Gallbladder Disease

Question 1

Ascending Cholangitis

Answer 1

Ascending cholangitis is a bacterial infection of the biliary tree. The most common predisposing factor is gallstones.

Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
fever is the most common feature, seen in 90% of patients
RUQ pain 70%
jaundice 60%
hypotension and confusion are also common

Management
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
In patients who are unfit for an ERCP, a percutaneous transhepatic cholangiogram could be done.

Question 2

Ascending Cholangitis - Mx: Example Question

Answer 2

A 75-year-old man was admitted to hospital with a three-day history of right sided abdominal pain and vomiting. He has a history of ischaemic heart disease, chronic obstructive pulmonary disease and peripheral vascular disease.

On examination, he appears unwell. His temperature is 38.5ºC, heart rate is 120 beats per minute, respiratory rate is 24 breaths per minute and blood pressure is 90/60 mmHg. He appears jaundiced. Examination of his abdomen reveals tenderness over the right upper quadrant on palpation.

Blood tests show:

Hb	115 g/l	
Na+	146 mmol/l	
Bilirubin	225 µmol/l
Platelets	650 * 109/l	
K+	5.8 mmol/l	
ALP	894 u/l
WBC	24.3 * 109/l	
Urea	10.5 mmol/l	
ALT	160 u/l
Neuts	20.5 * 109/l	
Creatinine	190 µmol/l	
γGT	279 u/l
CRP	348 mg/L			
Albumin	27 g/l

An urgent ultrasound of his abdomen reveals sludge in his gallbladder and a dilated common bile duct at 13mm. His spleen and kidneys appear normal. He was fluid resuscitated and started on piperacillin-tazobactam after blood cultures were taken. After 6 hours of treatment, his blood pressure improves to 130/70 mmHg, his heart rate has decreased to 95 beats per minute and he is passing 50 millilitres of urine an hour.

What is the next appropriate management for this patient?

	Watch and wait
	> Endoscopic retrograde cholangiopancreatography
	Percutaneous transhepatic cholangiogram
	Urgent cholecystectomy
	Refer to intensive care

This patient has sepsis secondary to ascending cholangitis due to a common bile duct stone causing obstruction. The Charcot’s triad of fever/rigors, jaundice and abdominal pain is commonly seen in patients with ascending cholangitis. His LFTs show a cholestatic picture and his high serum bilirubin is indicative of an obstruction. Sludge in his gallbladder and a dilated common bile duct is indicative of choledocholithiasis.

The most important management for this patient after initial resuscitation would be to urgently decompress the biliary system and remove the obstructing gallstone via an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. Intensive care input is not indicated at this stage as the patient has shown signs of clinical improvement. However, in severe septic shock, inotropic support may be needed to stabilise the patient prior to an ERCP. In patients who are unfit for an ERCP, a percutaneous transhepatic cholangiogram could be done.

Question 3

Gallstones

Answer 3

Asymptomatic gallstones which are located in the GB are common and do not require treatment

However, if stones are present in Common bile duct > there is an increased risk of Cx such as cholangitis, pancreatitis and surgical Mx should be considered

Sx:

• RUQ pain
• Positive Murphy’s sign

Ix:

• Increased ALP and ALT (ALP more!)
• NB US is not perfectly sensitive for gallstones but should always be performed