Bilary Disease

Gallstones are common, with a prevalence of approximately 10–15% of adults in Europe and the U.S. Most of the time patients are asymptomatic. but there are several ways gallstone disease can present.

Presentations

Biliary colic

  • This is the most common presentation.
  • Cause: Occurs when the gallbladder, cystic duct, or common bile duct contracting around a gallstone
  • Symptoms and signs: Steady non-paroxysmal biliary pain occurs in the epigastrium or right upper quadrant and typically lasts for more than 30 minutes, but less than eight hours. It is often severe, and may be associated with nausea and vomiting, but is not associated with fever, or abdominal tenderness. (Pain less than 30 min is less likely to be biliary colic)

Acute cholecystitis (0.3-0.4% annually in asymptomatic gallstone carriers)

  • This is the second most common presentation
  • Cause: Occurs when obstruction of the cystic duct leads to gallbladder inflammation
  • Symptoms and signs: similar to biliary colic, but in addition other classical features are fever and tenderness in the right upper quadrant.
  • Complications: May progress to more severe infection, perforation or fistula formation.

Obstructive jaundice (0.1-0.4% annually in asymptomatic gallstone carriers)

  • Cause: Occurs when a partially or completely blocked common bile duct causes an accumulation of bile pigments in the bloodstream.
  • Symptoms and signs: yellowish discolouration of the skin, dark urine and pale stools.
  • Complications: May precipitate infection if untreated.

Acute/Ascending Cholangitis (Rare) 

  • Cause: Occurs when there is complete obstruction of the bile duct resulting in cholestasis and infected bile which can be life threatening
  • Symptoms and signs: Charcot’s triad, are diagnostic: fever (often with rigors), jaundice, and upper quadrant abdominal pain.
  • Complications: Can be life threatening.

Gallstone pancreatitis (0.04-1.5% annually in asymptomatic gallstone carriers)

  • Cause: Occurs when a stone that has migrated along the common bile duct becomes stuck in the biliopancreatic duct causing pancreatic outflow obstruction
  • Symptoms and signs: Constant epigastric pain radiating through to the back, and profuse vomiting.
  • Complications: Can be life threatening.

Fistula formation

  • Cause: A gallstone erodes through the gallbladder and a fistula develops
  • Complications: Duodenal obstruction (Bouveret’s syndrome). Biliary fistula (a form of Mirizzi syndrome), Gallstone Illius can occur if it erodes into the small bowel

Investigation

  • ECG: these patients are typically in  an age group at risk for ACS, and symptoms can be difficult to distinguish clinically.
  • Bloods: FBC, U&E, LFT, Amylase, Blood Culture (if ? infection), CRP (if admitting to surgery)
  • Imaging: Ultrasound is the best diagnostic tool but occasionally the surgical team may request CT if other diagnosis are being considered

Management

  • Analgesia: often Intravenous
  • Antiemetic:
  • Fluid: IV fluids may be required
  • Antibiotics: will be needed in acute cholecystitis and cholangitis (Red-Flag Sepsis Antibiotics <60min)

Follow-up/Referral

  • Emergency admission – Systemically Unwell OR Suspected Complications
    • Acute Cholecystitis, Cholangitis, Pancreatitis, Uncontrollable Pain.
  • Refer urgently (potentially SDEC or Surgical Avoidance Clinic after discussion with surgical team): 
    • Jaundice, OR if there is a clinical suspicion of biliary obstruction (e.g, significantly abnormal liver function tests).
    • D/W Surgical Team – as destination will depend on patient (Admission, SDEC, Surgical Avoidance Clinic)
  • Surgical Follow-Up 
    • The urgency of referral depends on clinical judgment.
    • Typically via their GP. However, some patients may need referral directly to the surgical team and may be suitable for SDEC or surgical avoidance clinic.

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