Managing Gallstones in Clinical Scenarios - A Comprehensive Guide

1. Elusive Gallstones Interactive Clinical Scenarios Aiming at Safe & Sound management by Professor M Al-Fallouji PhD (London), FRCS Ed, FRCS Glas, FRCSI

2. Q1 35 years-old woman post delivery complained of right loin pain. O/E there was right loin tenderness. Urine was murky and on exam. showed pus cells. U/S revealed normal kidneys, spleen, and pancreas, but gallbladder was full of medium size stones. Discuss the management?

3. A1: Incidental Asymptomatic Gallstones • Treat her UTI with high fluid intake and antibiotic. • For gallstones: Do nothing and Discharge her without Follow up • In Leed’s study, 25% of postmortem patients harbour silent gallstones. Although gallstones affect 10% of people in Western World, more than 80% are asymptomatic. • However, in potential infection, Asymptomatic gallstones may be treated in immunocompromised patients and prior to organ transplantation (e.g. kidney). Also in sickle cell disease or hereditary spherocytosis, porcelain fallbladder (risk of malignancy), and those on long-term parenteral nutrition (develop sludge in gallbladder). • It can also be treated in Morbid Obesity surgery, to avoid further surgery in such high risk patient.

4. Q2 89 years-old man presented to ER with right upper quadrant pain. O/E there was mild tenderness in right hypochondrium with positive Murphy’s sign. FBC revealed leucocytosis. U/S showed normal-looking gallbladder and no gallstones. Upper GI endoscopy was normal apart from a moderate size hiatus hernia. Discuss the management?

5. A2: Non-Calculous Cholecystitis (20%) • Acute Acalculous Cholecystitis Can occur in elderly patients, especially those who are already critically ill. • Admit for iv fluids, nill by mouth, antibiotic cover for aerobes and anaerobes (13%) and iv analgesia (e.g. Pethidine) with buscopan (to counteract peripheral narcotic side-effect of sphincter spasm). • Book patient for urgent (before discharge) Laparoscopic / Open Cholecystectomy. • Hiatus hernia is not GORD and if it is non symptomatic, then no treatment.

6. Q3 55 years-old woman presented to ER with upper abdominal pain penetrating in nature associated with vomiting. O/E there was a tinge (trace) of jaundice, epigastric tenderness with guarding. FBC showed leucocytosis, abnormal LFT profile, and high serum amylase. U/S revealed normal kidneys, spleen, and pancreas; however, gallbladder wall was slightly thickened, but without gallstones. Discuss the management in details?

7. A3: Gallstone-induced Acute Pancreatitis • There may have been a tiny solitary CBD stone which sparked acute pancreatitis and then spontaneously passed away (majority of stones pass away into the stool – famous study), or there is a tiny stone in the intra-duodenal portion of CBD undetected on U/S. • There are, therefore, 3 Causes of Cholecystitis without gallstones: (non-calculous Cholecystitis plus above-mentioned 2 causes). • Admit for iv fluids, nill orally, antibiotic cover for areobes and a naerobes (13%) and iv analgesia (e.g. Pethidine) with buscopan (to counteract peripheral narcotic side-effect of sphincter spasm). • Presence of Jaundice (clinical or chemical with high direct bilirubin > 90 umol/L) +chlangitis in severe acute pancreatitis necessitate ERCP & endoscopic sphincterotomy Only if it is within 48 hr of disease onset . • Book for Urgent (before discharge) Lap. Cholecystectomy with intra-operative cholangiography. Presence of stone is not absolute indication for CBD exploration, as postop. ERCP can be done for stone extraction.

8. Q4 Same patient in Q3 underwent laparoscopic Cholecystectomy and was well and discharged. But 4 years later presented to ER with jaundice of 2 weeks duration with past history of recurrent upper abdominal pain dating to 2 years ago. FBC was normal. LFT showed high direct bilirubin. U/S revealed no gallbladder and no gallstones. Pancreas, kidneys, spleen and liver were all normal. Discuss the management?

9. A4: Chronic Pancreatitis with benign CBDstricture causing Obstructive Jaundice • ERCP and sphincterotomy may help. • If not, then choledocho-duodenostomy internal drainage to bypass low CBD stricture and relieve jaundice. • For chronic pain, refer to pain clinic. • If pain clinic fails, then pancreatic surgery. Whipple’s surgery: indicated in biliary obstruction or in gastric outlet obstruction (both are due to inflammatory mass or pseudocyst resulting in fibrosis of bile ducts as a consequence of recurrent episodes of inflammation).

10. Q5 45 years-old farmer presented with jaundice and right upper quadrant pain. O/E there was right hypochondriac tenderness only. Hepatitis screen was negative. U/S revealed normal kidneys, spleen, and pancreas, slightly thickened gallbladder with no gallstones and no dilatation of bile ducts. Discuss the management?

11. A5: Chronic Active Hepatitis(not yet sero-converted or it is chemical / drug-induced hepatitis) • Do liver biopsy and Refer to Department of Medicine. • No indication for surgery. Anaesthesia may be harmful in hepatitis. Cholecystectomy will not cure jaundice. • No indication for ERCP because there is no stones(U/S revealed no dilated ducts).

12. Q6 25 years-old woman weighing 120 kg and 1.5 meter in height presented to OPD with recurrent right upper abdominal pain. Last attack was yesterday at night after a dinner of fish and chips. O/E there was right loin tenderness. Urine was murky and on exam. showed pus cells. U/S revealed solitary large gallstone, but rest of examination was normal. Discuss the management?

13. A6: Morbid Obesity with mild Gallstone Cholecystitis • Her BMI= 120/1.5 x 1.5= 53. Thus she must reduce her weight first, before any surgery:- Dietary regimen, Exercises, and Xenical (Orlistat) oral tablet ½ hour prior to each meal. • See her in OPD every 4-6 months checking her weight, aiming for BMI circa 35. • Treat her UTI with high fluid intake and antibiotic • W/L Laparoscopic Cholecystectomy under double dose of DVT prophylaxis.

14. Q7 65 years-old man presented with deep jaundice of 2 weeks duration and occasional right upper abdominal pain. O/E greenish jaundice with scratch marks but no palpable masses. LFT revealed Direct bilirubin of 350 mmol/L. ERCP reveled 2 stones with total CBD obstruction. Sphincterotomy was done but no bile passed through, Dormia basket passed up but again failed to retrieve stones. Diagnosis of (?) Malignant tumour, with 2 proximal CBD stones, was made pre-operatively. Discuss the management?

15. A7: Two CBD Stones impacted above mid CBD narrow stricture portion • Open Cholecystectomy & CBD exploration with choledochoscopy, biopsy, and T-Tube insertion. • Peri-operative i.v. hydration with Vitamin K injection and Honey consumption. • This should settle the Jaundice, but future recurrence of Jaundice (lithogenic bile) may necessitate a bypass surgery: either a choledocho-duodenostomy or (Roux-en-Y Hepatico-Jejunostomy)

16. Q8 77 years-old frail woman presented with acute right upper abdominal pain of 2 days duration with history of recurrent abdominal pain. O/E she was feverish with a tinge of jaundice, and there was tenderness in right upper quadrant. U/S revealed thick gallbladder wall with multiple gallstones. Discuss the management?

17. A8: Acute Gallstone Cholecystitis with CBD stones in Old Frail woman • ERCP for CBD stones retrieval. • For the hot gallstone Cholecystitis, percutaneous Cholecystostomy, removing stones and draining gallbladder with large Foley’s catheter (done by Interventional Radiologist) or under Local Anaesthesia and i.v. sedation by General Surgeon. • Optional to inject a dye one week later via the catheter to insure empty gallbladder. • And , What if there was a residual CBD stone?

18. Q9 65 years-old woman complained of right upper abdominal pain. O/E there was right upper quadrant tenderness. U/S revealed gallstones with thickened gall bladder wall. She underwent Laparoscopic Cholecystectomy. On 3rd Postoperative day she start developing mild jaundice with low grade fever and mild abdominal distension. Patient otherwise was not in pain and not complaining. Discuss the management?

19. A9: Post-Lap Chole Duct injury, Biliary Peritonitis, and Paralytic Ileus • Emergency Laparotomy with abdominal cavity lavage of bile. • Most likely injury is trans-section of CBD during the clipping of a tented low cystic duct insertion. CBD repair by doing choledocho-dochostomy with T-Tube insertion and on-table cholangiography. • Remove T-Tube on 7-10th postoperative day.

20. Q10 70 years-old man presented with Jaundice noticed 2 weeks earlier with vague upper abdominal pain. He consulted a physician, who did for him plain abdominal X-ray revealing widened duodenum. U/S revealed gallstones with minimal wall thickening and nothing else. OGD was performed for abdominal pain; it was normal apart from compressed antrum from which he took biopsies (showed chronic inflammation). The Doctor then did ERCP, which did not show anything sinister. Patient was then referred to surgeon to do ‘Open Cholecystectomy with CBD exploration’. Postoperative T-tube cholangiogram was normal with no residual stone, and so tube was removed, and patient was discharged. Eight (8) months later, patient developed jaundice again. Discuss the management?

21. A10: Obstructive Jaundice due to Carcinoma of Pancreatic Head & Secondary Biliary Stones (Red Herring) • Gallstones diagnosis should never be confidently entertained in the presence of obstructive jaundice and/or widened C -loop of Duodenum. Also, Biopsies from OGD & ERCP are False Negative (Positive biopsy of Pancreatic Carcinoma preoperatively is not always possible). This is a dilemma and surgical nightmare. • Story of Steve Jobs, Inventor of iPhone. • Do Whipple’s operation for obstructive jaundice due to pancreatic compression whether by tumour or by Chronic Pancreatitis (biopsy negative).

22. Q11 55 years-old woman complained of recurrent right upper abdominal pain at night every time after eating fish and chips over last 3 years. She had U/S done one week prior to her last admission, and shown solitary gallstone with thickened wall of Gallbladder, no dilatation of biliary ducts, and liver, spleen, and pancreas, were all normal. She was previously reluctant to surgery. O/E patient was jaundiced (with blood test confirming mild elevation of direct bilirubin). There was right upper quadrant tenderness. Discuss the management?

23. A11: Mirizzi’s syndrome Type I • Most recent U/S revealed no dilatation of biliary ducts excluding intrabiliary pathology; the fact that pancreas was also normal suggest the possibility of extrinsic compression of CBD due to a very recent gallstone impaction in the neck of inflamed gallbladder or cystic duct (solitary stone). • Type II Mirizzi’s syndrome occurs when there is erosion of the stone into CBD, creating a fistula. • If conservative treatment is unsuccessful in reduction of inflammation and resolution of jaundice, Urgent Open Cholecystectomy is recommended. This will be a difficult Cholecystectomy. The stone must be released, by lateral incision to minimise risk of CBD & CHD, but removal of gallbladder neck is unwise. A temporary bile leak is anticipated with drain placed in the area.

24. Q12 51 years-old woman complained of right upper abdominal pain of 12 hr duration, last night following a meal of French Fries. O/E there was No jaundice. There was however, right upper quadrant tenderness, and Murphy’s sign was briskly positive. U/S on admission revealed gallstones, with very thickened Gallbladder wall, but without dilatation of biliary ducts; liver, spleen, and pancreas, were all normal. She underwent open Cholycystectomy, and because of obscure anatomy a Calot’s triangle, the surgeon was forced to perform Fundus-First Cholecystectomy. For 5 post-operative days, patient was discharging copious amounts of bile through subhepatic drain, which then became associated with epigastric pain and rapid pulse rate, hypotension and tinge of jaundice. What exactly had happened? Was Surgeon wise in doing Fundus-First operation? What else could have been done? What procedures should be done NOW and in LATE future?

25. A12: Postoperative Leak/Fistula with signs of WWS. • Upper abdominal pain with tachycardia and persistent hypotension following postoperative bile leak into subhepatic drain are classical signs of Waltman-Walters syndrome, indicating local or general biliary peritonitis, secondary to iatrogenic (doctorogenic) injury to CBD. • Yes, he was wise in doing Fundus-First cholecystectomy; paradoxically and ironically in such obscure anatomy he could have inadvertently done an excessive mobilization and GB traction, thus tenting CBD and pulling out right hepatic artery of their normal alignment, rendering them liable to be clamped or included in ligature (late stricture). • Thus, it was better if he had done Subtotal Cholecystectomy. • Percutaneous drainage of bile collection under U/S and ERCP stenting to seal the leakage point and heal fistula and stabilise patient for later CBD repair by doing standard Hepatico-Jejunostomy with Roux-loop & Entero-Enerostomy.