Disorders of the Gallbladder and Biliary Tree

Disorders of the gallbladder and biliary tree account for about one third of abdominal operations performed in patients > 70. Gallstones (cholelithiasis), cholecystitis, acute cholangitis, and gallbladder cancer are the most important disorders. Cancer of the gallbladder and biliary tree is discussed in Ch. 113.

Gallstones

An estimated 25% of persons > 50 develop gallstones. The incidence rises with age; gallstones are found at autopsy in about one third of persons > 70. Gallstones are the indication for nearly all of the > 500,000 cholecystectomies performed annually in the USA (1 in every 500 persons).

The primary symptom of gallstones is biliary colic. Colic, or steady pain, usually is felt in the right subcostal area but often radiates to the right scapula or the right shoulder and, in some cases, is similar to angina. At times, the pain may be felt anywhere in the abdomen. Vomiting may occur but is not repetitive. Usually, slight tenderness occurs in the right upper quadrant. Epigastric distention, gas, and vague dyspepsia occur in so many people that these findings cannot be considered specific for gallbladder disease.

Acute cholecystitis, a complication of gallstones, is characterized by increased local tenderness, fever, and leukocytosis. The gallbladder often is palpable. Migration of a stone into the common duct can lead to jaundice, chills and fever, and gallstone pancreatitis. Pancreatitis is accompanied by more diffuse epigastric tenderness and elevated serum amylase levels.

Ultrasound shows gallstones in > 95% of cases and distended intrahepatic ducts when a patient has a common duct obstruction. However, ultrasound does not visualize the distal common duct adequately, and CT is better for diagnosing pancreatic lesions. Transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are valuable when common duct involvement is suspected.

Treatment

The patient may decide to live with the gallstones. If not, the first surgical choice is cholecystectomy. Laparoscopic cholecystectomy is widely used, although damage to the common duct is more common with this procedure than with open cholecystectomy. Other methods (eg, stone dissolution by chenodeoxycholic acid) are successful in some cases but require continued medication. The recurrence rate for lithotripsy is so high that the procedure has been abandoned. Cholecystectomy combined with common duct exploration (open or laparoscopic) is the preferred operation for common duct stones. Endoscopic papillotomy and basket removal of an obstructing stone from the common duct may be advisable if the patient is very ill or the gallbladder already has been removed.

With acute cholecystitis, antibiotics are given for a longer period but surgery should be performed within 2 or 3 days of the onset. With diabetic patients, glucose levels should be controlled, and surgery should be performed as soon as possible because the danger of perforation is high. In some cases, the pathologic changes at the base of the gallbladder are so great that the surgeon should perform a cholecystostomy, leaving the elective cholecystectomy for later. Another option when the cystic duct is very inflamed and there is no evidence of common bile duct obstruction is to remove the gallbladder and simply drain the gallbladder fossa.

Although asymptomatic gallstones are common in patients > 70, the mortality rate for elective cholecystectomy is estimated at 5%. Therefore, surgery for asymptomatic gallstones in patients > 70 is not advised, and the standard of care in the USA remains surgery only for patients with symptomatic gallstones. Despite previous teachings, even diabetics should not undergo surgery for asymptomatic gallstones.

If an initial attack of biliary colic occurs, a second attack is probable within 2 years in two thirds of patients. The argument for cholecystectomy, therefore, becomes more compelling, and such patients are usually advised to undergo cholecystectomy. However, the diagnosis should be confirmed and symptoms of other diseases (eg, coronary insufficiency) ruled out, especially in elderly patients. In equivocal cases, waiting for at least one more attack before recommending surgery is advisable. Usually, patients have several attacks before surgery is advised.

Acute Cholangitis

Acute cholangitis usually results from a stone impacted in the ampulla of Vater, but the syndrome may occur secondary to pancreatic cancer. Other causes (eg, ascending infection after sphincterotomy of Oddi's sphincter, infection secondary to stricture from a previous choledochoduodenostomy or choledochojejunostomy) are rare. In the Far East, Oriental cholangitis results from ascending infection from the intestinal tract by parasites. Patients may develop symptoms of infection as in septic shock. Right upper quadrant pain and tenderness may be present.

Patients in septic shock on admission must be treated vigorously with antibiotics before surgery. Gentamicin 1 to 1.5 mg/kg IV q 8 h (corrected for renal function and blood levels), ampicillin 1 to 2 g IV q 6 h, and clindamycin 600 mg IV q 8 h are recommended (other antibiotic combinations with a similar spectrum and bioavailability are acceptable). Fluid balance must be restored. Emergency operations performed before the patient is stabilized are associated with a high mortality.

Endoscopic sphincterotomy has been valuable in treating Oriental cholangitis and is used widely in the USA and Europe for stones impacted in the distal common duct. Skill in endoscopy is essential because of the hazards of perforation, bleeding, and infection.

Miscellaneous Disorders

Gallstone pancreatitis: Patients with gallstone pancreatitis present with symptoms and signs similar to those of acute cholecystitis, except that the pain is more likely to be epigastric and is associated with elevated serum amylase levels and often with increased bilirubin and alkaline phosphatase levels. Initial treatment is conservative, with the patient taking nothing orally and receiving IV alimentation. Typically, pain subsides rapidly, and laparoscopic or open cholecystectomy is performed 5 to 7 days after admission.

Acalculous cholecystitis: This condition is caused by inflammation of the gallbladder resulting from a combination of biliary stasis, bacterial overgrowth, and ischemia in critically ill patients. It tends to occur in patients in intensive care units and in those whose oral intake is poor (eg, because of total IV alimentation). Symptoms are minimal. Unexplained fever and vague abdominal distress warrant ultrasound examination of the gallbladder, which may show edema of the gallbladder wall and increasing distention on successive examinations. Cholecystectomy or cholecystostomy is the usual procedure. Percutaneous cholecystostomy under ultrasound guidance performed by interventional radiologists has become common over the past 10 years.

Retained stones in the common duct: These stones are common, particularly if multiple hepatic duct stones were found during the initial exploration. The surgeon prepares for this possibility in questionable cases by placing a large T tube (No. 14 French) to drain the common duct. The radiologist can extract the stones later. Endoscopic removal also is feasible.

Fistulas: Fistulas can form between the gallbladder and the intestine, allowing gallstones to migrate and cause intestinal obstruction. Patients usually present with signs of distal small-bowel obstruction, often with tenderness over the gallbladder. Abdominal x-ray may show the stone and usually shows gas in the biliary tree. The proper surgical procedure is removal of the stones (if a stone is faceted, then others are present) and cholecystectomy. Cholecystectomy may be deferred if the patient is very ill; it should also be deferred if the gallbladder and porta hepatis are encompassed in a dense phlegmon.

Iatrogenic stricture of the common duct: A major complication of cholecystectomy is damage to the common bile duct. Usually, the problem is manifested very early by protracted biliary drainage; diagnosis is made by fistulogram. Surgical repair is a Roux-en-Y anastomosis of the upper duct to the jejunum. However, a stricture may form at the anastomosis and cause symptoms many years later. Intermittent attacks of pain, fever, and jaundice suggest the diagnosis, which can be confirmed by transhepatic cholangiography. Surgical repair is necessary. For the patient with comorbidities that preclude surgery, a permanent stent can be deployed transhepatically.

Gallbladder polyps: Usually small and filiform, gallbladder polyps have little malignant potential. Many defects shown on ultrasound simulate polyps but actually are small stones. Although of minimal concern when small, a polyp that appears > 1 cm in diameter on repeat ultrasound should prompt cholecystectomy to rule out a malignancy.

Jaundice: The differential diagnosis of jaundice is extensive, and many diagnostic methods are available. The first task is to determine whether jaundice is obstructive. Often, the history is helpful, and the physical examination can give important information. Gastrointestinal causes include cirrhosis, cancer, gallstones, and hepatitis.

Ultrasound determines the presence of gallstones and the size of the intrahepatic and common bile ducts. If necessary, endoscopy follows, providing direct visualization of the lumen of the stomach and duodenum. Endoscopic retrograde cholangiopancreatography (ERCP) usually can be performed safely, and if required, transhepatic cholangiography can follow. Fine-needle percutaneous biopsy is positive in nearly 80% of patients with pancreatic cancer, although cancer cannot be ruled out by a negative biopsy.

The value of radioisotope scans using dyes (eg, hepato-iminodiacetic acid) that are excreted with the bile is controversial. If the patient has low-grade jaundice and the dye passes through the common duct into the duodenum, obstructive jaundice is unlikely. Some authorities believe that such scans do not reliably detect acute cholecystitis, although others believe that an inability to visualize the gallbladder after giving the dye is a presumptive sign of a blocked cystic duct and, when associated with local tenderness, a presumptive sign of acute cholecystitis. In many cases, establishing a diagnosis is impossible without exploratory laparotomy.