Acute Biliary Disease
Gallstone disease is prevalent in western society, with 10–15 % of adults having gallstones (Stinton and Shaffer, Gut Liver 6(2):172–87, 2012). In the USA, 500,000–750,000 cholecystectomies are performed annually. Given the prevalence of biliary disease,
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Ning Lu and Walter L. Biffl
Gallstone disease is prevalent in western society, with 10–15 % of adults having gallstones [1]. In the USA, 500,000–750,000 cholecystectomies are performed annually. Given the prevalence of biliary disease, it is important to understand the spectrum of gallstone-related pathologies and how to treat them. The major problems caused by gallstones are symptomatic cholelithiasis; acute cholecystitis; choledocholithiasis; cholangitis; and biliary pancreatitis. In addition, the surgeon may encounter a patient with acute acalculous cholecystitis or gallstone ileus. This chapter offers an overview of each of these clinical entities and outlines a diagnostic and treatment strategy for each.
Asymptomatic Cholelithiasis The incidental finding of gallstones in an asymptomatic patient is not generally considered an indication for cholecystectomy. Although gallstones are common, only 20 % of patients become symptomatic, with 1–4 % of patients with gallstones becoming symptomatic each year [2]. Further, while cholecystectomy is a commonly performed operation with minimal operative mortality (0.14–0.5 %) [3], there can be severe complications. Major and minor complications occur in 2.1 % and 5.9 % of patients, respectively [4]. Given the potential risks of surgery compared to the low incidence of developing symptomatic gallstones over time and the demonstration of the safety of a strategy of observation [2, 5]
N. Lu University of Hawaii Residency Program in General Surgery, Honolulu, HI, USA e-mail: [email protected] W.L. Biffl (*) Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI, USA Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA e-mail: wbiffl@Queens.Org
the accepted management of asymptomatic gallstones is expectant, i.e., watchful waiting. There are, however, populations of patients with asymptomatic gallstones who are at higher risks of developing gallstones and potentially complicated gallstone disease. This may be related to conditions that alter the cholesterol:bile salt ratio, impaired gallbladder motility with resultant bile stasis, or the accessibility of the gallbladder for future operative interventions [6, 7]. Obese patients have a higher than average incidence of gallstones, and this rises to nearly 6-fold higher than the general population during the first 2 years after gastric bypass. Rapid weight loss, decreased fat absorption, and decreased cholecystokinin secretion due to duodenal bypass can all contribute to gallstone formation. That said, the data do not demonstrate an increase in gallstone-related complications after bariatric surgery. Furthermore, the performance of laparoscopic cholecystectomy may actually be easier after weight loss and ursodeoxycholic acid is effective in avoiding gallstone complications. Thus, prophylactic cholecystectomy is not recommended after bariatric surgery except, possibly, after biliopancreatic diversion [6, 8]. Small bowel resection that alters the enterohepatic circulation is associat
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