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Patient Information for Gallstone disease. This guidance focuses on the treatment of patients aged 18 years and over with gallstones. In the UK around.
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When there is discordance between clinical and ultrasonographic findings, the most accurate second imaging test is scintigraphy of the biliary tract, usually performed with technetium-labeled hydroxy iminodiacetic acid. Given intravenously, the radionuclide is rapidly taken up by the liver and then secreted into the bile. In acute cholecystitis, the cystic duct is functionally occluded and the isotope does not enter the gallbladder, creating an imaging void compared with a normal appearance.


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Even though scintigraphy is more sensitive, abdominal ultrasonography is often the initial test for patients with suspected acute cholecystitis because it is more widely available, takes less time, does not involve radiation exposure, and can assess for the presence or absence of gallstones and dilation of the intra- and extrahepatic bile ducts. When acute cholangitis due to choledocholithiasis is suspected, abdominal ultrasonography is a prudent initial test to look for gallstones or biliary dilation suggesting obstruction by stones in the common bile duct.

The normal bile duct diameter ranges from 3 to 6 mm, although mild dilation is often seen in older patients or after cholecystectomy or Roux-en-Y gastric bypass surgery. ERCP should be reserved for managing rather than diagnosing common bile duct stones because of the risk of pancreatitis and perforation.

Gallstone disease overview

Patients undergoing cholecystectomy who are suspected of having choledocholithiasis may undergo intraoperative cholangiography or laparoscopic common bile duct ultrasonography. The management of patients with asymptomatic gallstones typically is based on the risk of developing symptoms or complications. Standard treatment for these patients is expectant management.

Cholecystectomy is not recommended for patients with asymptomatic gallstones. These patients have a higher risk of developing calcium bilirubinate stones, and cholecystectomy has improved outcomes. This condition was thought to be associated with a high rate of gallbladder carcinoma, but analyses of larger, more recent data sets found much smaller risks. Thus, prophylactic cholecystectomy is no longer recommended in asymptomatic cases of porcelain gallbladder. In addition, concomitant cholecystectomy in patients undergoing bariatric surgery is no longer considered the therapeutic standard.

Historically, cholecystectomy was performed in these patients because of the increased risk of gallstones associated with rapid weight loss after surgery. However, research now weighs against concomitant cholecystectomy with bariatric surgery and most other abdominal surgeries for asymptomatic gallstones. Patients with symptomatic gallstones are at high risk of biliary complications. Clinical management and emergency laparoscopic cholecystectomy are recommended for large pigmented or radiopaque stones.

Otherwise, clinical follow-up is recommended.


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Figure 1. Management of patients with gallstones. For patients experiencing acute cholecystitis, laparoscopic cholecystectomy within 72 hours is recommended. However, a large meta-analysis found no significant difference between early and delayed laparoscopic cholecystectomy in bile duct injury or conversion rates.

For patients with bile duct stones. Figure 2. Management of patients with symptomatic bile duct stones choledocholithiasis. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endoscp ; —9 with permission from Elsevier.

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Biliary decompression should be done as early as possible to decrease the risk of morbidity and mortality. For acute cholangitis, ERCP is the treatment of choice. The timing of laparoscopic cholecystectomy in acute gallstone pancreatitis has been debated. Studies conducted during the era of open cholecystectomy reported similar or worse outcomes if cholecystectomy was done sooner rather than later. They concluded laparoscopic cholecystectomy could be safely performed within 7 days in patients with mild disease, whereas in severe disease at least 3 weeks should elapse because of the risk of infection.

Rates of perioperative complications and need for conversion to open surgery were similar between the 2 groups. If there is associated cholangitis, patients should also be given broad-spectrum antibiotics and should undergo ERCP within 24 hours of admission. Gallstones are common in US adults. Abdominal ultrasonography is the diagnostic imaging test of choice to detect gallbladder stones and assess for findings suggestive of acute cholecystitis and dilation of the common bile duct. Fortunately, most gallstones are asymptomatic and can usually be managed expectantly.

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In patients who have symptoms or have gallstone complications, laparoscopic cholecystectomy is the standard of care. Gallstones: Watch and Wait, or Intervene? Share this article via email with one or more people using the form below. Advertising Policy. Burke, MD Advertising Policy. Scintigraphy as a second test Acute cholecystitis is primarily a clinical diagnosis and typically does not require additional imaging beyond ultrasonography.

Looking for stones in the common bile duct When acute cholangitis due to choledocholithiasis is suspected, abdominal ultrasonography is a prudent initial test to look for gallstones or biliary dilation suggesting obstruction by stones in the common bile duct. Watch And Wait, Or Intervene?

Asymptomatic gallstones The management of patients with asymptomatic gallstones typically is based on the risk of developing symptoms or complications. Cholelithiasis and cholecystitis. Epidemiology of gallbladder disease: cholelithiasis and cancer.

Gut Liver ; 6 2 — Diagnosis and treatment of gallstone disease. Practitioner ; — Digestive and liver diseases statistics, Gastroenterology ; 5 — Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases.

Who Gets Gallstones?

Gastroenterology ; 2 — Gallstone classification in Western countries. Indian J Surg ; 77 suppl 2 — Pathogenesis of gallstones. Am J Surg ; 4 — Nat Rev Dis Primers ; Pathogenesis of pigment gallstones in Western societies: the central role of bacteria. Because of the potential life-threatening characteristics of acute cholecystitis, patients require careful monitoring and supportive care. Antimicrobial therapy is required, and in cases of moderate to severe intensity, the treatment plan is based on culture and sensitivity results [ 58 , 64 ]. In the most severe cases, when there is the presence of signs of severe inflammation, acute renal injury, shock, liver injury, and disseminated intravascular coagulation DIC , treatment should also include monitoring of respiratory function and hemodynamics and appropriate organ support [ 61 , 65 ].

Hirota M et al. Early laparoscopic cholecystectomy is indicated in patients fulfilling the criteria for surgery during initial hospitalisation within one week. In this context, there is no increased rate of serious complications, as compared to delayed laparoscopic cholecystectomy. However, the hospital stay is shortened [ 66 , 67 , 68 , 69 , 70 ].

There is evidence that morbidity is higher if cholecystectomy is performed between seven and forty-five days compared with early cholecystectomy. Thus, when early cholecystectomy is not possible because of late diagnosis or high risk of surgery, it is advisable to delay cholecystectomy for another six weeks.

When patients with acute cholecystitis are too ill and show organ dysfunction or are considered to be non-responsive to initial medical treatment, therapy includes biliary drainage such as percutaneous transhepatic gallbladder drainage or open cholecystostomy and drainage, as well as percutaneous gallstone extraction, or delayed cholecystectomy. Endoscopic nasobiliary gallbladder drainage is an option in critically ill patients unfit for urgent or early cholecystectomy.

Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery - A SAGES Publication

In a small subgroup of less than 0. The fistula is most often cholecystogastric, cholecystoduodenal or cholecystocolonic. Following the development of an enteric fistula, stone s may enter the bowel. A potential complication arises if the stone impacts the ileocecal valve, a condition causing the gallstone ileus.

The clinical picture may present as mechanical bowel obstruction associated with a high rate of morbidity and mortality in elderly patients [ 72 ]. Stones found in the common bile duct can be part of either primary or secondary choledocholithiasis, the latter being due to the migration of gallstones from the gallbladder into the common bile duct.