Gallstones
Clinical presentation
Gallstones may cause upper abdominal (epigastric and right upper quadrant) pain, bloating, nausea and vomiting when gallstones block emptying of the gallbladder after meals. Sometimes stones may travel into the bile duct and cause a blockage. If this occurs, the person may turn yellow (jaundiced) and need urgent treatment.
Gallstones may lead to a number of clinical conditions and potential life-threatening complications:
- Upper abdominal pain (Biliary colic).
- Inflamed and infected gallbladder (Acute cholecystitis/ gangrenous cholecystitis, perforation of gallbladder).
- Blockage of the bile duct causing jaundice (choledocholithiasis) and severe infection (Cholangitis).
- Inflammation of the pancreas (Pancreatitis) – Severe acute pancreatitis may lead to mortality in 10%.
- Mirizzi’s syndrome – gallstones eroding into the bile duct and/or into the duodenum (leading to bowel obstruction – gallstone ileus).
- Gallbladder carcinoma is associated with gallstones and chronic inflammation of the gallbladder.
Diagnosis
After a careful history and examination, an abdominal ultrasound is performed to detect gallstones, to assess the thickness and tenderness of the gallbladder and to determine the size of the bile ducts. Blood tests including full blood counts and liver function tests are often also required.
Treatment
Asymptomatic gallstones do not generally require surgical treatments except in certain situations. Conservative measures such as avoiding fatty meals may reduce the frequency of gallstone attacks, but the risks of complications from gallstone disease are not eliminated. Medical treatments including dissolution therapy and breaking up gallstones (lithotripsy) are not effective in treatment of gallstone disease, therefore they are generally not recommended.
Laparoscopic cholecystectomy (a key hole surgery to remove gallbladder and gallstones) is the treatment of choice for symptomatic gallstone disease.
Gallbladder carcinoma
Gallbladder carcinoma is an uncommon cancer affecting the gallbladder. Risk factors for gallbladder carcinoma include chronic inflammation due to gallstones, porcelain gallbladder, South American Indian ethnicity and advancing age. Incidental gallbladder carcinoma is noted in approximately 0.2 - 1% of patients following laparoscopic cholecystectomy. Further treatment may not be necessary if the tumour is at an early stage and it is confined to the superficial layer of the gallbladder wall (stage T1a), but most require gallbladder bed (segment 4/5 liver) resection, adjacent lymph node dissection +/- bile duct excision and reconstruction. Patients with advanced gallbladder carcinoma may present with jaundice, persistent upper abdominal pain and metastatic disease. Treatment of gallbladder carcinoma depends on accurate staging of the disease and assessment of patients.
Choledochal cyst
Choledochal cyst is a congenital cystic dilatation of bile ducts. Most patients present as a child, but some patients may present later in life with recurrent episodes of upper abdominal pain, fever, abnormal liver function tests and dilated bile ducts on Ultrasound or CT abdomen/Pelvis. Excision of the dilated bile duct is generally indicated to prevent recurrent episodes of pain and infections, and to prevent development of bile duct cancer.
Cholangiocarcinoma – Hilar and Distal cholangiocarcinoma
Cholangiocarcinoma is a primary tumour affecting bile ducts either inside (intrahepatic cholangiocarcinoma) or outside the liver (extrahepatic cholangiocarcinoma, including hilar and distal cholangiocarcinoma).
Hilar cholangiocarcinoma occurs when there is a tumour at the junction of the right and the left hepatic duct. It is a complex and difficult tumour to diagnose and treat, because of it’s location and relationships to adjacent structures such as bile ducts, the hepatic artery and the portal vein. A patient with hilar cholangiocarcinoma usually presents with painless jaundice. Treatment depends on accurate staging and careful assessment of the patient’s resectability, volume and quality of future liver remnant. A patient who is assessed suitable for curative treatment initially undergoes pre-operative drainage of bile ducts to relieve jaundice, followed by portal vein embolisation to grow the size of future liver remnant and eventual liver resection (often extended right hemihepatectomy) and bile duct reconstruction using small bowel.
Distal cholangiocarcinoma is a tumour affecting the distal bile duct below the junction of the cystic duct and the common hepatic duct. Again a patient presents with painless jaundice. Curative treatment usually involves complete excision of the distal bile duct, duodenum and head of the pancreas and reconstruction (Whipple’s procedure).
