Special Surgery 10. Gallstone Complications and Treatment

I. Acute and Chronic Cholecystitis

Acute Calculous Cholecystitis

Definition and Pathomechanism

Acute inflammation of gallbladder, usually due to gallstone obstruction of cystic duct
Stone impacted in cystic duct / Hartmann pouch → bile stasis
Distension + chemical irritation → inflammation
Secondary bacterial infection can occur
Common bacteria: E. coli, Klebsiella, Enterococcus, anaerobes

Clinical Features

Persistent right upper quadrant pain, usually > 6 h
Pain can radiate to right scapula/back
Fever
Nausea, vomiting
Local tenderness and guarding in RUQ
Murphy sign:

Palpate right subcostal area during deep inspiration
Inflamed gallbladder contacts examiner hand → pain and inspiratory arrest

Mild jaundice can occur, but marked jaundice suggests CBD stone/cholangitis/Mirizzi syndrome

Diagnosis

Laboratory:

Increased WBC
Increased CRP
Procalcitonin can increase in severe bacterial infection/sepsis
Mild liver enzyme elevation possible

Ultrasound:

Gallstones
Gallbladder wall thickening
Pericholecystic fluid/edema
Distended gallbladder
Sonographic Murphy sign

HIDA scan if US inconclusive and suspicion remains
CT if perforation, abscess, emphysematous cholecystitis or alternative diagnosis is suspected

Treatment

Hospital admission
Nil by mouth initially
IV fluids and electrolyte correction
Analgesia, usually NSAID/opioid as needed
Antibiotics covering Gram-negative enteric 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 of symptom onset, or during index admission when feasible
Convert to open if anatomy is unsafe

High-risk/unfit patient:

Percutaneous cholecystostomy drainage + antibiotics
Interval cholecystectomy later if patient becomes fit

Complicated Acute Cholecystitis

Empyema: pus in gallbladder
Gangrenous cholecystitis: ischemic necrosis of gallbladder wall
Emphysematous cholecystitis: gas-forming infection, often diabetic/vascular disease
Perforation:

Localized abscess
Free perforation → biliary peritonitis
Cholecystoenteric fistula

Treatment: urgent source control by cholecystectomy or drainage depending on fitness and anatomy

Chronic Cholecystitis

Repeated biliary colic or subclinical inflammation
Gallbladder wall fibrosis and thickening
Contracted gallbladder can develop
May be associated with porcelain gallbladder and increased cancer risk depending on calcification pattern
Symptoms:

Recurrent RUQ pain after meals
Dyspepsia, nausea, fatty food intolerance

Treatment: elective laparoscopic cholecystectomy

II. CBD Stone, Cholangitis and Pancreatitis

Choledocholithiasis

Definition and Etiology

Gallstone in common bile duct
Secondary CBD stone: migration from gallbladder, most common
Primary CBD stone: forms in bile duct due to infection, biliary stasis, stricture/stenosis

Symptoms and Diagnosis

RUQ or epigastric pain
Jaundice, dark urine, pale stool, pruritus
Nausea and vomiting
Labs:

Increased total/direct bilirubin
Increased ALP and GGT
Increased AST/ALT possible

Ultrasound: dilated bile duct, sometimes visible CBD stone
MRCP/EUS: non-invasive confirmation when probability is intermediate
ERCP: diagnosis and therapy when stone extraction/drainage is needed

Treatment

ERCP with sphincterotomy and stone extraction
Temporary biliary stent if complete extraction fails or drainage is urgent
Follow with laparoscopic cholecystectomy during same admission or planned soon if gallbladder present
If ERCP fails: repeat expert ERCP, percutaneous drainage/intervention, or surgical CBD exploration

Ascending Cholangitis

Definition and Pathomechanism

Infection of biliary tree due to obstructed bile duct
Usually CBD stone obstruction
Obstruction → increased intraductal pressure → bacterial translocation → sepsis
Medical emergency

Clinical Features

Charcot triad:

Fever/chills
Jaundice
Right upper quadrant pain

Reynolds pentad = Charcot triad + septic shock signs:

Hypotension
Confusion / altered mental status

Diagnosis

Labs:

Leukocytosis, high CRP/procalcitonin
Cholestatic pattern: bilirubin, ALP, GGT increased
Blood cultures before antibiotics if this does not delay treatment
Lactate, renal function and coagulation for sepsis severity

Imaging: US first, MRCP/CT if needed
Diagnosis requires evidence of infection + cholestasis + biliary obstruction

Treatment

ABCDE/sepsis resuscitation
IV fluids
Broad-spectrum IV antibiotics:

Example severe case: piperacillin-tazobactam
Adjust to cultures, renal function and local resistance

Urgent biliary drainage:

ERCP with sphincterotomy, stone extraction and/or stent
Urgency depends on severity; severe cholangitis needs immediate/urgent drainage
Percutaneous transhepatic biliary drainage if ERCP unavailable/impossible

Cholecystectomy after stabilization/CBD clearance if gallbladder remains

Gallstone Pancreatitis

Pathomechanism

Gallstone/sludge transiently obstructs ampulla of Vater
Pancreatic outflow obstruction → premature enzyme activation → acute pancreatitis

Symptoms and Diagnosis

Severe epigastric pain radiating to back
Nausea and vomiting
Increased amylase/lipase
Liver enzyme spike, especially ALT, supports biliary cause
Ultrasound: gallstones and biliary dilation
CT only if severe disease, diagnostic uncertainty or complications after initial phase

Treatment

Supportive pancreatitis care:

IV fluids
Analgesia
Early enteral nutrition as tolerated
Monitor organ failure and complications

ERCP urgently only if:

Concomitant cholangitis
Persistent biliary obstruction / retained CBD stone

Mild gallstone pancreatitis: laparoscopic cholecystectomy during same admission after clinical improvement
Severe pancreatitis: delay cholecystectomy until inflammation/collections stabilize; use ERCP sphincterotomy if surgery must be delayed and recurrence risk is high

III. Mechanical and Late Complications

Gallbladder Perforation

Usually complication of acute/gangrenous cholecystitis
Types:

Free perforation → generalized biliary peritonitis
Localized perforation → pericholecystic abscess
Chronic perforation → cholecystoenteric fistula

Treatment:

Resuscitation + antibiotics
Urgent cholecystectomy if fit and anatomy manageable
Percutaneous drainage/cholecystostomy in high-risk septic patients

Mirizzi Syndrome

Impacted stone in cystic duct or Hartmann pouch compresses common hepatic duct
Can erode into bile duct and form cholecystocholedochal fistula
Clinical features:

Obstructive jaundice
RUQ pain
Sometimes cholangitis

Diagnosis: US/CT/MRCP; ERCP can define anatomy and drain if needed
Treatment: careful cholecystectomy by experienced biliary surgeon; subtotal cholecystectomy or bile duct reconstruction may be needed
High bile duct injury risk if mistaken for simple cholecystitis

Gallstone Ileus

Pathomechanism

Large gallstone enters bowel through cholecystoenteric fistula, usually cholecystoduodenal
Stone impacts most often in terminal ileum/ileocecal valve
Mechanical small bowel obstruction

Clinical Features and Diagnosis

Elderly patient, often female
Intermittent bowel obstruction symptoms:

Colicky abdominal pain
Vomiting
Distension
Constipation/obstipation

Rigler triad:

Small bowel obstruction
Pneumobilia
Ectopic gallstone

CT is best diagnostic imaging

Treatment

Resuscitation, NG tube, fluids/electrolytes
Operation: enterolithotomy and stone extraction
Cholecystectomy/fistula repair at same operation only in selected fit patients
In frail elderly patients, enterolithotomy alone is often preferred to shorten operation

Bouveret Syndrome

Variant of gallstone ileus
Gallstone obstructs gastric outlet/duodenum after passing through cholecystoenteric fistula
Symptoms: vomiting, epigastric pain, gastric outlet obstruction
Treatment: endoscopic removal/lithotripsy if possible; surgery if endoscopy fails

Gallbladder Cancer Risk

Long-standing stones increase risk of gallbladder carcinoma
Risk is still low for most patients
Higher risk situations:

Porcelain gallbladder with suspicious calcification pattern
Large gallstones
Large or growing gallbladder polyp
Chronic inflammation, anomalous pancreaticobiliary junction in some populations

Treatment: cholecystectomy if high-risk features or suspicious lesion

IV. Treatment Strategy and Cholecystectomy Risks

Management Summary

Complication	Key Signs	Main Treatment
Acute cholecystitis	RUQ pain > 6 h, fever, Murphy sign	IV fluids, antibiotics, early laparoscopic cholecystectomy
Choledocholithiasis	Jaundice, cholestatic labs, CBD dilation	ERCP stone extraction, then cholecystectomy if gallbladder present
Ascending cholangitis	Charcot triad; Reynolds pentad if severe	Sepsis care, antibiotics, urgent ERCP drainage
Gallstone pancreatitis	Epigastric pain to back, high lipase	Supportive care; same-admission cholecystectomy in mild disease
Gallstone ileus	Bowel obstruction + pneumobilia + ectopic stone	Enterolithotomy; fistula/cholecystectomy selectively

Safe Cholecystectomy Principles

Identify hepatocystic triangle clearly
Critical view of safety before clipping:

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

If anatomy unsafe:

Stop dissection in danger zone
Intraoperative cholangiography if available/indicated
Subtotal cholecystectomy
Fundus-first approach in selected cases
Convert to open if needed

Complications of Cholecystectomy

Bile duct injury:

Most feared complication
Can cause bile leak, stricture, cholangitis, secondary biliary cirrhosis
Early recognition and hepatobiliary referral improve outcome

Bleeding:

Cystic artery
Right hepatic artery
Liver bed

Bile leak:

Cystic duct stump
Duct of Luschka/accessory bile duct
Treated by drainage, ERCP stent/sphincterotomy or surgery depending on severity

Injury to duodenum, colon or small bowel
Retained CBD stone
Wound infection, intra-abdominal abscess
Post-cholecystectomy diarrhea or dyspepsia