Grand Round Presentation – 21/11/06. Prologue: Journey Of The Stone Overview of the biliary system & related organs Presentation of 2 patients with.

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

Investigation & management of gallstones

Fig 1: The Biliary System

Fig 2: ERCP - Contrast

Fig 3: ERCP - Sphincterotomy

Fig 4: ERCP - Endoscope

Fig 5: Double Pig-Tail Stent

Fig 5: MRCP

Fig 6: Gallstone Pancreatitis

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 ↡

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

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

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

4.2: Problems With The Pancreas

GET SMASHED!• Gallstones

• Ethanol

• Trauma

• Steroids

• Mumps

• Autoimmune (PAN)

• Scorpion Sting

• Hyper -lipidaemia -Ca2+, Hypothermia

• ERCP, Emboli

• Drugs

4.2: Problems With The Pancreas

(…cont’)

Age > 55 years

pO2 < 8 mmHg

Glucose > 10 mmol/l

Blood Urea Nitrogen > 46 mg/dl

Calcium < 2 mmol/l

LDH > 600 u/l

WBC > 15 x109/l

Albumin < 32 g/l

Glasgow Modified Severity Scale (>3 = Severe)

Also APACHE-II, Ranson & Multi-Organ System Failure

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

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

5.1: Removing The Rock

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

(…cont’)

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

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