1. Gallbladder Disease Robert C Moesinger, MD/FACS Northern Utah Surgeons Ogden Surgical-Medical Society May 17, 2013

2. Disclosures I have no conflicting financial relationships with any of the devices, drugs or organs that I will be discussing. However, like many general surgeons, the gallbladder is largely responsible for educating my children, and so anything I say could be skewed by that relationship.

3. Objectives Understand the many varied presentations of gallstone disease and their management. Understand the workup and treatment of acalculous gallbladder disease. Understand the management of gallbladder disease in the critical care setting.

4. Introduction It hardly seems reasonable to have gallbladder disease be part of “What’s New In My Specialty?”. Gallstones go back at least as far as ~1000 BC. An Egyptian mummy—an apparent priestess—has been found to have gallstones. First recognition of gallstones in life is credited to Alexander of Tralles in the 6 th century BC. John Stough Bobbs (1809-1870)—first cholecystotomy in 1867. Carl Langenbuch (1846-1901)—first cholecystectomy in 1882—recognizing that horses, elephants and rats don’t have gallbladders.

5. Introduction The last really big innovation for gallbladder disease was laparoscopic cholecystectomy, first performed in France in 1987. Perhaps MRCP, developed in 1991, could be considered a major development, but that was 22 years ago. Single-port cholecystectomy – No good evidence that it makes much difference NOTES—Natural Orifice Translumenal Endoscopic Surgery – Not likely to become common

6. Introduction

8. Sleisenger and Fordtran: Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management, Ninth Edition Mark Feldman, Lawrence S. Friedman, and Lawrence J. Brandt, 2010.

9. Introduction Sleisenger and Fordtran: Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management, Ninth Edition Mark Feldman, Lawrence S. Friedman, and Lawrence J. Brandt, 2010.

10. Scope of Gallbladder Disease and Cholecystectomy Among the most common surgical procedure performed—about 500,000 per year. Prevalence of gallstones estimated at 10-20% over a lifetime. A patient base of almost 7000 patients – 1988—1.35 cholecystectomies per thousand – 1992—2.15 cholecystectomies per thousand – 59% increase! JAMA. 1993;270:1429-1432 Today—1.68 just in ambulatory surgery centers, perhaps up to 3.00 in all. Multiply 2.15 times 75 years of life and that is 160 gallbladders removed per thousand over a lifetime. (16%) By Comparison—Northern Ireland—1.01 per thousand in 2009.

11. Scope of Gallbladder Disease and Cholecystectomy Local data January 2013: 80 cholecystectomies in Ogden – Approximately 1000 cholecystectomies/year – 9291 births in Ogden in 2012 Approximately 10% of people in Northern Utah will lose their gallbladders before they die.

12. Scope of Gallbladder Disease and Cholecystectomy Description of old Boitnott study. Taken together we can conclude that in the laparoscopic era we are taking out more gallbladders and less sick gallbladders. Data from 2013—11/40 consecutive gallbladders at both hospitals did not have stones. (28%)

13. Implications of Increasing Cholecystectomy Are we reducing complications of gallbladder disease? Maybe?? – A nationwide study of multiple databases concluded that Acute Cholecystitis as a reason for hospital admission declined 14% from 2000-2009. – Is this related to more management of acute cholecystitis as an outpatient? – Peery, AF, et al. Burden of Gastrointestinal Disease in the United States: 2012 Update. Gastroenterology. 2012;143(5):1179-1187.

14. Implications of Increasing Cholecystectomy Acute Pancreatitis – 30% increase in admissions for acute pancreatitis from 2000-2009. – 40-50% would be “gallstone pancreatitis” Taken together, despite a decrease in acute cholecystitis, with the increase in pancreatitis, complications from gallstones are probably not decreasing despite increasing cholecystectomy.

15. Implications of Increasing Cholecystectomy Bile Duct Injury – Rate of bile duct injury is at a fairly constant 0.1-0.2% – If 28% of 1000 gallbladders per year are not “that sick”, then every 2-4 years we are causing an additional bile duct injury in Weber County. Colon Cancer – Several studies show an increased risk of colorectal cancer after cholecystectomy in the 10-40% range. – If cholecystectomy increases risk of colon cancer from 5-6% (a 20% increase), then about 2 patients a year with gallbladders that are “not that sick” are getting needless colorectal cancer in Weber County. Overall, increasing rates of cholecystectomy are not necessarily beneficial to the population as a whole, which could become fairly important as we move in the direction of accountable and/or bundled care models for a population instead of individual patients.

16. Manifestations of Gallstone Disease Sleisenger and Fordtran: Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management, Ninth Edition Mark Feldman, Lawrence S. Friedman, and Lawrence J. Brandt, 2010.

17. Manifestations of Gallstone Disease Biliary Colic and Chronic Cholecystitis Most common indication for cholecystectomy Intermittent cystic duct obstruction Presence of stones on ultrasound and symptoms are appropriate for cholecystectomy without any further workup. Eventually symptoms tend to escalate. Atypical presentation in the elderly

18. Manifestations of Gallstone Disease Acute Cholecystitis – 226,000 admissions and 959 deaths in 2009 Persistent Cystic Duct Obstruction Charcot’s triad Ultrasound for diagnosis HIDAscan in difficult cases Expeditious cholecystectomy

19. Manifestations of Gallstone Disease Choledocholithiasis and Cholangitis – It is estimated that 5-10% of patients will have CBD stones at time of cholecystectomy. – Probably 90% of these pass without intervention. – Nevertheless, approximately 50,000 admissions Painful Jaundice +/- Fever Reynold’s Pentad Expeditious Therapeutic Cholangiogram— Cholecystectomy is actually optional. 5% per year will have further trouble. Note Gastric Bypass Population

22. Manifestations of Gallstone Disease Gallstone Pancreatitis – Perhaps 120,000 admissions per year. – Perhaps 1200 deaths. Since the gallbladder has no Constitutional rights, it is often appropriately removed in the absence of another cause of acute pancreatitis.

23. Manifestations of Gallstone Disease Gallstone Ileus Gallbladder Cancer – Fortunately, only 3300 cases in 2008 – Many are incidental, but 2000 deaths per year.

24. Manifestations of Gallstone Disease Asymptomatic Gallstones – 10% will have symptoms after 5 years. – 20% after 20 years. Cholecystectomy for: – Pediatric population – Pigmented stones (Hemolytic anemia) – “Already there” – Stones greater than 3 cms – Extended time away from reliable medical care – Bariatric surgery—30% develop stones – ? Diabetes

25. Gallbladder Disease in Critically Ill Patients 2 Scenarios Presentation with acute cholecystitis and becoming critically ill. – Fortunately rare. – Expeditious cholecystectomy usually definitive.

26. Gallbladder Disease in Critically Ill Patients Presentation with critical illness and developing acute calculous or acalculous cholecystitis. 5-10% of cholecystectomies Seen in trauma, burn, and other critically ill patients. Tend to be men and older Treatment can be surgical or percutaneous drainage.

27. Gallbladder Polyps A somewhat common incidental finding. The standard of care is cholecystectomy at 10mm. The question is what to do in the symptomatic patient.

28. Cholesterolosis An acquired histologic abnormality of the gallbladder epithelium characterized by excessive accumulation of cholesterol esters and triglyceride within epithelial macrophages. Present on 12% of autopsy specimens and 18% of cholecystectomy specimens. It does not clearly cause symptoms but has been implicated in acalculous biliary pain in which patients seem to have better results when this is found. Also implicated in idiopathic recurrent pancreatitis.

29. Cholesterolosis

30. Chronic Acalculous Cholecystitis AKA Biliary Dyskinesia Different than acutely ill discussed above. Ultrasound accuracy exceeds 95% and rarely misses stones larger than 2mm. “Microlithiasis” or presence of cholesterol crystals in bile does exist.

31. Work up of Gallstone-negative “Biliary Symptoms” HIDAscan – In healthy volunteers, the average ejection fraction is 75% and virtually all exceed 35%, which is generally the threshold for normal on these scans. – This has become very popular and is often done immediately after a negative ultrasound which makes the test less predictive. – With an abnormal test, cholecystectomy will show some gallbladder inflammation in 90% and cholesterolosis in 30%. – 65-80% will have improvement in symptoms, however up to 50% will eventually have pain relief without surgery. – Comment about “Hyperkinetic Gallbladder”.

32. Work up of gallstone negative “biliary symptoms” CT Scan Very good at excluding other causes of abdominal pain Rarely adds much to gallbladder diagnosis unless a thickened wall is seen.

33. Work up of gallstone negative “biliary symptoms” MRCP Another way to look for gallstones Very good non-invasive way to look for biliary and pancreatic ductal anomalies including pancreas divisum and common bile duct cysts.

34. Work up of gallstone negative “biliary symptoms” ERCP Although invasive, a very good look at ductal anatomy. Can allow for stenting. Can do manometry, but difficult.

35. Algorithm for patient with mystery “biliary” symptoms Biliary Symptoms Ultrasound SurgeryPositive HIDAscan NegativeLow EF Time Normal Do Nothing Resolution CT Scan Appropriate Treatment Positive Negative Time Resolution Consider GI Consult Endoscopy MRCP Find Something To Treat Time and Counseling Negative

36. Conclusions Gallbladder Disease is common and highly variable in its presentation and treatment. A thoughtful understanding and approach to the various complications of gallbladder disease can streamline diagnosis and therapy. We probably take out too many gallbladders.