some evidence that larger stones carry a higher risk of gall-
Intestinal factors , including reduced gallbladder motility , small bowel diseases such as Crohn ’ s dis-
Gallbladder
bladder cancer , in some studies up to ninefold . 19 Prophylactic cholecystectomy has been recommended with a
ease , and major intestinal resection impairing intestinal-hepatic bile circulation , may promote gallstone for-
stone size larger than 3cm , but is not
mation . Gallstones may result from
a uniformly accepted indication for
abnormal bilirubin metabolism , such
surgery .
as haematological diseases with high
Asymptomatic gallstones
There is a lack of randomised controlled
trials and systematic reviews
bilirubin turnover ( see table 2 ).
Prevention
There is currently no pharmacologi-
regarding the natural history of gall-
cal prevention advisable in the general
bladder stones . Data is poor but sug-
population . Maintenance of healthy
gests 1-4 % of patients per annum with
body weight and moderate physical
asymptomatic gallstones will develop
activity can be recommended as pre-
symptoms ; this is probably more com-
ventive strategies .
mon in areas where gallstones are endemic . 20 , 21 Patients with insulin dependent diabetes are often offered preventive surgery because of the risk of gangrenous cholecystitis , which is highly morbid .
MANAGEMENT TECHNIQUES
Laparoscopic cholecystectomy
LC is the treatment of choice for the
EPIDEMIOLOGY
About 20 % of the Caucasian European adult population have gallstones . 22 It is more common in females , and symp-
management of symptomatic gallstones and has the lowest mortality and morbidity ( see figure 9 ). The procedure can be safely performed in very elderly patients and those with mul-
Figure 6 . Gallbladder ‘ polyp ’ on ultrasound .
Polyp
tomatic gallstones were found in up to 57 % of women between the ages of 70 and 79 . Some ethnic populations
tiple comorbidities . The advantages of LC over open surgery are shorter hospital stays ( especially if the proce-
Planned open surgery may be indicated in a small cohort of patients for
ERCP
ERCP is an endoscopic technique uti-
cholangiogram is performed , or before surgery because of the presence of
have increased rates , and prevalence
dure is performed in the absence of
disease severity or patient factors .
lised to access the bile duct through
pancreatitis , jaundice or abnormal
has increased with the availability of
sepsis ), fewer complications , earlier
Key to LC is adequate control of the
the duodenum and is used to clear
liver function tests , or on preopera-
high-calorie , high-carbohydrate diets
recovery and substantially less pain . It
cystic duct junction with the bile duct
the CBD of stones ( see figure 10 ).
tive MRCP . Some 5-9 % of patients may
and decreased rates of physical activity . 23 , 24 A large list of external factors
is unusual for laparoscopic surgery to need to be converted to laparotomy .
and prevention of bile duct leakage or injury , which is very uncommon . 29
Stones in the CBD may be diagnosed at the time of LC , when an operative
experience complications from ERCP depending on complexity , including