Gallstones. Gallstones. More gallstones.
Definition: inflammation and infection of the bile duct caused by obstruction, usually by gallstones
Aetiology/ risk factors:
Occurs when there is complete obstruction of the common bile duct resulting in cholestasis and infected bile.
R/F for gallstones: Female, Fat, Forty, Fertile (do not say this to a patient!)
Also-parenteral nutrition, drugs (OCP, octreotide), FHx, interruption of enterohepatic circulation of bile salts (e.g. Crohn’s disease), terminal ileal resection. Pigment stones: haemolytic disorders (e.g. Sickle cell), liver cirrhosis
R/F for stones becoming symptomatic: smoking, parity (previously carried pregnancies to viable gestational age).
Less common causes of acute cholangitis: iatrogenic biliary duct injury (e.g. during cholecystectomy) causing stricture, chronic pancreatitis causing biliary stricture, chemotherapy/ radiation-induced biliary injury, sclerosing cholangitis (1ry or 2ry), parasite entry into bile ducts, malignant strictures etc.
-Gallstones very common- prevalence = 8% of those over 40 years. 90% remain asymptomatic.
-Cholangitis is relatively uncommon, presenting as a complication in about 1% of cases of gallstones.
-Sudden onset, severe right upper quadrant pain
-RUQ or epigastric tenderness
+ hypotension and confusion = Reynold’s pentad
FBC- ↑WCC, ↓platelets CRP↑
LFTs- ↑bilirubin, ↑alkaline phosphatase, transaminases may be elevated
U&Es- urea and creatinine elevated in severe cases
Blood cultures-evidence of sepsis? (usually gram -ves)
ABG- metabolic acidosis in severe cases (sepsis)
Coagulation- Prothrombin time may be raised with sepsis
Amylase- risk of pancreatitis
–Ultrasound– may show gallstones in common bile duct, and dilation of common bile duct, indicative of obstruction. USS is more sensitive to stones in the gallbladder than in the ducts. (Common bile duct dilatation if > 6cm)
–ERCP/MRCP (endoscopic retrograde/ magnetic resonance cholangiopancreatography) = ERCP allows for direct observation of bile duct stone or other obstruction and is a good first intervention as it has therapeutic value
-IV fluid resuscitation
-Antibiotics e.g. IV CEFUROXIME (cephalosporin) (1.5g/8h) & IV/PR METRONIDAZOLE (500mg/8h)
-Analgesia (e.g. pethidine or morphine)
-within 24 to 48h, but more urgent in severe cases
→ERCP with biliary sphincterotomy (cut the sphincter of Oddi) and stone extraction. If this is not successful- lithotripsy (stone fragmentation), papillary balloon dilation (at the duodenal papilla, where the dilated junction of the bile and pancreatic ducts- ampulla of Vater- enters the duodenum) and long-term biliary stenting.
-If ERCP fails, percutaneous drainage or surgical common bile duct exploration may become necessary.
-This is followed up by a cholecystectomy.
Definition: surgical removal of the gallbladder. Laparoscopic is usually the first choice. Open surgery may be more suitable in some cases e.g. GB perforation, suspected GB cancer, conversion from laparoscopic if there are difficulties.
Indications: acute and chronic cholecystitis, biliary colic, obstructive jaundice with common bile duct stones, cholangitis, gall bladder perforation, gall bladder cancer
Complications: bleeding, infection, bile leak, bile duct injury, post-cholecystectomy syndrome (persistent dyspeptic syndrome), biliary stricture, incisional hernias
-Sepsis (toxic cholangitis), hypotension, multi-organ failure
-Post-ERCP Pancreatitis, or pancreatitis caused by the gallstone in the distal common bile duct
-Iatrogenic bile duct injuries
Prognosis: if adequate biliary drainage is quickly obtained, most patients experience rapid clinical improvement