Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (36 page)

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In the emergency setting, biliary colic or acute cholecystitis are the most common presentations of symptomatic cholelithiasis and it is often difficult at the initial assessment to distinguish between the two conditions as they form part of a continuum. Biliary colic is thought to occur following the impaction of a gallstone within the cystic duct or gallbladder infundibulum, leading to gallbladder obstruction. In a functioning gallbladder, obstruction results in marked gallbladder contraction with the perception of pain. Following disimpaction of the stone, the pain subsides. Disimpacted gallstones may either fall back into the gallbladder or pass into the common bile duct (CBD).

Persistent gallbladder obstruction leads to acute mural inflammation, although there is often a poor correlation between the clinical presentation and the histopathological features of acute and chronic inflammation in the gallbladder wall. Initially, in acute cholecystitis, the inflammatory process within the gallbladder is sterile; however, bacterial colonisation of the obstructed bile and inflamed tissue occurs and may result in an empyema of the gallbladder. Further, if the inflammatory process is particularly severe, gallbladder ischaemia and necrosis can occur, with the risk of gallbladder perforation and subsequent biliary peritonitis.

Biliary colic presents with severe upper abdominal pain in the epigastric and right upper quadrant regions, commonly with radiation to the back or shoulders. Although termed ‘colic’, the pain is usually constant when present, but remits after a period of minutes to hours. Pain may be provoked by eating, and the patients frequently describe an association with ingestion of fatty foods. A history of previous similar episodes may be obtained. Palpation of the abdomen may reveal epigastric/right upper quadrant tenderness but no evidence of peritoneal irritation. Blood investigations are usually normal.

In acute cholecystitis the pain is localised to the right upper quadrant, and also may radiate to the back or right shoulder tip. Because of peritoneal irritation the pain is exacerbated by movement and breathing. Commonly, the patient is nauseated and may have vomited. Systemic signs of inflammation including tachycardia and pyrexia may be present and abdominal examination will typically reveal right upper quadrant tenderness with signs of localised peritonitis. Classically, Murphy's sign (acute tenderness during palpation below the tip of the right ninth rib elicited on inspiration) can be observed in patients with acute cholecystitis. A tender gallbladder may occasionally be palpable in the right upper quadrant, particularly in the presence of an empyema. Haematological investigations typically demonstrate a leucocytosis and liver function tests (LFTs) may be mildly deranged. An obstructive picture to the LFTs may be a consequence of choledocholithiasis, but may also be a consequence of impacted gallstones in Hartmann's pouch pressing on or eroding into the common hepatic duct (Mirizzi syndrome) or contiguous inflammation affecting the biliary tree or adjacent hepatic parenchyma.

Transabdominal ultrasound is the initial investigation of choice in both biliary colic and acute cholecystitis and has a sensitivity of greater than 95% for detecting gallstones (see also
Chapter 5
). In addition, ultrasound (US) can demonstrate signs of acute inflammation such as gallbladder wall thickening, pericholecystic fluid and a positive sonographic Murphy's sign (
Fig. 8.1
). US may also demonstrate gas in the gallbladder wall in patients with emphysematous cholecystitis. Newer techniques of colour velocity imaging and power Doppler ultrasound can provide additional information, and may therefore be helpful in distinguishing patients with true acute cholecystitis from those with upper abdominal pain and incidental cholelithiasis. In addition, transabdominal ultrasound can detect the presence of biliary tree dilatation, which may indicate choledocholithiasis, although the sensitivity for choledocholithiasis may be significantly impaired by obesity or gas within overlying bowel. In patients where US is equivocal either computed tomography (CT) or magnetic resonance imaging (MRI) can be helpful (
Fig. 8.1
).

Radionucleotide scintigraphy has historically been reported to have greater accuracy in diagnosing acute cholecystitis than standard US techniques. However, these techniques are time-consuming, involve the use of radiopharmaceuticals, and their use is now generally restricted to individuals who are clinically suspected of having abnormal gallbladder function in the presence of a normal ultrasound scan (gallbladder dyskinesia).

Concomitant choledocholithiasis may be indicated by obstructive LFTs or US evidence of biliary dilatation and/or evidence of ductal calculi. In the acute setting several additional factors may complicate the decision-making process. Most importantly, if there are signs of generalised peritonitis, operative intervention cannot be deferred and investigation for CBD calculi becomes of secondary importance. In this situation, any ductal stones can be looked for at operation. It is also important to bear in mind the clinical overlap between acute cholangitis and acute cholecystitis, and patients with cholangitis due to CBD calculi may have upper abdominal tenderness and guarding. An appropriate index of suspicion together with findings on US should result in such individuals being appropriately treated for their ductal calculi.

In the majority of patients with acute biliary colic or cholecystitis who have deranged LFTs there will be an opportunity to assess the CBD preoperatively. The management options include endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). MRCP has the advantage that it is non-invasive and is as accurate as ERCP in detecting bile duct stones (
Fig. 8.2
),
²
as well as providing valuable additional information about more complex presentations, e.g. Mirizzi syndrome (
Fig. 8.3
). Nowadays, ERCP is reserved for therapeutic intervention, e.g. sphincterotomy and stone removal or stenting, rather than for diagnosis (
Fig. 8.4
).

An alternative management strategy is to undertake intraoperative cholangiography during acute cholecystectomy (
Fig. 8.5
). If a ductal stone is demonstrated on intraoperative cholangiography, the options are to undertake laparoscopic CBD exploration, convert to an open procedure with exploration of the CBD or to perform a postoperative ERCP or, in some cases, intraoperative ERCP. The potential risk with adoption of a postoperative ERCP strategy is failure to cannulate at endoscopy; however, in practice, success rates are high with experienced endoscopists and few patients require further surgery.

Although laparoscopic CBD exploration is a logical extension to laparoscopic cholecystectomy and is now becoming much more widely practised, the associated inflammation around Calot's triangle and the CBD in patients with acute cholecystitis may make laparoscopic exploration difficult and/or hazardous. A suggested algorithm for the management of patients with suspected biliary colic/acute cholecystitis and suspected CBD stones is described in
Fig. 8.6
.