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Hey, everyone. So we are essentially starting a little teaching series called Bed. So, which was started by Mr Ascari. It's going to be a few different topics in general surgery, things that people would want to know at F one F two ct one level and hopefully it's helpful for everyone. Yeah. Ok. Hi, everyone. Er, thanks for coming. Uh, my name is Martin. I'm one of the Sh Os and I'll be presenting today on Gallstone Disease. Um, unfortunately, some of the other presenters are working today so they can't make it, but I'll be doing my part of the presentation. It will be a bit shorter than unexpected. So, apologies for that. And Erria has currently introduced BEA, um, and yes, so hopefully this session will spark an interest in general surgery and hope um, juniors get bearing in general surgery as well. So, um, this presentation will focus on gallstone disease. I won't be going into any of these sort of prehepatic or hepatic causes of jaundice, but I'll try to stay as closely relevant as to what you'll see in, uh, on a general surgery, uh, placement which, er, can also be viral hepatitis, which is wrongly preferred. So it's always good to keep those sort of differentials at the back of your mind. But anyways, um, today, what we'll go through is cholelithiasis, which are stones in the gallbladder. Um, biliary colic, which is the classical pain that I'll go into, which is associated with gallstones. Um, acute cholecystitis, which is inflammation of the gallbladder itself and then chronic cholecystitis, which is repeated inflammation and infection of the gallbladder, which leads to um sort of structural changes of the gallbladder and some classical symptoms. And on the next session, we'll go through um choledocholithiasis, choledocolithiasis, which is gallstones in the common bile duct, uh cholangitis or ascending cholangitis, um which is uh infection of the biliary tree or bile ducts and gallstone pancreatitis, which is inflammation of the pancreas secondary to a lodged stone. Ok. So we start off with um biliary colic and cli uh lithiasis. So, biliary colic, as I mentioned is the pain associated with gallstones. Um, ancho lithiasis is the presence of gallstones in the gallbladder. So many people have asymptomatic gallstones which may never be investigated or present a hospital or to a primary care. Um, but it's only when the symptoms arise or complications arise secondary to gallstones, but uh an intervention would be needed and we'll discuss these complications. So, just the question, does anyone know what the composition of gallstones are? Main cholesterol? Yeah. Yeah, that's one type of uh composite. Exactly. Um So, yeah, they can be cholesterol, they can be pigment stones or they can be mixed, which is the most common um pigment stones are sort of dark blackish, um almost uh dark blackish and composed of bilirubin calcium, some cholesterol or cholesterol which is mostly cholesterol which is light yellow and dark green, but most of them are mixed um which can be brownish. Um The composition is also important to know because uh it can be differentiated on certain imaging modalities, especially if they're inclined towards one, composition or another. And er treatment and investigation isn't per se most of the time. But there may be some cases where um using some agents like CD oxy acid, uh can be used to alleviate symptoms of cholesterol stones um by reducing their size. So it's somewhat useful to know if you have an understanding of what the etiology of the stone is. But again, the treatment is usually fairly straightforward uh for um symptomatic debilitating gallstones without any complications. So, the two common presentations of gallstones we'll be discussing today as mentioned, biliary colic, the pain and then acute cholecystitis, which is inflammation and subsequent infection of the gallbladder. Um, and for the other presentations, we'll leave for the next time, next session. So, starting with Bilary Colic, what do you wanna do? You wanna start off with a good history, uh, use a structured approach. You wanna know how long it's been going on for the duration? Is it an acute issue or is it the first time someone has come in with this issue, which has been longstanding? But what has brought them in this time? Is it the fact that they have a fever or is it the fact that they have um just not presented to the hospital and the pain is unbearable? So you have to know at the progression, the onset, is it sudden, is it first episode like I mentioned? Um, and the timing is it worse at certain times of the day? Is it associated with meals and so on. So, you can combine a sort of a duration onset progression timing approach with a Socrates approach where you go for sight onset, character, radiation associated symptoms and so on and so forth. Um I'll go through that in the next slide. So what is biliary colic itself? It's classically an epigastric or right upper quadrant colicky pain, which is, uh it can last for a few hours but comes and goes. It's often associated with uh fatty foods, but not always. And does anyone know the reason why it's associated with fatty foods? What's the mechanism behind it? Yeah. So, um essentially there's a hormone called called Cholecystic Iine. And that stimulates gallbladder contraction by the um er small intestine which secrete that er, during digestion when uh fats come into the small intestine. Um, but again, it's not always present as in the classic history, where does right, upper quadrant pain after a fatty meal, it can be present in the absence of that. Um, there's also some associated symptoms like sweating, nausea, vomiting and so on. Um, so when the gallbladder is essentially contracting against a large stone, that's when you get that pain lodged stone somewhere in the sort of neck region arms house that kind of. Um, yeah. Ok. So, um, the pain can also be more pronounced during periods of fasting or when you eat a large meal, suddenly causing a contraction of the gallbladder. It's classically an intense and dull pain. And most importantly, there will be an uh an absence of obstructive jaundice symptoms, symptoms like itching, yellowing of the eyes, yellowing of the skin, pale stools or dark urine because there's no obstruction here yet. And uh usually there's no fever as well. The bloods are more or less normal. The only caveat is that there is um, something called Mirizzi syndrome and Merisi syndrome is when you have a stone in either the cystic duct or the neck of the gallbladder, the in fib and that it compresses the common hepatic duct. So, if you just imagine a sort of um, so cystic duct which presses on the common hepatic duct that will also the join and that's not um a stone in the common duct. Ok. Now, um, we have to also, uh talk about why does rapid weight loss lead to, um biliary colic? It's because there will be extra cholesterol secreted into the bile for causing a precipitation of stones fasting because it concentrates cholesterol into potential stones. And also remember the um five sort of risk factors for stones themselves. Um It's just a loose association. It's just good to know. Uh The five FS. You got the female 40 fertile f and uh high in BM. I, um, the history of presenting complaint and past medical history is also important to ascertain, ascertain. Um, if it's the first time or if it's a repeated episode. Um, and also you have to differentiate it from more acute conditions like perforated ulcer, a uh pancreatitis. And we'll discuss how you can do that as well. Um, there are certain drugs that can cause it. Um, gallstones. Um, the contraceptive pill, you've got, um, some other medications that are listed, HRT can cause it as well, high risk and uh, pregnancy as well because, uh, increased progesterone causes reduced. Um, this causes stasis of the gallbladder and that can cause a precipitation of, um, gallstones. And it's also good to know a bit about the social history as well to rule out other things. We're talking drug using possible hepatitis pancreatitis, know if they're a smoker or a drinker or if they've had any sort of recent travel, again, effective causes of hepatic jaundice. Um Yeah. Any questions so far. So, continuing on Biliary colic. We've done our history today. Ok. It's time for the examination and the investigations, the abdominal exam findings can be relatively unspecific if it's just purely bi biliary colic. Um, the patient can have that right, upper quadrant pain, uh tenderness, sorry, and maybe some epigastric tenderness, but there will be a negative uh Murphy sign and um I'll explain how to elicit Murphy sign in just a minute, but most patients who come in with gallstone issues or what you suspect is a gallstone issue. Always do a, uh, check for Murphy's, er, if it's positive or negative. Um, yeah, so just to quickly show, uh, what does anyone know what Murphy sign is, how to elicit it, you just press the right upper quadrant whilst they're breathing in and if they get pain. Exactly. So, just palpate the right upper quadrant just under the costal margin, um, and ask them to take a deep breath in and as they're taking a deep breath in, if they have pain or they have sort of an inspiratory pause pain, uh, then the, the, um, the gallbladder is coming into contact with your hand and that will cause that pain and the gallbladder is. Yeah, er, if it's inflamed, then you're thinking acute cholecystitis. If it's not, then going more towards the biliary colic gallstones. Ok. And, uh, there will be an absence of fever on the observations. There might be some tachycardia. Um, this is, we're considering no inflammation, the bloods, um, the bloods themselves are grossly normal. Um, there might be some transient ap, uh, G GC bilirubin rice. But that's a different reason as to why. Um it's called raised in obstructive jaundice, which is secondary to extensive biliary black BP, um which would cause uh the biliary cells and the hepatocytes to release um those enzymes a larger amount, but it's more of an acute inflammatory reaction, uh causing inflammatory mediators to affect the liver cells. Um Yeah. So you rule out pancreatitis. How do you rule it out or what's a good test to see if someone might, may or may not have pancreatitis? Quite sensitive. Specific. Exactly. So you do a light pace, you do a coagulation profile. Most patients who come in who are being clogged have a coagulation profile done is good for um things like uh if you're considering a possible um obstructive jaundice. The reason being is because when uh bile, the function of bile is to solubilise dietary fats. If you're not able to solubilise dietary fats, you're not able to solubilise fat soluble vitamins like Vitamin K If you can't so utilize Vitamin K you have an increased risk of we did. So what do you give? Right. Ok. If the prothrombin time is above 20 seconds, I believe, but don't quote me on that. Um Yeah, and if there's a persistent fever, consider doing a blood culture as well. Ok. So let's say this presentation is very, very indicative of uncomplicated sys symptomatic ulcers. You've got that right? Upper quadrant pain. You don't have a fever, you have um, repeated episodes. Um, bloods are ok. What do you do? You do an ultrasound? Ok. Um, ultrasounds will uh, confirm gallstones in the absence of an acute inflammation and the ultrasound can be done as an outpatient as well if the pain is settled, if you're not suspicious of anything like cholecystitis, cholangitis, and the ultrasound is very, very, uh sensitive for picking up gallstones, I believe even more than c yeah, treatments of uncomplicated gallstones. Uh, relatively, er, with biliary colic, of course, um, it's relatively straightforward. You start them off with some pain relief, make sure they have adequate, er, analgesia, you start off lower in the sort of wh o ladder, which is, you can give some paracetamol and if you're give, considering giving them codeine to go home with, start off with a, a short period and also make sure you always have, um, them covered with some laxatives if they need it, cos er, opiates can cause um, slowing off the bowels. Um, and then you can give some ibuprofen but again, PPI cover and you start off lower down with the opioid ladder. Um, and then the, they would eventually need to come in for a laparoscopic cholecystectomy. You, uh you might get a bit confused about, sometimes some people say a hot lap chole, which essentially means um an urgent la laparoscopic cholecystectomy within 72 hours to one week of an admission or an acute cholecystitis attack or complication. Um And where the patient is sort of very unwell despite antibiotics and resuscitative treatments, I'll get into that in a bit as well. Um, it's also important to safety net, the patients if you get any fevers, if you get any pain that won't settle despite adequate pain relief, jaundice symptoms and so on. So any questions about biliary colic so far, just about the hot gallbladder list? What, what is the indication that you would send her to the heart gallbladder instead of just I'll get into that in a second. Ok. Yeah. Um So now we're going to acute cholecystitis. So, acute cholecystitis is inflammation of the gallbladder. Ok. Um It presents as a severe, persistent, well localized right upper quadrant pain that may radiate to the back and the around the flax. There may be some rebound tenderness, especially in the right upper quadrant and some guarding. Um but most importantly, um usually they can come in with a positive Murphy sign. Um So we've explained Murphy sign and similar to pancreatitis. It is initially an inflammatory reaction caused by a blocked gallstone often in heart's pouch, uh a mucosal fold which extends off the neck of the gallbladder. Um but it's often complicated by a bacterial infection. So people often start on antibiotics just uh from the get go. Um the common gut bacterias who know that may cause it is e coli clps, strep fal and some anaerobic bacterias. Um Other than the abdominal symptoms mentioned above tachycardia fever. Um, and they may have, they might have some complications if you consider that they might have complications, then, uh, discuss with a senior of course and consider other imaging modalities and I'll talk about the complications as well. Um, things like, um, a gallbladder perforation, an abscess formation. Um, you're thinking if they have a persistent fever despite antibiotics, they have severe tenderness, um, a gallbladder pus in the gallbladder. Um, and then, uh, chronic cholecystitis which can be managed. Um, is there's a different management of chronic cholecystitis, it's not just the sort of antibiotics and keep them in until they settle because it's the, uh, gallbladder has, um, structurally changed. They have a fixed scarred gallbladder because they've had so many episodes of cholecystitis. They have ongoing right, upper quadrant and epigastric pain episodes. Um, the issue with those structural changes is that eventually that can lead to a gallbladder, carcinoma or it can lead to complications like a biliary enteric fistula, which is a connection between the intestine and the bile, uh, the gallbladder which uh causes something called Beauvais syndrome, which is a bit extra, but it just is good to have in your mind, which is essentially a stone in the proximal duodenum. Um, and that can cause a gastric outlet obstruction. And then you might also get some, uh, gallstone ileus, er, which can cause a gallstone in the ilium, which can cause a potential small bowel obstruction. So just to be aware of those, um, it's not, I haven't seen much but you can see it can present like this. Um, so always have that in the back of your mind. Um Blood wise, you'll see some increased white cells, neutrophils. Um, liver function as well is not too bad. Again, this is the same situation as a biliary colic. Unless there's a Mirizzi syndrome, you might see some raised A B but nothing C and bilirubin but nothing to the extent of something with an obstructive jaundice, an act obstructive jaundice secondary to a stone in the common bar. Um ok. So diagnosis, how do we diagnose it? Ultrasound? We see a thick distended gallbladder surrounding edema, presence of gallstones. Uh And there are a few other characteristic changes there um clinically, uh the findings mentioned above and if you consider to think of there are certain complications like the ones above go for a CTC. Uh management cholecystitis, fairly straightforward. Um IV fluids, analgesia antibiotics like um I think they use A MG here, um which is amoxicillin, metroNIDAZOLE and gentamicin, but checked micro as well. Um And they would have to do an eventual cholecyst er cystectomy. So either you can do a hot choles, uh hot gallbladder removal. LA C or you can do an interval cholecystectomy, which is antibiotics for a few weeks, anti antibiotics. And then uh after 6 to 8 weeks, you let the inflammation die down because you don't wanna um, remove an, an angry gallbladder because all the blood vessels are all dilated and all that. So, it's a bit difficult to remove that. So it's preferred to let the inflammation die down on its own with antibiotics and then remove the gallbladder. But in the case that you've tried the antibiotics, patients, septic patients very unwell. You might either consider inserting a drain cholecystostomy or going for a hot, uh, gallbladder removal. A cholecystostomy is a, you might see as well. It's a drain put into the gallbladder, either transhepatic or through the peritoneum. And this is if a patient is unfit for surgery or if you want to prevent sepsis. Um Yeah. Ok. So this is just a history summarized. Um, yeah, just if you have doubt, just go through your regular history taking, um, adjusting your bit based on what you think the diagnosis differentials are always have malignancy in the back of your mind, especially if it's been going on for a while. Weight loss, red flag symptoms going for those questions. Um Yeah, always taking to account the patients, risk factors, their age, family history having gallstones puts you at a five times higher risk of if you have it in the family history, you have a five times higher risk of developing it yourself. Ok. Murphy sign, we've done that. Ok. Cholecystostomy versus cholecystectomy. We've done that patients who frail, not suitable for surgery or to prevent sepsis or further deterioration despite uh efforts of antibiotics, fluid resuscitation, et cetera, et cetera. Ultrasound. The most sensitive imaging modality. Um What you will see on ultrasound is uh sometimes you might see something called sludge, um which is essentially just before they become gallstones, they will be sludged. It's the same particles of gallstones. You've got the cholesterol, the calcium, the bilirubin, it's inevitable that they will become gallstones. Um It is very sensitive as well. So how specific threshold for admitting patients uncontrollable pain infection? If not, then you might consider safety net discharging them. So, when you're larking whether it's in the morning or night, um sorry, just uh ignored that if it's in the morning, consider getting an early ultrasound after for um discharging room if you can get a slot, um because it will save the long delays. Um If it's in the evening, you can ask them to send them home and ask them to come in for um ultrasound after. Um if the pain and er if there's pain and infection, of course, admit them if uh they're very unstable, consider a CTA P of a peritonitic, is there a perforation somewhere? This might be shown on the abdominal X ray, uh chest X ray of the diaphragm and so on, want to escalate. So, patient becomes septic. Do your A two, I'm sure a senior is aware. Um start antibiotic, fluids, analgesia, et cetera. If the patient's pain is not being managed, you've tried everything you've gone down up the ladder. Um You might wanna ask for some help. What can I consider next? Should I contact the pain team? And so, um, if you're concerned about an alternate dia diagnosis, you know, it's always good to work within your capacity. If you are clueless of what's going on, just ask. Um, yeah. All right. Why do we, um, what's the sort of normal preparation for someone before an ultrasound abdomen for uh to see if there's gallstones? And why do we do keep them by mouth? Is that what I mean? Yes. Why do we keep them by mouth? And is it only foods and water or is it both or is one more important than the other? Uh, food is more important? Um But usually it's food and water. They can have sometimes clear, very little sips of clear fluid. Um But only for comfort and why is it to not kind of get the gallbladder going? Yeah. So it's in uncontracted state. It's as big as it can be. So we can actually vis visualize it properly the best view for the gallbladder. Um You can have some water, no food in different troughs, it's different. Um, some troughs say two hours before no water, uh food, six hours before of tr say you can have sos of water throughout the whole, until you have the scan itself. Um But the food is what we're concerned about. Cos we want don't want the gallbladder to contract and become tiny. We wanna see the stones. So this is an example of a radiology request. We have a 45 year old male. Uh, he's admitted with uh three weeks of intermittent abdominal pain after eating and drinking. Just the pain and severity is seven out of 10, some associated nausea and vomiting. The pain is currently being managed with uh pain relief over the counter and on examination but tender in the right upper quadrant Murphy sign positive blood shown uh derangement in in effective marker. Crp 78 white cell 12. Can we currently do an ultrasound abdomen to rule out query cholecystitis. So that's something you might send. It's a bit more detailed than usual, but you can just use an abbreviate. They include the stuff so that the the radiologist won't request um further details and usually we fairly lenient with these things if you have something that's indicative of gallstones or um cholecystitis and you mention some of these things, they will accept it better. Um There's some evidence that when a patient, you know, when you discharge a patient with simple gallstones, you tell them that, ok, you can have a low fat diet. There's some evidence that may help to reduce the pain around gallstones. Um But yeah, ensure that the take for pain relief and also weight loss is also is always beneficial, healthier lifestyle. These are my sources and any other questions. Thank you, if I could just get you guys to do a feedback, I'll be really appreciate one upstairs. Interesting. This.