Andrew Davies BSc (hons), MBChB, MSc, MD, FRCS, Consultant General, Laparoscopic and Upper Gastro-intestinal Surgeon, Guy’s & St Thomas’ NHS Foundation Trust and Spire Clare Park, Farnham
Gallstones are a common problem, affecting 15% of the UK population. Symptoms can be particularly debilitating, ranging from severe abdominal pain with biliary colic to the systemic upset caused by cholecystitis, cholangitis or gallstone pancreatitis. Many gallstones are discovered incidentally during routine investigations for other conditions, often by abdominal ultrasound. Asymptomatic, uncomplicated gallstones can be managed conservatively according to NICE guidelines. However, patients should be made aware of the possibility of developing symptoms in the future such as pain, cholecystitis and the small risk of stone migration into the bile duct causing cholangitis or pancreatitis.
Most patients with symptomatic gallstones elect for surgery because the symptoms are unpleasant and unlikely to resolve spontaneously. Elective laparoscopic cholecystectomy is a very safe, well tolerated procedure that remains one of the most commonly performed general surgical operations. Most patients can be managed as a day-case. The risks of the surgery include conversion to an open operation (1-2% risk) and the small chance of injury to the common bile duct (CBD)(0.2%).
For patients being referred from primary care, a history suggestive of gallstones (acknowledging a significant overlap with dyspepsia and indigestion symptoms), a confirmatory abdominal ultrasound and blood tests (including liver function tests [LFT]) represent a good patient work up. Patients with a very suggestive history but a negative ultrasound may still benefit from referral as Endoscopic ultrasound (EUS) or Magnetic Resonance Cholangio-Pancreatography (MRCP) may pick up occult microlithiasis in some patients. For patients with deranged liver function and gallstones there tends to be a low threshold for pre-operative MRCP. This is because a varying range of subtle LFT abnormalities can be the only sign of common bile duct stones, which occur in up to 15% of gallstone patients. Due to the small but significant risks of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) (mortality 0.5%, pancreatitis 5-15%, bleeding), MRCP (or alternatively EUS) is generally used for the diagnosis of CBD stones and ERCP is reserved only for therapeutic intervention. Most surgeons would elect to clear the bile duct prior to surgery although intra-operative cholangiography and CBD clearance is an alternative. Patients undergoing straightforward laparoscopic cholecystectomy should recover quickly following surgery. Inevitably there is some pain following laparoscopy but patients who are unwell in the days following surgery should be referred back to hospital to exclude haematomas, collections and bile leaks that can complicate these procedures.
Patients presenting to hospital with acute cholecystitis will initially be managed by analgesia, fluid resuscitation and antibiotics. Acute “hot” cholecystectomy is a safe procedure when performed by experienced surgeons. Although the risks of open conversion, and in some studies CBD injury, are marginally increased, the benefits to the patient of immediate resolution of symptoms and the avoidance of multiple re-admissions to hospital with recurring cholecystitis justify this risk. Surgery is ideally performed within the first 3-4 days. Whilst there are clear organizational challenges to surgical teams in trying to accommodate the high volumes of patients who would ideally be managed by in-patient cholecystectomy, this should remain a target area for improvement.
Pancreatitis is a potentially life-threatening complication of gallstones. NICE guidelines recommend in-patient cholecystectomy or surgery within 2 weeks for patients with confirmed gallstone pancreatitis. Again, this represents a significant logistical challenge but the guideline is justified by the fact that, untreated, 30% of patients with gallstone pancreatitis will suffer a further episode within 3 months of the index admission. This may be one example where a patients’ GP can be an important advocate by urgently re-referring patients who may have slipped through the net back to the surgical team for early definitive management.
Finally, to gallbladder polyps which may sometimes be mistaken for gallstones on ultrasound imaging. Polyps greater than 10mm in diameter should be recommended for cholecystectomy based on their increased risk of cancer. Patients with polyps less than 10mm should be surveyed by ultrasound at six months and then annually until the surgical team are satisfied there has been no serial progression in size. Whilst there are no strict guidelines on the duration of follow-up, the surgeon will use other known risk factors (such as patient age >50, solitary polyps and polyps associated with gallstones or symptoms) and a discussion with the patient to finalise the decision for surgery or conservative management.
More information on gallstones can be obtained at www.londonsurgicalgroup.co.uk. Mr. Davies sees both private and choose & book patients at Clare Park. Appointments can be made by contacting the practice secretary (02037635933) or Clare Park hospital directly (01252 895490)
Comment on article :- This article was principally written for GPs and so contains some medical “jargon”. Patients with gallstones often suffer with severe and unpredictable symptoms. One of the challenges within the NHS is long waiting times to be seen and even longer to reach surgery. Removal of the gallbladder (cholecystectomy) is generally a very safe, keyhole surgical procedure with most patients going home the same day. Some patients can be more complicated and this would be discussed on a case-by-case basis. Prof. Davies offers consultations and surgery for gallstones (and where appropriate gallbladder polyps) in London, Guildford and Farnham.