Ch. 54 – Biliary System

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1558 Section X Abdomen patients tend to have recurring symptoms, usually repeated episodes of biliary colic. 10 Over a 20-year period, two thirds of asymptomatic patients with gallstones remain symptom-free. Chronic Calculous Cholecystitis Ongoing infl ammation with recurrent episodes of biliary colic or pain from cystic duct obstruction is referred to as chronic cholecystitis. About two thirds of patients with gallstone disease present with these repeated attacks. Although the pathologic changes in the gallbladder can vary, repeated attacks, scarring, and a nonfunctioning gallbladder are the rule. Histologically, chronic cholecystitis is characterized by an increase in subepithelial and subserosal fi brosis and a mononuclear cell infi ltrate. Clinical Presentation The primary symptom of chronic cholecystitis or symptomatic cholelithiasis is pain, often referred to as biliary colic (see earlier section, Abdominal Pain). The pain is constant and usually lasts 1 to 5 hours. The attacks usually last for more than 1 hour but subsides by 24 hours; if pain persists longer than 1 day, acute cholecystitis is likely the underlying etiology. The attacks are discrete and severe enough that patients can accurately recall and number them. Other symptoms such as nausea and vomiting often accompany each episode, and bloating and belching may also be present in 50% of cases. Fever and jaundice are rare with simple biliary colic. Patients without symptoms, about two thirds of patients with gallstones, develop symptoms infrequently and complications at an even lower rate. In most cases, treatment is not necessary in these asymptomatic patients. Patients with gallstones but an atypical presentation should have other causes of right upper quadrant pain ruled out such as peptic ulcer disease, pneumonia, renal calculi, liver disease, hernia, refl ux, or angina. The physical examination and liver function tests are usually completely normal in patients with chronic cholecystitis, particularly if they are pain-free. During an episode of biliary colic, mild right upper quadrant tenderness may also be present. Diagnosis The diagnosis of symptomatic gallstones or chronic calculous cholecystitis relies on the clinical presentation and evidence of gallstones on diagnostic imaging. The presence of symptoms, typically biliary colic, attributable to the gallbladder is necessary to consider any treatment for gallstones. An abdominal ultrasound is the standard diagnostic exam for gallstones (Fig. 54-11). Ultrasonography also provides important anatomic information for the surgeon—presence of polyps, common bile duct diameter, or any hepatic parenchymal abnormalities. Occasionally, patients with typical attacks of biliary pain have no evidence of stones on ultrasonography, or only sludge is present. If the patient has recurrent attacks of typical biliary colic and sludge is detected on two or more occasions, cholecystectomy is indicated. In addition to sludge and stones, cholesterolosis and adenomyomatosis of the gallbladder may cause typical biliary symptoms and may be detected on ultrasonography. Cholesterolosis is caused by the accumulation of cholesterol in macrophages in the gallbladder mucosa, either locally or as polyps. It produces the classic macroscopic appearance of a “strawberry gallbladder.” Granulomatous polyps develop in the lumen at the fundus; the gallbladder wall is thickened, and septa or strictures may be seen in the gallbladder. In patients with these symptoms, cholecystectomy is the treatment of choice. Management The optimal treatment for patients with symptomatic cholelithiasis is elective laparoscopic cholecystectomy (Box 54-3). Patients should be advised to avoid dietary fats and large meals while awaiting surgery. Diabetic patients should have a cholecystectomy promptly because they are at higher risk for acute cholecystitis or even gangrenous cholecystitis. Pregnant women with symp- Figure 54-11 Gallbladder ultrasound in patient with biliary colic demonstrating multiple dependent echogenic foci with posterior acoustic shadowing consistent with gallstones. Box 54-3 Indications for Cholecystectomy Urgent* Acute cholecystitis Emphysematous cholecystitis Empyema of the gallbladder Perforation of the gallbladder Previous choledocholithiasis with endoscopic duct clearance Elective Biliary dyskinesia Chronic cholecystitis Symptomatic cholelithiasis *Within 24 to 72 hours.
tomatic gallstones who fail expectant management with dietary modifi cation can safely undergo surgery during the second trimester. Cholecystectomy offers excellent long-term results for patients with symptomatic gallstones. About 90% of patients are rendered symptom-free after cholecystectomy. For patients with atypical symptoms or painless dyspepsia (fatty food intolerance, fl atulence, belching, or bloating), the percentage of patients experiencing relief of symptoms falls. Acute Calculous Cholecystitis Pathophysiology Acute cholecystitis is related to gallstones in 90% to 95% of cases. Obstruction of the cystic duct leading to biliary colic is the initial event in acute cholecystitis. If the cystic duct remains obstructed, the gallbladder distends, and the gallbladder wall then becomes infl amed and edematous. Initially, acute cholecystitis is an infl ammatory process with a thickened and reddish wall with subserosal hemorrhage. The mucosa may show hyperemia and patchy areas of necrosis. In the most common scenario, the gallstone dislodges, and the infl ammation will gradually resolve. In the most severe cases, this process can lead to ischemia and necrosis of the gallbladder wall (5%-10%). Acute gangrenous cholecystitis results in formation of an abscess or empyema within the gallbladder. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall of the gallbladder on imaging resulting in emphysematous cholecystitis. Clinical Presentation Right upper quadrant pain, similar in severity to but much longer in duration than pain from previous episodes of biliary colic, is the most common symptom of acute cholecystitis. Other common symptoms include fever, nausea, and vomiting. On physical exam, right upper quadrant tenderness and guarding are usually present inferior to the right costal margin, distinguishing the episode from simple biliary colic. When infl ammation spreads to the peritoneum, patients develop more diffuse tenderness, guarding and rigidity. A mass, the gallbladder and adherent omentum, is occasionally palpable, and Murphy’s sign, inspiratory arrest with deep palpation in the right upper quadrant, may also be present. A mild leukocytosis is usually present (12,000-14,000 cells/mm 3 ). In addition, mild elevations in serum bilirubin (>4 mg/ dL), alkaline phosphatase, the transaminases, and amylase may be present. Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts by severe pericholecystic infl ammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct, known as Mirizzi’s syndrome. Diagnosis Ultrasound is the most useful radiographic test for diagnosing acute cholecystitis, with sensitivity and specifi city of 85% and 95%, respectively. It is sensitive for identifying the presence of gallstones. Ultrasound also shows the Chapter 54 Biliary System 1559 presence of thickening of the gallbladder wall (>4 mm), pericholecystic fl uid, gallbladder distention, impacted stone, and a sonographic Murphy’s sign (focal tenderness directly over the gallbladder). Biliary radionuclide scanning is used less frequently today but may be helpful in atypical cases. No fi lling of the gallbladder with the radiotracer ( 99m Tc-HIDA) after 4 hours indicates an obstructed cystic duct with a sensitivity and specifi city for acute cholecystitis of 95%. A normal HIDA scan excludes acute cholecystitis. However, when the patient is fasting for more than 5 days, HIDA scan is much less helpful, with a 40% false-positive rate. CT scan, although performed frequently in patients with abdominal pain, may identify some of the fi ndings mentioned previously, similar to ultrasonography, but is less sensitive than ultrasonography for acute cholecystitis. Management After the diagnosis of acute cholecystitis is made, IV fl uids, antibiotics, and analgesia should be initiated. Antibiotics should cover gram-negative aerobes as well as anaerobes (see Box 54-1). More than half of patients with acute cholecystitis have positive cultures from the gallbladder bile. Because it is diffi cult to know who is secondarily infected, IV antibiotics are an appropriate part of the management. Cholecystectomy is the defi nitive treatment for patients with acute cholecystitis. Early cholecystectomy performed within 2 to 3 days of presentation is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial medical therapy. 11,12 About 20% of patients fail initial medical therapy and require surgery during the initial admission or before the end of the planned cooling-off period. Laparoscopic cholecystectomy is the preferred approach to patients with acute cholecystitis. Conversion to an open procedure should be made if the infl ammation prevents adequate visualization of important structures. The conversion rate to an open cholecystectomy is higher (4%-35%) in the setting of acute cholecystitis than with chronic cholecystitis. Numerous studies have shown the morbidity rate, hospital stay, and time to return to work are lower in patients undergoing laparoscopic cholecystectomy than open cholecystectomy. 13-15 Early laparoscopic cholecystectomy, due to a reduced length of hospital stay and readmissions, is a more costeffective approach than open cholecystectomy for acute cholecystitis. 16 Patients who are operated on early in the course of their illness (within 48 hours) are more likely to have their procedure completed laparoscopically (4% versus 23%) than patients with a longer duration of symptoms. 17 Additional factors predicting the need to convert to an open cholecystectomy include increased patient age, male gender, elevated American Society of Anesthesiologists class, obesity, and thickened gallbladder wall (>4 mm). Acute cholecystitis may progress to empyema of the gallbladder, emphysematous cholecystitis, or perforation of the gallbladder despite antibiotic therapy. In each case, emergency cholecystectomy is indicated, if the patient
Page 1 and 2: Biliary System Ravi S. Chari, MD an
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Page 9 and 10: Cholangiography Cholangiography fun
Page 11: Cholesterol Gallstones The pathogen
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Page 33 and 34: Figure 54-31 Operative photography
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Page 37 and 38: Figure 54-35 Bismuth classifi catio
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Ch. 54 – Biliary System

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