Australian Doctor 8th Dec 2023 8th Dec 23 | Page 25

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HOW TO TREAT 25 discharging umbilical wound , which is treated with antibiotics ( amoxicillin-clavulanate ), and this settles .

Acute cholecystitis is often preceded by episodes of biliary colic . The presence of inflammation in the peritoneum leads to the localisation of pain over the site of the gallbladder . The temperature indicates infection , and expeditious surgery is most effective for the patient and safely performed by laparoscopy within the first 2-3 days of symptoms . A large stone impacted in Hartmann ’ s pouch frequently leads to the early onset of cholecystitis .

Case study two

Iris , an 81-year-old woman , presents to her GP with episodes of epigastric pain . The pain is dull but severe in nature , going straight through to the back and lasting several hours . The attacks are self-limiting , not associated with exercise and frequently occur in bed at night .

On detailed questioning , she has no fevers but has noticed that she is anorexic for heavier meats and more comfortable eating a light diet over the past several months . There has been no weight loss and no change in bowel habits , although she has noticed that after an attack of pain the bowel motions become significantly lighter in colour and then return to normal . Further questioning reveals that she passes dark urine following attacks and generally feels lethargic .

1 . Which THREE statements regarding biliary colic are correct ? a It is characteristically severe , unpredictable and episodic . b It occurs centrally in the epigastrium or behind the lower third of the sternum . c It may radiate into the scapula or to the shoulder tip or jaw . d It is easy to distinguish from other causes of gastrointestinal pain .

2 . Which ONE is not a usual feature of cholecystitis ? a Biliary colic . b Diarrhoea . c Right upper quadrant pain . d Abdominal tenderness in the epigastrium and underneath the right rib .

3 . Which THREE statements regarding gallstones are correct ? a Bile duct dilatation seen on ultrasound is pathognomonic of CBD stones . b Biliary pancreatitis is thought to occur because of either pressure on the pancreatic duct or retrograde passage of bacteria into the pancreatic duct . c Gallbladder polyps are a predictor of biliary colic . d Long-standing gallstones in the gallbladder may be associated with a higher risk of gallbladder cancer .

Figure 10 . ERCP ( sphincterotomy stone retrieval ).

Iris has a history of insulin-dependent later-onset diabetes , previous multiple cardiac stents for ischaemic heart disease , a left total hip replacement two years ago , a cholecystectomy seven years ago , and osteoarthritis . Her medications included apixaban , NSAIDs , insulin and metformin .

There is no abnormality on examining the periphery , sclera or abdomen . Her pulse rate is 72 beats per minute . Investigations include an

How to Treat Quiz .

4 . Which THREE are thresholds for cholangitis according to Tokyo guidelines ? a Body temperature greater than 38 ° C . b Total bilirubin 2mg / dL or greater . c Age over 65 . d LFTs greater than 1.5 x upper limit of normal value .

5 . Which THREE features may be present in a patient with gallstones ? a Frequent diarrhoea and bloating . b Clinical intervals when there is no pain ; abdominal examination may be negative . c In acute biliary colic there may be significant focal right upper quadrant tenderness and focal peritonism . d Nausea and vomiting in pancreatitis .

6 . Which ONE is the first investigation recommend in patients with upper abdominal pain ? a Endoscopic retrograde cholangiopancreatography ( ERCP ). b Ultrasound .

FBC , UEC , LFTs , iron studies and a CT scan . The FBC is normal , as is the EUC .

The liver function tests are abnormal , bilirubin 21μmol / L ( normal 3-15μmol / L ), GGT 105U / L ( normal 5-35U / L ), ALP 221U / L ( normal 30-115U / L ), AST 60U / L ( normal 10-35U / L ) and ALT 81U / L ( normal 5-30 U / L ). Neither amylase nor lipase is performed as there is no current dominant pain . CT scan confirms a dilated common bile duct of 11mm with slight

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c CT . d MRI .

7 . Which THREE statements regarding gallstones are correct ? a Gallstones are more common in females . b A range of pharmacological measures are available to prevent gallstones in the general population . c The prevalence has increased with the availability of high-calorie , high-carbohydrate diets and decreased rates of activity . d The formation of gallstones may be associated with the chemical imbalance of cholesterol solubility .

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GALLSTONES

intrahepatic ductal dilatation , normal pancreas and normal pancreatic duct . Several cysts are noted in the liver . There is focal fatty sparing of no consequence in segment four alongside the bus form ligament .

The findings are considered congruent with the likelihood of recurrence of common bile duct stone without evidence of malignancy ; the positive diagnosis of common bile duct stone was not made . Because of Iris ’ age and substantial comorbidities ,

8 . Which TWO statements regarding the management of gallstones are correct ? a Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones . b The presence of stones in the CBD may be associated with cholangitis or bile duct obstruction . c The management of acute cholecystitis is best performed after 3-4 days of onset of symptoms . d Symptoms are present in most patients with stones in the CBD .

9 . Which THREE statements regarding the management of gallstones are correct ? a Gallbladder cancer is rare but may be associated with the presence of gallstones . b Early recurrence of pancreatitis occurs frequently if the gallstones are not expeditiously treated . c Patients with insulin dependent diabetes are often offered preventive surgery for asymptomatic gallstones because of the risk of gangrenous cholecystitis . d Gallstones in the elderly usually present classically .

10 . Which THREE statements regarding the management of gallstones are correct ? a LC is the treatment of choice for the management of symptomatic gallstones . b ERCP is used to clear the cystic duct of stones . c Not all patients require surgical management of symptomatic stone disease . d Key to LC is adequate control of the cystic duct junction with the bile duct and prevention of bile duct leakage or injury .

MRCP is obtained after discussion with hepatobiliary surgery .

MRCP confirms bile duct dilatation , and several small calculi are confirmed within the bile duct .

Iris is referred to hepatobiliary surgery for management of CBD stone disease . It is felt that ERCP is indicated despite her comorbidities , because of the risk of developing bile duct obstruction , pancreatitis or cholangitis . Treatment of the gallstones will also likely relieve her episodes of bile duct pain .

ERCP is undertaken with hospital admission , cessation of anticoagulation , sliding scale insulin , antibiotic cover , and delayed reintroduction of anticoagulation .

Sphincterotomy is required ( endoscopic division of the ampulla of Vater ) to allow balloon removal of three small stones in the bile duct . Treatment is uncomplicated , and apixaban anticoagulation is reinstituted 72 hours after ERCP , the intervening period being covered by subcutaneous heparin administration .

Recurrent or retained CBD stones may present with biliary colic , jaundice or abnormal liver function testing . It is common to treat elderly patients with this condition and marked comorbidities .

ERCP may be complicated by pancreatitis , cholangitis or bleeding from sphincterotomy . Anticoagulation increases the risks of haemorrhage or thrombotic disease when managing these patients .

CONCLUSION

Gallstones are very common , with a lifetime risk of more than 20 % in Western populations . Many are without symptoms , and there is a low but real rate of becoming symptomatic yearly .

Laparoscopic cholecystectomy is the mainstay of management of symptomatic stones , which are prone to complications such as infections , jaundice or pancreatitis , if not treated .

More complicated gallstone disease requires specialised diagnosis and management with multiple different modalities and may cause severe life-threatening complications .

References Available on request from howtotreat @ adg . com . au