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home - Biliary - Gallstone Disease - Gallstone Management Written by Dr Sebastian Zeki
Knowledge


Knows the physiology and biochemistry of bile and the pathogenesis
of gallstones

Is familiar with the normal anatomy and the anatomical variations of
the biliary tree

Recognises the symptoms and signs of the potential complications of
galllstone disease including biliary colic acute cholecystitis jaundice
due to calculous bile duct obstruction cholangitis and carcinoma

Knows the various techniques of diagnostic imaging including
ultrasound CT MRI ERCP EUS radionuclide techniques

Knows the various treatment options the indications for operative and
non-operative management and the risks of each

Knows the current national guidelines for use of ERCP and the risks
of the technique

Knows the ways in which gallbladder polyps are diagnosed and
managed

Knows that gallbladder and sphincter of Oddi dysfunction (SOD) may
account for otherwise unexplained abdominal pain

Recognises different types of SOD how they may present and how
they are investigated

Skills
Can select the most appropriate diagnostic and therapeutic
techniques for each clinical situation

Recognises possibility of diagnostic uncertainty in biliary dysmotility
and shows thoughtful judgement in each individual situation

Behaviours
Makes appropriate assessment stratifies urgency and plans
management of patients who have complications of gallstones

Gallstone Management

If expertise available Lithotripsy Cholecystectomy Written by Dr Sebastian Zeki Methods include dietary and other lifestyle modifications and continued bile acid therapy. High cholesterol, low calcium, low bilirubin salts are the best for dissolution (ie not calcified and pigment stones). Gallstone Presentation Categories Ca Secondary prevention This refers to the prevention of symptoms in asymptomatic gallstones.No therapy is recommended. Tertiary prevention (prevention of recurrence)60% of lithotrypsy patients will have recurrence.In such cases, retreatment is effective as the stones are often lucent. Patients with typical biliary symptoms but no gallstones on USS (category 4) Patients in this category have either small stones (microlithiasis) or sludge or other causes of biliary symptoms unrelated to gallstones such eg. sphincter of Oddi dysfunction. Patients with gallstones but atypical symptoms (category 3) This is usually not gallstone diseaseUDCA can be tried if appropriate gallstones, which will relieve sx in 3 months well before gallstones have gone. Patients with biliary symptoms and gallstones (category 2) Treat these, as likely to have recurrent and more severe symptoms.The recurrence and complication rate is 70% in 2 yrs. Patients with gallstones but no symptoms (category 1) They should be left alone as risk of becoming symptomatic is 1%/yr. If they get symptoms, theyare usually mild. (pain occuring 2-3 times a month and which responds to oral analgesics) Primary preventionThe highest risk of symptomatic gallstones in those with known biliary sludge, pregnant women, rapid weight loss, long-term octreotide, long-term total parenteral nutrition (TPN).Patients with biliary sludge should have tds meals with sufficient fat or protein to ensure good gallbladder contraction.High fibre diet ,high calcium, and low in saturated fats.Low body weight should be achieved.Urso benefits those with biliary sludge. Primary Prevention In Weight Reduction.Risk of gallstone formation= 50%, so cholecystectomy is now performed in many undergoing bariatric surgery.May also be a benefit of urso without cholecystectomyPrimary Prevention In TPNEnteral feeding assessment to be done regularly in those receiving total parenteral nutrition (TPN).Daily injections of cholecystokinin may promote gallbladder emptying and clearance of sludge if on prolonged TPN High doses of crystalline amino acids may produce the same effect by inducing secretion of endogenous cholecystokinin.Screening of patients on long-term TPN for the development of biliary sludge is not useful. If sludge seen, may profit from UDCA. N Y Lucent stone? a)ERCPb)Percutaneous lithotomy, c)Gallbladder drainage (cholecystotomy) Complicated Mild-Moderate Acute Management of biliary colic Pain control - iv meperidine,-less of an effect on sphincter of Oddi motility than morphine.- NBM to prevent the release of cholecystokinin.- (NSAIDs) -preferably ketorolac (30 to 60 mg im)- Relieves symptoms within 20 to 30 minutes-Ibuprofen 400 mg po -take during attacks until definitive treatment

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