General Surgery  |  Gallbladder Pathway - Biliary Code Suspected




General Surgery

Gallbladder Pathway - Biliary Code Suspected

Biliary Tract Disease includes:

  • Biliary colic

    • Occurs when a gallstone obstructs the cystic duct.
    • Pain is usually severe, dull, boring, constant, 1-5hrs duration, starting 30 minutes to hours after a meal, often at night waking the patient and in the epigastrium or RUQ. May radiate to right scapula or back.
    • Nausea and vomiting often occur.
    • Patients tend to move around to seek pain relief.
    • On abdominal examination the patient has epigastric or RUQ abdominal tenderness and guarding. There are no signs of peritonitis.
    • The patient is not jaundiced and vital signs are usually normal.
    • Patients who present with biliary colic may be candidates for Direct Access Gallbladder Surgery.

  • Cholecystitis

    • Occurs when gallstone obstruction of the cystic duct is prolonged (>6hrs). There is initially a chemical inflammation and then a superimposed bacterial infection of the gallbladder.
    • The pain is like that felt with biliary colic but lasting > 24hrs.
    • Patients tend to lie still as movement aggravates the pain.
    • On abdominal examination the patient has epigastric or RUQ abdominal tenderness and guarding and 97% have a positive Murphy sign.
    • Jaundice occurs in < 20% but may occur if the stone in the cystic duct compresses the common bile duct. Choledocholithiasis must be excluded if the patient is jaundiced.
    • The patient's vital signs may become abnormal with fever and tachycardia.
    • Cholecystitis is referred to the Surgical Registrar on call as an emergency.

  • Choledocholithiasis and Cholangitis

    • Occurs when a gallstone passes into the common bile duct.
    • The pain is similar to biliary colic and cholecystitis.
    • Cholangitis is more often associated with fever, jaundice, nausea and vomiting.
    • The patient is unwell with jaundice, fever or rigors, tachycardia and may be hypotensive with a reduced level of consciousness - this is a surgical emergency.
    • The abdominal examination findings are similar to those of cholecystitis.
    • Rigors, RUQ abdominal pain and jaundice (the Charcot triad) is highly suggestive of cholangitis.
    • Cholangitis is referred to the Surgical Registrar on call as an emergency.

  • Asymptomatic gallstones

    • Smaller stones more likely to be symptomatic than large stones.
    • Indigestion, belching, bloating and fatty food intolerance may occur but are often not cured by cholecystectomy.
    • Only 2-3% of patients with asymptomatic gallstones will develop symptoms each year.

    • Refer asymptomatic gallstones to the General Surgical Outpatient clinic when:

      • Patient is immunocompromised, is waiting for organ transplantation or has Sickle Cell Disease.
      • Calcified (porcelain) gallbladder.
      • Gallbladder polyp > 10mm in size or showing rapid growth in size.
      • Gallbladder trauma.
      • Patients develop symptoms.


Last updated : Friday, August 21, 2015
Next review date : Saturday, August 20,2016


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