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Grand Round Presentation – 21/11/06

A Tale Of Two Gallstones. Grand Round Presentation – 21/11/06. Prologue: Journey Of The Stone. Overview of the biliary system & related organs Presentation of 2 patients with gallstones Pathology & aetiology of gallstones Problems associated with gallstones

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Grand Round Presentation – 21/11/06

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  1. A Tale Of Two Gallstones Grand Round Presentation – 21/11/06

  2. Prologue: Journey Of The Stone • Overview of the biliary system & related organs • Presentation of 2 patients with gallstones • Pathology & aetiology of gallstones • Problems associated with gallstones • Investigation & management of gallstones

  3. Fig 1: The Biliary System

  4. Fig 2: ERCP - Contrast

  5. Fig 3: ERCP - Sphincterotomy

  6. Fig 4: ERCP - Endoscope

  7. Fig 5: Double Pig-Tail Stent

  8. Fig 5: MRCP

  9. Fig 6: Gallstone Pancreatitis

  10. Chapter 3: The Birth Of A Gallstone • Risks: 4 F’s: Fat, Fertile Females of Forty. • Also diet, rapid weight loss, drugs (OCP), diabetes • 80% cholesterol-based, 20% pigment (Ca-bilirubinate): • Cholesterol & bile salts secreted from hepatocytes & stored in gallbladder • Stones form on a nidus (mucins) often when motility is ↡

  11. 3.1: Heart Of Stones • Cholesterol: super-saturation with relation to bile salts. Predisposes as cholesterol can precipitate on nidus • Pigment: black (Ca-salts & glycoproteins) which are associated with haemolysis • Pigment: brown (Ca-salts & fatty acids); occur during stasis. Can cause recurrent stones post-cholecystectomy • Cholesterol stones missed on radiographs as radiolucent

  12. Chapter 4: Struggles With The Stones • Most are asymptomatic (80%), discovered incidentally • Biliary Colic +/- nausea, vomiting & jaundice • Aggravated by food (especially fatty), relieved by opiates • 2ndry complications associated with pyrexia & ↟ pain • Cholecystitis (acute or chronic), empyema, mucocele, pancreatitis, cholangitis, perforation, fistulae & gallstone ileus

  13. 4.1: Judging The Jaundice • Unconjugated (haemolytic) or conjugated (congenital or cholestatic) • Biliary Obstruction: Intra-hepatic or Extra-hepatic: Extra-ductal or Intra-ductal • Intra-hepatic: Hepatitis, Cirrhosis, Drugs, Pregnancy. Associated with ↟ AST & ALT • Extra-hepatic: Carcinoma, strictures, inflammation, gallstones. Associated with ↟ ALP & GT

  14. 4.2: Problems With The Pancreas • GET SMASHED! • Gallstones • Ethanol • Trauma • Steroids • Mumps • Autoimmune (PAN) • Scorpion Sting • Hyper -lipidaemia -Ca2+,Hypothermia • ERCP, Emboli • Drugs

  15. 4.2: Problems With The Pancreas (…cont’) • Glasgow Modified Severity Scale (>3 = Severe) • Also APACHE-II, Ranson & Multi-Organ System Failure

  16. Chapter 5: Chasing The Calculi • Clinical: History & Examination (jaundice, pain) • Bloods: ↟ ALP +/- amylase & bilirubin if obstructed • Radiograph / CT not useful without contrast • USS: imaging investigation of choice: non-invasive, accurate, cheap, sensitive (95%). Can be endoscopic • MRCP: T2, better for visualising ducts & level of calculi but not as sensitive in early dilatation

  17. 5.1: Removing The Rock • ERCP: Uses contrast to visualise biliary tree. Can be used to remove stones from CBD, insert stents and perform sphincterotomies. Can cause pancreatitis (5%) • Percutaneous transhepatic cholangiogram (PTC) sometimes used if close to the liver • If asymptomatic manage conservatively • Medical interventions include: shockwave lithotripsy, ursodeoxycholic acid (↡cholesterol secretion) & bile salts

  18. 5.1: Removing The Rock (…cont’) • Surgical includes laparoscopic & open cholescystectomy • Most laparoscopic. Incision in umbilicus, fill peritoneum with gas, insert light. 3 more incisions in RUQ for instruments. CD clipped & gallbladder removed in bag • 5% need to convert to open: midline scar • Complications if wrong duct clipped, infection, perforation and if stones spilled into peritoneum or ducts

  19. Epilogue: Legacy Of The Stone • Gallstones are a common problem in the middle-aged and elderly population but are often asymptomatic • Diagnosis often made on history & examination +/- USS • Obstruction may present with jaundice & complications • MRCP & ERCP often used in cases of obstruction • Medical treatment may be used but most often laparoscopic cholecystectomy is performed

  20. References: Writings On The Stone • Burroughs AK, Westaby D: Liver, biliary tract and pancreatic disease, In Kumar P, Clark M: Clinical Medicine (5th Edition). WB Saunders, 2002 • Longmore M, Wilkinson I, Török E: Oxford Handbook Of Clinical Medicine. Oxford University Press, 2001 • Adamek HE, Albert J, Weitz M: A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut, 1998; 43(5): 680-683 • Ahmed A, Cheung RC, Keeffe EB: Management of gallstones and their complications. Am Fam Physician, 2000; 61(6): 1673-1688 • Werner J, Feuerbach S, Uhl W, Buchler MW: Management of acute pancreatitis: from surgery to interventional intensive care. Gut, 2005; 54(3): 426-436

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