24 HOW TO TREAT : GALLSTONES ausdoc . com . au
81 DECEMBER 2023
24 HOW TO TREAT : GALLSTONES ausdoc . com . au
pancreatitis ( 3-4 %), perforation or bleeding . 30 Complete clearance of the bile duct is not always possible at the first treatment , so it may be necessary for repeated therapy . Occasionally , CBD stones prove particularly difficult to manage endoscopically and may require a surgical approach . ERCP may be performed before surgery , during LC , or subsequently if CBD stones are identified later .
Common bile duct exploration
CBD exploration may be performed laparoscopically or at open surgery ; this is a definitive procedure to remove gallstones from the bile duct when there are associated symptoms . This is a more complicated surgical procedure and may have a higher complication rate ( approaching 10 %) including infection , collection of bile or infected fluid and bile duct leakage , and may necessitate several more days in hospital . CBD exploration may be performed by laparoscopy in skilled hands or at open surgery .
The high-risk patient
Depending on the clinical presentation , the very high-risk patient with either gallbladder stones or stones in the CBD may be managed with observation , intermittent antibiotics , or even persistent long-term , low-grade antibiotics rather than intervention . This is a difficult decision , best managed in a hepato-biliary unit and often by a multidisciplinary team . Not all patients require surgical management of symptomatic stone disease . These include patients with severe cardiorespiratory failure , advanced cirrhosis , advanced cancer , or other critical illnesses with limited life expectancy .
CASE STUDIES
Case study one
AMANI , a 59-year-old woman , presents to her GP complaining of two episodes of sudden onset of severe epigastric and lower thoracic anterior chest pain , radiating through to the right scapular region . These lasted for 20 minutes on each occasion , and the pain was severe , forcing her to lie down until it subsided . The nature of the pain was persistent with fluctuations , and she found it difficult to describe ; however , it felt like “ there was a bursting brick in the upper abdomen ”. There was associated nausea , but no vomiting , and one episode terminated with diarrhoea . Belching and a sensation of fullness during the episodes were prominent .
Amani has a history of stable asthma treated with preventive puffers , and osteoarthritis of the left knee requiring intermittent NSAIDs . She is otherwise well and has two children .
Her mother had gallstones in her late 80s .
The diagnosis symptomatically is one of biliary colic and the likely diagnosis is believed to be gallstones .
Investigations include upper abdominal ultrasound , FBC , LFTs , EUC , serum lipase and ECG . All blood tests were normal and there is no acute abnormality on ECG . Troponin is not estimated because the pain was more than three days earlier . Because of the severity of the attacks , it is thought prudent to exclude any cardiac disease , and a cardiology referral is arranged .
Upper abdominal ultrasound confirms a large 3cm gallstone , present low in the gallbladder and that appears
Figure 7 . Common bile duct stones on cholangiogram .
to be fixed in Hartmann ’ s pouch . CBD is 4mm , not dilated , and the gallbladder is thin-walled with no signs of inflammation .
Over the next 48 hours , a weekend , Amani has several further attacks of pain across the lower ribs . She presents again on Monday morning , quite unwell with pain in the epigastrium and under the right ribs . Examination demonstrates a temperature of 37.6 ° C , tachycardia of 81 beats per minute , discomfort on full inspiration , and tenderness and guarding under the right costal edge . Urgent blood tests confirm an elevated WCC of 12,450 x 10 9 / L ( normal range 4000-11,000 x 10 9 / L ) , bilirubin 11μmol / L ( 3-15μmol / L ), normal ALP 64U / L ( normal 30-115U / L ), GGT slightly elevated 45U / L ( normal 5-35U / L ), and borderline transaminases AST 33U / L ( normal 5-30U / L ), ALT 31U / L ( 5-30U / L ). Lipase is normal .
Amani is urgently referred to a surgeon for consideration of early surgery for cholecystitis . The surgeon concurs , and she is admitted that day for IV antibiotics and supportive care . Acute cholecystectomy is performed the following morning and she is discharged , well , after 48 hours . Eight days later she presents with a red and
Figure 9 . Laparoscopic cholecystectomy .
Figure 8 . Cholesterolosis .