Gallstones, cholecystitis, obstructive jaundice and bile duct disorders

Overview

Gallstone disease is one of the commonest reasons for general surgical admission. PGET questions focus on the anatomy of Calot's triangle, the clinical signs (Murphy, Charcot, Courvoisier), the choice of investigation (ultrasound, MRCP, ERCP) and timing of surgery. Gallbladder cancer is relatively common in the north of the subcontinent, including Pakistan.

Anatomy and physiology

• Gallbladder: fundus, body, neck and Hartmann's pouch (where stones lodge); it concentrates bile 5-10 times.
• Cystic duct (with spiral valves of Heister) joins the common hepatic duct to form the common bile duct (CBD), which runs behind the duodenum and pancreatic head to the ampulla of Vater (sphincter of Oddi) in the second part of the duodenum.
• Cystic artery: usually from the right hepatic artery; variations are common (the right hepatic artery or cystic artery may cross in front of the duct).
• Calot's (hepatobiliary) triangle:
  • Boundaries: cystic duct (below), common hepatic duct (medially), inferior surface of the liver (above; Calot's original roof was the cystic artery).
  • Contents: cystic artery, cystic lymph node (of Lund), sometimes the right hepatic artery or an accessory duct.
• The terminal ileum takes back about 95% of bile salts (the enterohepatic circulation), so ileal resection or Crohn's disease predisposes to gallstones.
• Phrygian cap: a folded fundus; a harmless variant.

Gallstones

Types

Only about 10% of gallstones are radiopaque on plain X-ray (unlike 90% of renal stones).

Presentations

Investigations

• Ultrasound (first-line): stones as echogenic foci with acoustic shadowing; in cholecystitis, thickened wall, pericholecystic fluid, sonographic Murphy sign; CBD diameter (dilated CBD suggests duct stones).
• LFTs: raised bilirubin and alkaline phosphatase and GGT point to duct obstruction; amylase or lipase for pancreatitis.
• MRCP: non-invasive picture of the ducts; best to detect CBD stones before deciding on ERCP.
• ERCP: for therapy (sphincterotomy, stone removal, stent), not for diagnosis alone.
• Endoscopic ultrasound: sensitive for small duct stones.
• CT: complications (perforation, abscess), pancreatitis and malignancy; misses many gallstones.
• HIDA scan: non-filling of the gallbladder confirms acute cholecystitis when ultrasound is unclear.

Acute cholecystitis

Cause: in most cases a stone obstructs the cystic duct (calculous); the trapped bile causes chemical then bacterial inflammation (E. coli, Klebsiella, enterococci).

Acalculous cholecystitis: in critically ill patients (ICU, burns, trauma, sepsis, TPN); high risk of gangrene and perforation; often treated by percutaneous cholecystostomy.

Clinical features: RUQ pain radiating to the right shoulder, fever, vomiting, RUQ tenderness and guarding, Murphy sign (patient catches breath as the inflamed gallbladder descends onto the examiner's fingers), raised white count; sometimes a tender mass (omentum wrapping the gallbladder). Mild jaundice can occur.

Tokyo severity grades: I mild; II moderate (white count above 18 000/mm3, palpable tender mass, symptoms over 72 hours, marked local inflammation such as gangrene or abscess); III severe (organ dysfunction).

Management

1. Admit: nil by mouth, IV fluids, analgesia, IV antibiotics.
2. Over 90% settle on conservative treatment.
3. Early laparoscopic cholecystectomy in the same admission (ideally within about a week of onset) is safe and shortens total hospital stay. The alternative is interval cholecystectomy after about 6 weeks.
4. Severe disease or unfit patient: percutaneous ultrasound-guided cholecystostomy, followed by interval cholecystectomy later.
5. Emergency surgery for empyema, gangrene, perforation or emphysematous cholecystitis (gas-forming organisms, diabetics).
6. If jaundiced or LFTs abnormal, MRCP to look for CBD stones.

Cholecystectomy

• Laparoscopic cholecystectomy is the standard operation for symptomatic gallstones.
• Indications: symptomatic stones (colic, cholecystitis, pancreatitis after the attack settles, CBD stones after clearance); some asymptomatic patients (porcelain gallbladder, large stones, gallbladder polyps 1 cm or more, sickle cell disease or other haemolytic anaemia, during bariatric surgery).
• Critical view of safety: before clipping anything, clear Calot's triangle so that only two structures (cystic duct and artery) are seen entering the gallbladder, with the lower gallbladder lifted off the liver bed.
• Conversion to open is not a failure; consider subtotal cholecystectomy when the anatomy is unsafe.

Complications:

• Bile leak (cystic duct stump, ducts of Luschka) and collection: ERCP stent and drainage.
• Bile duct injury (about 0.5% of cases; classified by Strasberg or Bismuth): the most feared; often a misidentified CBD clipped as the cystic duct. Major transection needs a Roux-en-Y hepaticojejunostomy by a specialist.
• Bleeding (cystic artery, liver bed), bowel injury from ports, retained CBD stones, port-site hernia, spilled stones.
• Post-cholecystectomy syndrome: continuing pain (retained stones, sphincter of Oddi dysfunction, missed alternative diagnosis).

Common bile duct stones

• Primary (formed in the duct, brown pigment, with stasis and infection) or secondary (passed from the gallbladder; commoner).
• Present with obstructive jaundice (often fluctuating), biliary pain, cholangitis or pancreatitis; some are found on intraoperative cholangiography.
• Diagnosis: ultrasound (dilated CBD), LFTs, MRCP or EUS.

Treatment:

• ERCP with sphincterotomy and balloon or Dormia basket extraction; stent if not cleared; then laparoscopic cholecystectomy.
• Or laparoscopic CBD exploration at the time of cholecystectomy (transcystic or choledochotomy).
• Open choledochotomy with T-tube drainage where endoscopy is unavailable or fails; a T-tube cholangiogram is done before removal; if stones remain, the tract is left to mature (about 6 weeks) for percutaneous removal.
• Lithotripsy for very large stones.

Acute (ascending) cholangitis

• Infection of an obstructed bile duct: stones (commonest), benign or malignant strictures, blocked stents, parasites (Ascaris).
• Charcot triad: RUQ pain, jaundice, fever with rigors.
• Reynolds pentad: Charcot triad plus hypotension and confusion (suppurative cholangitis; a surgical emergency).

Management:

1. Resuscitate; blood cultures; IV broad-spectrum antibiotics; correct clotting (vitamin K).
2. Urgent biliary drainage if not settling or severe: ERCP with sphincterotomy, stone removal or stent (first choice); PTC (percutaneous transhepatic drainage) if ERCP fails or for hilar blocks; open drainage with a T-tube as a last resort.

Obstructive jaundice: approach

Courvoisier law: in a jaundiced patient, a palpable gallbladder is unlikely to be due to stones, because stones cause chronic inflammation and fibrosis, leaving a shrunken gallbladder that cannot distend. A distended gallbladder suggests malignant obstruction below the cystic duct (head of pancreas, ampulla, distal CBD). Exceptions: double impaction (stone in cystic duct and CBD), Mirizzi syndrome, mucocele.

Biochemistry: raised conjugated bilirubin, high ALP and GGT, dark urine, pale stools, pruritus; urine urobilinogen absent in complete obstruction; prolonged PT.

Imaging pathway: ultrasound (dilated ducts, level of block) → MRCP or CT (cause and staging) → ERCP or EUS for tissue or therapy; PTC for high blocks.

Perioperative risks in the jaundiced patient

Other bile duct and gallbladder disorders

Choledochal cyst

• Congenital dilatation of the bile ducts; commoner in females and East Asians; often found in childhood.
• Classic triad: abdominal pain, jaundice, RUQ mass (seldom all three).
• Todani classification: type I (fusiform or cystic dilatation of the CBD) is commonest, about 75%; type IV multiple; type V (intrahepatic only) is Caroli disease.
• Risk of cholangiocarcinoma; treat by complete cyst excision with Roux-en-Y hepaticojejunostomy (not drainage alone).

Biliary atresia

Progressive obliteration of the extrahepatic ducts in neonates: persistent conjugated jaundice, pale stools, dark urine; Kasai portoenterostomy, best done early (before about 8 weeks); transplantation if it fails.

Primary sclerosing cholangitis

Inflammatory fibrosis of intrahepatic and extrahepatic ducts; strongly linked to ulcerative colitis; beaded ducts on MRCP; risk of cholangiocarcinoma; liver transplantation for end-stage disease.

Gallbladder polyps

Most are cholesterol polyps or adenomyomatosis. Cholecystectomy for polyps 1 cm or more (malignant risk), growing polyps, or symptomatic ones; smaller polyps are followed with ultrasound.

Gallbladder cancer

• Mostly adenocarcinoma; elderly women; high incidence in northern India and Pakistan, Chile and among American Indians.
• Risk factors: long-standing gallstones, porcelain gallbladder, typhoid carriers, adenomatous polyps, choledochal cyst, anomalous pancreatobiliary junction.
• Often found incidentally after cholecystectomy, or late with jaundice, a hard RUQ mass and weight loss; spreads directly into liver segments IVb and V.
• Treatment: radical (extended) cholecystectomy with liver wedge and node clearance for early disease; incidental T1b or more needs re-resection; palliation (stenting, chemotherapy) for most.

Cholangiocarcinoma

• Hilar (Klatskin) tumours are the commonest (about 60%); distal and intrahepatic types follow.
• Risk factors: primary sclerosing cholangitis, choledochal cyst, Caroli disease, liver flukes (Clonorchis, Opisthorchis), hepatolithiasis.
• Painless progressive jaundice, pruritus, weight loss; CA 19-9 often raised; hilar block gives dilated intrahepatic ducts with a collapsed gallbladder and normal CBD.
• Bismuth-Corlette classification of hilar tumours guides resection (bile duct excision with hepatectomy). Most are palliated with stents (PTC for hilar tumours).

Quick revision

• Calot's triangle: cystic duct, common hepatic duct, liver; contains cystic artery and node of Lund.
• Ultrasound first; MRCP to find duct stones; ERCP to treat them.
• Acute cholecystitis: fluids, analgesia, antibiotics; early lap chole within about a week, or interval at 6 weeks; cholecystostomy if unfit.
• Cholangitis: Charcot triad (Reynolds pentad if shocked and confused); antibiotics plus urgent ERCP drainage.
• Courvoisier: jaundice plus palpable gallbladder = probably not stones (think pancreatic head or ampulla).
• Jaundiced patient before surgery: vitamin K, hydration, antibiotics.
• Gallstone ileus: elderly woman, Rigler triad, stone in terminal ileum; remove stone by enterotomy.
• Gallbladder cancer: stones, porcelain gallbladder, typhoid carriers; common in Pakistan and north India.

Written by The House Job from standard references (Bailey & Love).

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