Special Surgery 10. Gallstone Complications and Treatment

I. Acute and Chronic Cholecystitis

Acute Calculous Cholecystitis

Definition and Pathomechanism

• Acute inflammation of gallbladder, usually caused by cystic duct obstruction by stone
• Cholelithiasis → bile stasis → distension + chemical irritation → inflammation ± bacterial infection
• Common bacteria: E. coli, Klebsiella, Enterococcus, anaerobes

Clinical Features

• Persistent RUQ pain > 6 h, often radiating to back/right scapula
• Fever, nausea, vomiting
• RUQ tenderness/guarding
• Murphy sign: right subcostal palpation during deep inspiration → pain + inspiratory arrest
• Marked jaundice suggests CBD stone or cholangitis

Diagnosis

• Labs: increased WBC, CRP ± procalcitonin; mild liver enzyme rise possible
• US: gallstones, gallbladder wall thickening, edema/pericholecystic fluid, distension, sonographic Murphy sign
• CT if perforation, abscess/peritonitis or alternative diagnosis suspected

Treatment

• Hospital admission, nil by mouth initially, IV fluids, electrolyte correction, analgesia
• Antibiotics covering enteric Gram-negative bacteria and anaerobes

• Example: ceftriaxone + metronidazole
• Severe/septic patient: broader therapy such as piperacillin-tazobactam according to local protocol

• Early laparoscopic cholecystectomy: preferred definitive treatment, ideally within 72 h or during index admission
• High-risk/unfit patient: percutaneous cholecystostomy + antibiotics; interval cholecystectomy if later fit

Complicated Acute Cholecystitis

• Empyema: pus in gallbladder
• Gangrene: ischemic necrosis of gallbladder wall
• Perforation: localized abscess or free biliary peritonitis
• Treatment: urgent source control by cholecystectomy or drainage depending on fitness and anatomy

Chronic Cholecystitis

• Repeated biliary colic or subclinical inflammation → fibrosis and thickening of gallbladder wall
• Symptoms: recurrent RUQ pain after meals, dyspepsia, nausea, fatty food intolerance
• Can be associated with porcelain gallbladder and increased cancer risk depending on calcification pattern
• Treatment: elective laparoscopic cholecystectomy

II. CBD Stone, Cholangitis and Pancreatitis

Choledocholithiasis

• Stone in common bile duct
• Secondary CBD stone: migration from gallbladder, most common
• Primary CBD stone: forms in duct due to biliary infection, stasis or stricture/stenosis
• Symptoms: RUQ/epigastric pain, nausea/vomiting
• Obstructive jaundice: direct bilirubin rises, dark urine, pale/acholic stool, pruritus
• Labs: increased bilirubin, ALP, GGT; AST/ALT can rise
• US: dilated bile duct ± visible CBD stone
• MRCP/EUS: confirm CBD stone when probability is intermediate
• Treatment: ERCP with sphincterotomy and stone extraction, then laparoscopic cholecystectomy if gallbladder remains

Ascending Cholangitis

• Infection of biliary tree due to obstructed CBD, usually stone obstruction
• Obstruction → increased duct pressure → bacterial translocation → sepsis
• Medical emergency
• Charcot triad:

• Fever/chills
• Jaundice
• RUQ pain

• Reynolds pentad: Charcot triad + hypotension + confusion
• Diagnosis: infection + cholestasis + biliary obstruction; take blood cultures if no delay
• Treatment: ABCDE/sepsis resuscitation, IV fluids, broad-spectrum antibiotics, urgent ERCP drainage/stone extraction/stent
• If ERCP impossible: percutaneous transhepatic biliary drainage

Gallstone Pancreatitis

• Gallstone/sludge temporarily obstructs ampulla of Vater → pancreatic enzyme activation
• Symptoms: epigastric pain radiating to back, nausea, vomiting
• Diagnosis: increased amylase/lipase + gallstones/biliary dilation; ALT spike supports biliary cause
• Treatment: supportive acute pancreatitis care

• IV fluids, analgesia, early enteral nutrition as tolerated
• Monitor organ failure and complications

• Urgent ERCP only if concomitant cholangitis or persistent biliary obstruction/retained CBD stone
• Mild gallstone pancreatitis: cholecystectomy during same admission after clinical improvement
• Severe pancreatitis: delay cholecystectomy until inflammation/collections stabilize

III. Mechanical and Late Complications

Gallbladder Perforation

• Usually follows acute/gangrenous cholecystitis
• Free perforation → generalized biliary peritonitis
• Localized perforation → pericholecystic abscess
• Chronic perforation → cholecystoenteric fistula
• Treatment: resuscitation + antibiotics + urgent cholecystectomy if fit; drainage/cholecystostomy in high-risk septic patients

Gallstone Ileus

• Gallstone ileus: large stone enters bowel through cholecystoenteric fistula, usually cholecystoduodenal
• Stone impacts most often in terminal ileum/ileocecal valve → mechanical small bowel obstruction
• Rigler triad: bowel obstruction + pneumobilia + ectopic gallstone
• Best diagnosis: CT
• Treatment: resuscitation, NG tube, fluids/electrolytes, enterolithotomy and stone extraction
• Cholecystectomy/fistula repair at same operation only in selected fit patients

Gallbladder Cancer Risk

• Long-standing stones increase gallbladder carcinoma risk, but absolute risk is low for most patients
• Higher-risk situations: porcelain gallbladder with suspicious calcification, large stones, large/growing polyp, chronic inflammation
• Treatment: cholecystectomy if high-risk features or suspicious lesion

IV. Cholecystectomy Safety and Complications

Safe Cholecystectomy Principles

• Identify hepatocystic triangle clearly
• Critical view of safety before clipping:

• Clear hepatocystic triangle of fat/fibrous tissue
• Separate lower gallbladder from liver bed
• Only two structures entering gallbladder: cystic duct and cystic artery

• If anatomy unsafe: stop dangerous dissection, use cholangiography if helpful, subtotal cholecystectomy, fundus-first approach or conversion to open

Complications of Cholecystectomy

• Bile duct injury: most feared; can cause bile leak, stricture, cholangitis, secondary biliary cirrhosis
• Bleeding: cystic artery, right hepatic artery, liver bed
• Bile leak: cystic duct stump or duct of Luschka/accessory bile duct
• Injury to duodenum, colon or small bowel
• Retained CBD stone
• Wound infection, intra-abdominal abscess
• Post-cholecystectomy diarrhea or dyspepsia