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Calot's triangle
Bile salts & enterohepatic circulation
Bile salt pool 2-4g (cycles 6-12 times/day)
hepatic synthesis (0.2-0.6g/day)
stored in gallbladder
(12-32g/day)
(0.2-0.6g/day)
Bilirubin
waste product excreted in bile
(not to be confused with bile salts!!)
Obstructive jaundice
The gallbladder
Yellow discolouration of skin & sclera
Clinically apparent when serum bilirubin > 50µmol/L (normal <20µmol/L)
haemolytic jaundice
eg:
-hereditary spherocytosis
-post blood transfusion
-haematoma formation (post operative/-accidental trauma)
congenital non-haemolytic hyperbilirubinaemia
eg: Gilbert's syndrome
"medical"
viral hepatitis
decompensated liver cirrhosis
drug overdose
etc
aka. obstructive/cholestatic jaundice
2 types:
-intrahepatic obstruction
-extrahepatic obstruction
intrahepatic obstruction of bile canaliculi
eg:
-acute/chronic liver disease
-drugs (eg: chlorpromazine)
extrahepatic obstruction
eg:
-gallstones
-cancer of head of pancreas
-cancer of periampullary region/major bile ducts
-extrinsic compression of bile ducts by metastatic tumour/iatrogenic biliary stricture/choledochal cyst
History:
Examination:
1) endoscopic extaction of CBD stones
2) biopsy of periampullary tumours
3) stent insertion to relieve obstructive jaundice
- acute pancreatitis
- cholangitis (give prophylatic antibiotics in complex interventions)
- haemorrhage
- perforation
- haemorrhage (check coag before procedure)
- bile leakage
- bacteraemia (prophylactic antibiotics)
- renal dysfunction (hydration before procedure)
(Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Internal Clinical Guidelines Team (UK). London: NICE (UK); 2014 Oct. Available from http://ncbi.nlm.nih.gov/pubmedhealth/PMH0070643/)
elective day case laparoscopic cholecystectomy
(to relieve symptoms and avoid complications)
alternatives rarely used: stone dissolution, extracorporeal lithotripsy
analgesia
IV fluids
broad spectrum antibiotics (eg: cephalosporin)
early cholecystectomy
(Takada et al. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20:1-7)
ultrasound-guided percutaneous cholecystostomy + elective cholecystectomy (2 months later) if unfit for surgery/delayed presentation/surrounding inflammation in severe disease/gallbladder empyema
offer treatment regardless of presence of symptoms
bile duct clearance (surgically or by ERCP before/during surgery) + laparoscopic cholecystectomy
5-10% of patients undergoing cholecystectomy have ductal stones, many of which are unsuspected
cholangitis and Charcot's triad (pain+jaundice+fever/rigor) frequently develop with ductal stones (treat with resuscitation+antibiotics+biliary decompression by ERCP)
perform sphincterotomy/ biliary stenting if failed ERCP duct clearance (reattempt with elective ERCP/surgical duct clearance)
Intraoperative:
Post operative:
Depending on resectability assessed on CT/MRI to exclude liver mets, nodal involvement, vascular invasion
Offer surgery if localised tumour and patient fit for radical resection:
Operative mortality=10%
Palliative management:
Offer liver function tests and ultrasound to people with suspected gallstone disease, and to people with abdominal or gastrointestinal symptoms that have been unresponsive to previous management. (Recommendation 1)
Consider magnetic resonance cholangiopancreatography (MRCP) if ultrasound has not detected common bile duct stones but the:
bile duct is dilated and/or
liver function test results are abnormal. (Recommendation 2)
Consider endoscopic ultrasound (EUS) if MRCP does not allow a diagnosis to be made. (Recommendation 3)
Refer people for further investigations if conditions other than gallstone disease are suspected. (Recommendation 4)
Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms. (Recommendation 5)
Offer laparoscopic cholecystectomy to people diagnosed with symptomatic gallbladder stones. (Recommendation 6)
Offer day-case laparoscopic cholecystectomy for people having it as an elective planned procedure, unless their circumstances or clinical condition make an inpatient stay necessary. (Recommendation 7)
Offer early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to people with acute cholecystitis. (Recommendation 14)
Offer percutaneous cholecystostomy to manage gallbladder empyema when:
surgery is contraindicated at presentation and
conservative management is unsuccessful. (Recommendation 8)
Reconsider laparoscopic cholecystectomy for people who have had percutaneous cholecystostomy once they are well enough for surgery. (Recommendation 9)
Offer bile duct clearance and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones. (Recommendation 10)
Clear the bile duct:
surgically at the time of laparoscopic cholecystectomy or
with endoscopic retrograde cholangiopancreatography (ERCP) before or at the time of laparoscopic cholecystectomy. (Recommendation 11)
If the bile duct cannot be cleared with ERCP, use biliary stenting to achieve biliary drainage only as a temporary measure until definitive endoscopic or surgical clearance. (Recommendation 12)
Use the lowest-cost option suitable for the clinical situation when choosing between day-case and inpatient procedures for elective ERCP. (Recommendation 13)
Advise people to avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed. (Recommendation 15)
Advise people that they should not need to avoid food and drink that triggered their symptoms after they have their gallbladder or gallstones removed. (Recommendation 16)
Advise people to seek further advice from their GP if eating or drinking triggers existing symptoms or causes new symptoms to develop after they have recovered from having their gallbladder or gallstones removed. (Recommendation 17)
(Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Internal Clinical Guidelines Team (UK). London: NICE (UK); 2014 Oct. Available from http://ncbi.nlm.nih.gov/pubmedhealth/PMH0070643/)