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This article will discuss the work-up and diagnosis of biliary diseases including cholelithiasis, cholecystitis, biliary dyskinesia, choledocholithiasis, gallstone pancreatitis, and gallstone ileus.
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This article will review the management of acute presentations of biliary disease for the emergency general surgeon.
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This article will describe the management of biliary disease in unique populations, such as pregnant women, and post bariatric surgery individuals.
Acute Biliary Disease
Section snippets
Key points
Cholelithiasis
In the United States, 10% to 15% of the population have gallstones. Of this group, about 10% to 25% develop symptoms related to their gallstones with the risk of asymptomatic gallstones becoming symptomatic at 1% to 2% per year. Incidental gallstones are commonly noted on routine imaging. In patients who are otherwise asymptomatic, it is not recommended to proceed with an elective prophylactic cholecystectomy. Multiple studies have been performed to identify prognostic factors to predict the
Acute calculous cholecystitis
Acute calculous cholecystitis occurs when a gallstone obstructs the cystic duct leading to inflammation, gallbladder distention, and eventual ischemia. Symptoms typically include right upper quadrant abdominal pain, nausea, vomiting, and fever. A common finding on physical examination is Murphy sign, which is defined as inspiratory arrest caused by pain during deep palpation in the right upper quadrant of the abdomen. Its sensitivity and specificity for acute cholecystitis has been reported as
Acalculous cholecystitis
Acute acalculous cholecystitis is a phenomenon that occurs in the critically ill population, associated with severe trauma, burns, sepsis, recent complex surgery, and patients requiring prolonged total parenteral nutrition. The exact pathophysiology of acalculous cholecystitis is still somewhat elusive but results from bile stasis and gallbladder ischemia likely as a response to systemic inflammation and illness. It is difficult to diagnose and there must be a high index of suspicion. It has
Biliary dyskinesia/sphincter of Oddi dysfunction
Functional gallbladder disorders are a controversial group of disease entities that general surgeons face, frequently in the acute setting. The diagnosis and determination of need for surgery is complicated, so it may be more prudent to manage on an elective basis. Biliary dyskinesia and sphincter of Oddi dysfunction make up functional gallbladder disorders in which patients have biliary colic, right upper quadrant and/or epigastric pain following eating, in the absence of gallstones or
Choledocholithiasis
The exact incidence of choledocholithiasis is unknown but has been estimated as 5% to 20% in patients with cholelithiasis.17 Choledocholithiasis is seen more commonly in its secondary form because of the existence of cholelithiasis. Primary choledocholithiasis is less common and these stones form de novo secondary to biliary strictures or certain bacterial infections. Secondary choledocholithiasis can present in varying forms: concurrently with cholelithiasis, acute gallstone pancreatitis, or
Cholangitis
Cholangitis refers to biliary duct inflammation and infection secondary to obstruction. Choledocholithiasis is the most common cause of biliary obstruction. Frequently isolated bacteria include E coli, Klebsiella, Enterobacter, and Enterococcus. Cholangitis is a life-threatening condition that can rapidly escalate into septic shock.21 Identification and emergent management is critical.
Gallstone pancreatitis
Gallstones are the most common cause of acute pancreatitis in the Western world and account for 50% of all pancreatitis cases.22 Inflammation of the pancreas occurs because of blockage of the pancreatic duct and/or common bile duct by gallstones. Other common causes of pancreatitis include alcohol, hypertriglyceridemia, hypercalcemia, certain medications and antibiotics, and anatomic variations of the pancreas. The severity of the disease process can vary widely from a mild, self-limited course
Gallstone ileus
Gallstone ileus is an uncommon manifestation of biliary disorders and a rare cause of small bowel obstruction, with an estimated range of 1% to 3%. It occurs in 0.3% to 0.5% of patients with cholelithiasis and is often preceded by an episode of acute cholecystitis. It is defined as a mechanical intestinal obstruction caused by an impacted gallstone within the gastrointestinal tract. Inflammation from an episode of cholecystitis leads to adhesions adhering a portion of the gastrointestinal tract
Biliary disease in post bariatric surgery patients
Rapid weight loss following bariatric surgery has been well documented to be associated with the development of gallstones or sludge.29 Routine cholecystectomy at the time of bariatric surgery has been suggested30 although other studies have shown the efficacy of prophylactic ursodiol to decrease gallstone formation following weight loss.31 The incidence of biliary disease seems to be low following bariatric surgery; however, it remains important for acute care surgeons to be comfortable caring
Biliary disease in pregnant patients
Acute biliary disease and appendicitis make up the most common nonobstetric surgical emergencies complicating pregnancy, affecting approximately 1 in 500 women.36 The goal in acute management is to accurately and rapidly diagnose the cause of acute abdominal pain while minimizing risks of diagnostic modalities. The best way to protect the fetus is to treat the mother appropriately. Ultrasound is the initial imaging modality of choice for abdominal pain, particularly with concern for biliary
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is one of the most commonly performed surgeries in the United States and is now the favored surgical approach to managing gallbladder pathology. The mortality rate of the operation is low at 0.1% to 0.5% with morbidity ranging from 2% to 6%.40 There are a plethora of variations to this common procedure. Laparoscopic cholecystectomy is performed using a single-port platform, but is more commonly performed with multiple ports, typically four total. Usually one larger
Summary
Biliary pathologies are one of the most common disorders encountered by general surgeons. The spectrum of diseases often presents in an acute fashion and it is important for emergency general surgeons to be able to quickly identify and diagnose the correct syndrome and implement a plan of care (Table 3). Surgeons should be comfortable with laparoscopic cholecystectomy and open surgery should the need for conversion arise. Emerging technologies, such as ERCP, has made more traditional
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Disclosure Statement: The authors have nothing to disclose.