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So I would like to uh welcome Miss Kelly Bateman, Vice President of the Moines Hand Academy, um who will be doing a great presentation for you. So, stay tuned. Hi, everybody. Um Good afternoon. Hope you've had a, a good lunch and you've been enjoying the program so far. Um As Mike, I said, I'm Kelly, I'm at ST six in general surgery in Wales. Um I'm Vice President in the Moynihan Academy and I'll be talking to you about gallstones for the next 20 minutes or choleda cholelithiasis. So, just to start with a little recap of the anatomy. Um So hopefully you'll all be quite familiar um with, obviously, you've got your right hepatic duct, your left hepatic duct that form together to make the common hepatic duct and the cystic duct joins onto this. Um Bile gets stored in the gallbladder and then it gets released going down the common bile ducts, uh and opens up at the um vata in D2 of the duodenum. So, what is bile and how is it released? Uh It's a combination of bile salts, phospholipids, um Bilirubin, electrolytes, cholesterol and water. Um And basically the liver secretes that bile as I said, it travels down the common hepatic ducts and some of that then gets stored in the gallbladder and it sits there and it waits until you eat a nice big meal. Um, and then some cholecystokinin um, is released and that helps stimulate the gallbladder to contract and to release all that bile, uh, which will then help digest some of the fatty foods. So, what are gallstones and what contributes to them and why do some people get them? And some people don't. It's a combination of things. Um Most of the ones particularly in the western world are cholesterol based. Um And various things contribute to these, particularly your genetics, having excess cholesterol in bile, um reduced bile acids and gallbladder, stasis can all contribute to the formation of these stones. Um However, you can also get brown pigment stones which are more related to increased bilirubin. Um So when we think of who's at risk of gallstones, uh obviously, it springs to mind your, your four ff 40 female and fertile. Um But actually, that's not always the case, but the reason that this subgroup is particularly at risk um is often to do with the high prevalence of the estrogen in the body. So that leads to increased cholesterol saturation and again, obesity and, and age can increase the estrogen in the blood as well. Um But other things that you might want to consider um is rapid weight loss. Uh Some people post bariatric surgery, increased risks. They get prolonged periods of fasting, you get more gallbladder, stasis, um, various medications that can impair gallbladder and small bowel motility, uh, such as such as oxide. Um, then you've got other medical conditions that again might affect the makeup of what's in, in your bile. So, if you've got Crohn's disease, you've got bile salt malabsorption. So again, you can get excess cholesterol within the blood, um, because it's not been excreted in the same way. Um And if you've got a sickle cell disease or beta thalassemia, then you've got increased hemoglobin, um, and uh deform cells. Um and then you can get increased bilirubin lead to more pigment stone formation as well. And I think the estimated prevalence of gallstones, um is between eight and 15% depending on where you look. Um So it's a relatively common condition and it's obviously going to increase with age. Um, but it affects us all differently in different ways. But how will gallstones present? Actually, the majority are asymptomatic and incidental findings and that they're often found during an investigation for other symptoms such as dyspepsia or some atypical abdominal pain, bloating some ibs symptoms. Uh However, some of these will go on to develop symptoms. So most people, so 10% of patients will develop bilary colic type symptoms within five years and about 20% or one in five will develop symptoms within 20 years. And then the thing that we're more interested in particular surgeons is the people that get complications of their gallstones. And this tends to be about 1 to 2% per year of patients with gallstones. And it can affect just the gallbladder itself or it can be related to the passage of stones along with the ducts, which we'll talk about in a second. So we're gonna go through some case studies to try and cover, let's set the scene. So start with your classic textbook patient. So a little bit overweight. Um, BM I 3448 year old, um comes in or comes to clinic, um complaining of right upper quadrant pain after eating, sort sort of things running through your head. What do you want to know? You start with a basic history, a good pain history. Um So I like the sort of Socrates mnemonic. So, you know, you think sight onset character, uh, does it radiate. Um, and they'll give this typical, you know, it's quite constant and severe for those 30 minute episodes where the gallbladder is in spasm. Um Sometimes it can radiate up to the shoulder tip and around to the back. Uh Typically it's quite, relatively soon after eating but not straight away. So sort of 10 to 20 minutes, 30 minutes after eating and they'll have these recurrent episodes as well. They can often be quite restless with the pain as opposed to when people have got peritonism and they just want to stay still and you know, they're quite agitated and moving around can be relieved by walking. Um and it can be quite severe and some people do need um morphine to try and get on top of their pain. And then it's important you take good past medical history, uh social history to think about any risk factors that they might have. Um so that, you know, this patients had Children, she's on contraception, high BMI, she's got a family history. She's got those genetic risk factors as well. Um, as well as thinking about risk factors for other differentials such as, you know, an alcohol history, um, or previous surgery as well. Obviously, if they've had a cholecystectomy, gallstones is less likely but not impossible. Uh, and then you'll think about the examination. Um, and against this lady, she got some mild discomfort but she's not guarding or peritinic no masses. Let's think about our differentials. Um, common thing here that we're thinking most likely is just simple bilary colic. Um, so this the gallbladder contracting, um, and as they can present with quite severe symptoms, try that. Yeah. So how are you gonna investigate and manage this patient? You're gonna start with the basics, do some blood, um, which are often normal in biliary colic. Um, some people might be tempted to do an X ray or a CT. Uh, but this is basically a waste of time. Uh, a lot of gallstones are, um, not visible on X rays, um, or CT, uh, if they're not calcified. So, really, you don't need to be doing that to look for complications related to your gallstones. But an ultrasound is the gold standard, but it's important to make sure the patients are starved before this. So, the gallbladder is nice and distended. So you can have a good look and then if they've just got bilary colic, um, and you talk about the management options, you know, you see them in clinic. Um, you might talk about your typical, you know, conservative options, a low fat diet, um, can help reduce that stimulation if the gallbladder can help manage the symptoms in the interim. Uh, there's some talk, you know, if people ask, can you not give me a medication just to get rid of them? Uh, the verdict on ursodeoxycholic acid is that it's probably not that helpful. But if you have no other options, it could be. But again, a cholecystectomy or surgery is our gold standard for all that. The patients put on the waiting list for a laparoscopic cholecystectomy. Um, but she comes into A&E with increase in pain, nausea and vomiting and a fever. She's very tender in that right upper quadrant garden. Um, and she's got Murphy signs. So when you put your hands under the gallbladder, ask her to take a deep breath in, you can see her jump, there's no catches and she gets the pain. So again, got various differentials and possibly related to gallstones. Also think about non gallstone related disease, peptic ulcers, um, ibs gastroenteritis. Um, but in this patient sounds fairly typical for cholecystitis. Um, and that's where the stones then become more impacted within the around the cystic duct. Hartmann's pouch. Um, the gallbladder is more in distended, inflamed. It's important to note that it's not always infected. It's often an inflammatory thing. So, actually, the use of antibiotics isn't always indicated. But if this patient's got a fever as well, then I'd go along those lines. So again, investigations hopefully would be fairly similar to last time you want some bloods, you might see some raised inflammatory markers. Um, an ultrasound can be helpful. Uh, and it can show that inflamed gallbladder and again, confirm you've got gallstones. It probably isn't going to change much in your management. It's more of a clinical diagnosis and a CT, again, depending on your hospital set up, you might have quite good access to CT. It could be useful adjunct out of hours to exclude differentials. Um, and can also help show if there's sort of a perforated gallbladder or an abscess related to that, particularly if the patient's not settling or responding to treatment. Um, but I wouldn't routinely go for a CT. Um, but you'd be looking for an ultrasound like this, it shows some wall thickening and some fluid around the gallbladder and the gallstones within the gallbladder. And so the main management is symptomatic, get the patient comfortable, give a good analgesia as per your h pain ladder, you know, regular paracetamol, regular anti-inflammatories if they can take them. Um, and then some mild strong opiates as needed. If they've got a fever, raised inflammatory markers, tachycardia, then you might want to think about sepsis management as well. Some fluids and IV antibiotics. Uh But really, we need to just get on and get a gallbladder out. Um assuming the patient is fit enough in this case scenario, she is, um and the guidelines tend to suggest that this should be quite early on. So, within 2 to 3 days, 72 hours, um while it's sort of bit early in that DHA or if not, you should probably be waiting for cholecystitis for everything to settle down because otherwise it's too stuck and inflamed, it bleeds too much. So you want to try and wait six weeks, but then to do them early on after that. And again, that'll depend a little bit on your local set up for doing hot gallbladders. So, what are the risks of a cholecystectomy? You're an aneurys consent, this patient. Um I think about it, I always think my general risks for any operations, bleeding, infection, pain, scarring, hernia, anesthetic risks, um, and drops in the legs, lungs, heart attacks. Um And then I think about the anatomy and how that relates to the more specific operation related risks. So, when we're going in and doing our operation we're going to be looking for a cystic duct where we can hopefully put some clips across it and the cystic artery as we dissect Carlos triangle to get that critical view of safety and then we can take the gallbladder off. Um But obviously, if you don't get that critical view of safety, there's a high chance that you can damage some of these other structures nearby, um, particularly the hepatic artery, um or the common bile ducts, common hepatic duct. Um, so you then you think about operation specifics, so said sort of damage to structures nearby such as the bowel, the liver, very rarely the spleen. You putting your ports in a crazy place, um, conversion to open and then bile duct injury, bile leak. Um, so that could be either from the cystic duct stump or from a dither related injury as well, um, or a duct of lusher. Um, it's very rare and then you've got retained stones. So if you've had an issue with stones slipping down that cystic duct into that common bile duct, they can still cause issues. Um, diarrhea, post cholecystectomy syndrome. So, particularly if it's for Bilary colic, it's important to counsel patients that this might not treat all of their symptoms that they've been having, um, and adhesions of scar tissue as well. And it's important you're familiar with these. So I got asked, um, in my, uh, core surgical training interview, uh, about a post lap Coly patient who had a fever. Um So it's important you can relate those complications of the operation to the patient. And now we're going to go on to another case study, um where it can be useful to sort of recap the anatomy again. So you've got that picture in your mind of the layout of the bilary tree. And this is a 54 year old patient, um, who's been having some recurrent right, upper quadrant pain. Uh, but it is also now jaundice and the GP arranged some bloods as an outpatient and an ultrasound. So, looking at these bloods and ultrasound, um, what are your thoughts? What are you thinking could be going on? So I can see that bilirubin is 86 that's raised as well as the ALP is 300 which is also raised in a greater proportion to the alt, um, but relatively normal inflammatory markers. So this fits with an obstructive jaundice pattern. Um, but it is not infective at present. And again, she's got known gallstones. We've confirmed that gallstones up in the gallbladder. Um, and she's got a nine millimeter common bile duct. Uh So that's why it's important to know what's a normal common bile duct for a patient of this age. And we normally say it's six millimeters is a normal common bile duct, um, up until the age of 70 then we expect it to increase by one millimeter for every decade. So, if your 77 millimeters is normal 88 millimeters, 99 millimeters. Uh So hers is dilated for her age. Um So as I said, she's clinically stable. She's got deranged LFT S. Um And she's got a dilated CBD, but no other red flags. So my thinking here is that she probably has choledocholithiasis or gallstones in the common bile duct, as we said in the chat well done. Um And so this is where the flow of bile is getting blocked and you get an increase in pressure um up into those liver ducts and you get deranged liver enzymes and you get that classic dark urine and pale stools with the obstructive jaundice as well as I said, you do some blood. Um so your liver function, you typically have an ALP greater than alt but not always. Um and you can also get a deranged coagulation coagulopathy with these patients with their impaired liver function. Um So it's really important you check that uh before you go on to any interventions. Um As you said, you want some imaging ultrasounds can be very helpful in the first line. It's quick, it's noninvasive. Um and it can give you your diagnosis. Sometimes it will show the gallstones in the common bile ducts, but not always. Um In which case, you would go on to do an MCP um to confirm that diagnosis. So, what is an M RCP? Um And why would you do? It's important that you know this So it stands for magnetic resonance cholangiopancreatography. And as in the pictures shown, um, these sort of t two weighted assessment of fluids in the bilary tree and they can help prove stones and look at that anatomy, um, as well as any potential causes of obstruction. And you can see in both these pictures here, there's sort of big dilated common bile ducts. You can see stones up in the gallbladder and you can see a bunch of stones right at the bottom of, of the common bile ducts, sort of arrow on the bottom picture. Um Again, it's important that the patient's starved for these. Um So you can get a good view. Uh Generally it's noninvasive, doesn't use contrast typically either. Um But it's important that you make sure that the patient is eligible for an MRI in general. So no metal and that they've, if they've got pacemaker's pacemaker, it's compatible as well. Um So the patient's had that and she's potentially awaiting some intervention, but she becomes increasingly jaundiced with right and right, upper quadrant pain and presents to a and a, um, this is hopefully a clinical sign you're familiar with of Charcot triad. So you've got that right, upper quadrant pain fever and jaundice and that's a patho of cholangitis. You're getting that overgrowth of bile overgrowth of bacteria due to the obstruction. So, here due to the uh great perfusion of the liver, patients can get very sick very quickly. So it's important that you treat their sepsis. Well, um for sepsis, six and broad spectrum antibiotics as per local guidelines, get some early imaging. So your ultrasound Mr CP to confirm your diagnosis and then again, it depends a little bit on your local set up, but you want to do an intervention relatively quickly within a couple of days. Um So often ERCP is easier to get um and that can help and block the stones. And then you can plan a more, a less urgent laparoscopic cholest omy after that. Uh But if you've got trained surgeons, then you might just want to crack on with lap Coly. And then you can do an on the table cholangiogram. So you can put a catheter down the cystic duct, inject some dye, see the stones, sometimes you can flush out the stones if there's just one or two small ones through that. Um If there's a lot of stones where they're very impacted, you might then have to proceed to do a common bile duct exploration where you open up the common bile duct. Um So you can fish out the stones typically with the basket. Um And then you'll have to repair the bile duct afterwards. So that also has some increased risks with it as well. Um But an ERCP uh it can be diagnostic as well as therapeutic. So if you haven't got access to MRI or the MRI is inconclusive, then it could be useful. Um although obviously we need to be aware of the risk of pancreatitis, but it's a quick way to relieve the obstruction for these patients. And again, it's a nice picture of, you can see the scope going down and then you've got the guide wire and inject contrast and you can see the big stone, the white thing in the middle of the common bile duct where the red arrow is. This is just a quick recap of some of the pathology related to gallstones. Um My next will talk about pancreatitis and that's why I haven't touched on that. Um But it's something to be aware of. Uh But your main thing is obviously going through, is it just b colic? Is it cholest, is it cholangitis? Um And then there's various guidelines um about when to operate on these patients. Typically, if they've got complications, it should be sooner rather than later. Um Most guidelines say less than two weeks. Um Although now it though they've had polycystis, obviously, as I've said, do you want that inflammation to settle down? And then we're just going to finish with a quick question from our sponsors who very kindly provided us with some questions. So this will teach me surgery. So again, you've got a 45 year old patient who is referred with symptomatic gallstones, which of the following conditions increases your risk of developing gallstones. So hopefully, you're listening at the start, um which is a risk factor is it a ulcerative colitis B Gardner syndrome, C intussusception or D Crohn's of the Ilium. I'll give you a second to put in your answer into the chat. And obviously, if you've got any other questions, um please do put them in the chat as well and we can answer those quickly. You've got a couple coming in. Uh Yeah, the answer is D as we said. Um So in the eye Crohn's, they've got that reduced reabsorption. The bile completes that imbalance and they've got more cholesterol in their bile salts, which leads to increased gallstone inflammation. So, again, important part of their past medical history um as a risk factor and again, that might affect your surgical planning as well. That's it for me. Thank you.