Topic: Splenomegaly, cholecystitis, portal hypertension, liver abscess, peritonitis, carcinoma head of pancreas.
Question:A 40 yr old lady came to casualty with pain in the right upper abdomen associated with vomitings for 5 days. On examination, she was found to be having tenderness in right hypochondrium; the rest of the abdomen was normal. Ultrasound abdomen revealed a thick walled gallbladder with gall stones and pericholecystic fluid. ① What is the clinical diagnosis and how will you manage this condition? ② Enumerate the complications of gallstones. ③ What is Mirizzi Syndrome? How would you investigate and manage it?
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The clinical diagnosis of this patient is acute cholecystitis, which is inflammation of the gallbladder. The presence of gallstones and pericholecystic fluid seen on ultrasound supports this diagnosis.
I would manage this patient as follows:-
– Admit the patient for IV fluids, antibiotics, pain management and observation. IV Ceftriaxone 1g BD and Metronidazole 500mg TDS are commonly used. Keep NPO (nil per oral) and start IV fluids to correct dehydration. Strong pain relievers like opioids may be needed to control the pain
– Investigations: CBC, LFTs, serum amylase/lipase, abdominal ultrasound. The ultrasound confirms the diagnosis of acute cholecystitis showing gallstones, thickened gallbladder wall, pericholecystic fluid and probe tenderness.
– Initial management is conservative with bowel rest, IV antibiotics and analgesia. Once fever and leukocytosis settle and pain is controlled, laparoscopic cholecystectomy can be performed during the same hospital admission.
– In high risk patients (age>60, DM, cardiac disease) percutaneous gallbladder drainage may need to be performed to temporize before delayed surgery.
– Open cholecystectomy is rarely required and only used if laparoscopic surgery is contraindicated or in case of complications like emphysematous cholecystitis or gallbladder perforation.
Complications of gallstones include:
– Acute cholecystitis: Inflammation of the gallbladder due to cystic duct obstruction by stones.
– Acute pancreatitis: Gallstones can migrate and obstruct the pancreatic duct, leading to pancreatitis.
– Mirizzi syndrome: Stone impacted in Hartman’s pouch compressing the common bile duct. Causes obstructive jaundice.
– Emphysematous cholecystitis: Gallstones and infection leading to gas accumulation within the gallbladder wall. Life-threatening condition requiring emergency surgery
– Gallstone ileus: Large stone erodes through the gallbladder into the duodenum causing intestinal obstruction. Requires enterotomy to remove the stone.
– Gallbladder cancer: Long standing gallstones are associated with higher risk of developing gallbladder malignancy. Prophylactic cholecystectomy is sometimes recommended in high risk groups.
Mirizzi syndrome refers to common bile duct obstruction due to an impacted gallstone in the gallbladder neck or cystic duct. It causes local inflammation that compresses and obstructs the common bile duct, leading to obstructive jaundice.
Pathophysiology:
– A gallstone becomes impacted in the gallbladder neck or cystic duct. This leads to inflammation and swelling of the tissues around the bile duct.
– The edematous and inflamed gallbladder wall then compresses the adjacent common bile duct, obstructing the flow of bile.
– Continued obstruction causes rising bilirubin levels leading to obstructive jaundice. If left untreated, cholangitis can also develop.Investigations:
– Blood tests: Raised bilirubin (especially direct) and alkaline phosphatase. Normal transaminases.
– Abdominal ultrasound: May detect the impacted gallstone in the gallbladder neck. Unable to visualize the bile ducts well, so the level/cause of biliary obstruction cannot be fully determined.
– MRCP or ERCP: Used to confirm the diagnosis, visualize the point of obstruction and assess the biliary tree for any stones or strictures. ERCP also allows for therapeutic sphincterotomy.
– CT scan: May show gallstones, dilated biliary radicles and tissue edema compressing the common bile duct.
Management:
– Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy: First-line treatment. Allows removal of bile duct stones and relieving the obstruction. Stenting may also be required in some cases.
– Laparoscopic cholecystectomy: If ERCP fails or is not feasible, laparoscopic removal of the gallbladder along with cholangiography and clearance of common bile duct stones is performed. Tissue adhesion from inflammation can make surgery challenging.
– Open surgery: Rarely required but may be needed for extremely complex cases where bile duct reconstruction is necessary after removal of tissue compressing the duct.Follow up: Regular LFT monitoring to ensure no recurrent obstruction. ERCP may be repeated if symptoms return. The risk of developing ascending cholangitis is life-long due to the altered biliary anatomy, so any fever or jaundice requires urgent medical review and admission.
