1. Gallbladder Disease Surgical Students Society of Melbourne, 2011 J. Bridie Mee RMH intern

2. www.jacksonregionalsurgery.com

3. Gallstone Disease Cholelithiasis Choledocolithiasis Biliary Colic Cholecystitis

4. Gallstone Types Cholesterol stones Pigment stones

5. Risk Factors Fair Female Fat Forties Fertile also DM, family Hx

6. Epidemiology Why do you need to know about it? 2 nd most common abdo organ requiring surgery Population prevalence 5-20% of which majority (70-80%) remain asymptomatic 1-4% develop symptoms each year

7. Biliary Colic - Symptoms Site Onset Timing Character Radiation Severity Assoc sympt Aggrav/reliev

8. Biliary Colic - Symptoms SiteRUQ Onsetsudden Timing30 min – 6 hrs Characterdull Radiation +/- to epigastrium, back Severityvery Assoc symptnausea & vomiting Aggrav/reliev fatty foods, analgesics

9. Biliary Colic - Examination General: Restless, +/- jaundice Obs: tachy Abdo: RUQ tenderness, guarding

10. Biliary Colic - Investigations FBE LFT UEC Amylase/lipase CXR/AXR Upper abdo ultrasound

12. Differentials Abdo: – Acute cholecystitis – Pancreatitis – GORD – Perforate PUD – Appendicits (atypical) – pyelonephritis Thoracic: – Pneumonia – angina

13. Biliary Colic - Management Analgesia Exclude complications/differentials Elective cholecystectomy

14. Acute Cholecystitis Acute inflammation of GB following impactions of stone, +/- infective Symptoms: – RUQ/epigastric pain – Nausea, vomiting – Fever – Aggravated by movement, deep breathing

15. Acute Cholecystitis - Examination General distressed, still, shallow breathing, +/- jaundice (scleral) Obs febrile, tachycardia Abdo RUQ tenderness, guarding +/- Murphy’s sign/peritonism

16. Acute Cholecystitis - investigations FBE, UEC, LFT, CRP Amylase/lipase ECG CXR/AXR Upper abdo US

17. Acute Cholecystitis - Ultrasound

18. 90-95% sensitive What are the ultrasound findings?

19. Acute Cholecystitis - Management Call surg admit! Analgesia opiods NBM IVFT Antibiotics

20. Cholecystectomy: Indications & Timing Not indicated for incidental findings of cholelithiasis that are asymptomatic Elective for biliary colic During admission elective or urgent for acute cholecystitis Alternatives if unfit for surgery – Abx and percutaneous drainage

21. Laparotomy vs Laparoscopy

22. http://www.laparoscopy.com/pictures/lap_chol.html

23. Complications Gangrenous cholecystitis Obstructive jaundice Cholangitis Gallstone ileus Pancreatitis Death!

24. Choledocolithiasis causing Obstructive Jaundice Post-hepatic jaundice (GGT, ALP) Symptoms – Hx of previous gallbladder disease – Jaundice – Pale stools, dark urine

25. Obstructive Jaundice – Ix LFT, FBE, UEC, CRP USS – GB, CBD, stones MRCP

27. Treatment obstructive jaundice ERCP Laparoscopic/open cholecystectomy with IOC

28. ERCP

29. Cholangitis When obstructed CBD becomes infected Charcot’s triad of signs – RUQ pain – jaundice – High fever/rigors Can be life threatening, early treament essential

30. Gallstone Ileus When stone perforates GB wall and erodes into duodenum, obstructing small bowel Treatment - laparotomy

31. Pancreatitis When gallstone irritates pancreas causing inflammation, or distal CBD blockage causing intrapancreatic release of enzymes 30-50% pancreatitis caused by gallstones Can be life threatening

32. Take home messages Gall stone disease very common, worth knowing about, understanding anatomy helps Feel lots of bellies Complications can be life threatening Get scrubbed for a cholecystectomy!