A computed tomographic scan was interpreted as cholelithiasis, but otherwise was normal despite a previous cholecystectomy. Endoscopic retrograde cholangiopancreatography was performed and a stent placed across a stenotic common hepatic duct.
The results of brush biopsies were negative. The stent rapidly occluded and surgical intervention was undertaken. At exploratory laparotomy, an abscess cavity containing multiple gallstones was encountered. This abscess had encircled the common hepatic duct, causing compression and fibrosis. The stones were extracted and a hepaticojejunostomy was tailored.
The patient's bilirubin level slowly decreased and she recovered without complication. Gallstones lost within the peritoneal cavity usually have no adverse sequela. Recently, however, numerous reports have surfaced describing untoward events. This case is certainly one to be included on the list. A surgeon should make every attempt to retrieve spilled gallstones due to the potential later complications described herein.
At present, laparoscopic cholecystectomy LC is the preferred method for removing the gallbladder in patients with cholelithiasis. In this case, spilled gallstones resulted in subhepatic abscess formation with near circumferential compression of the common hepatic duct and resultant obstructive jaundice 1 year after LC.
A year-old woman with a past medical history significant for coronary artery disease and coronary artery bypass grafting, chronic obstructive pulmonary disease, and depression was hospitalized for an episode of gallstone pancreatitis. After fluid resuscitation and a period of observation, she underwent LC prior to discharge. No mention was made of spilled or dropped gallstones in the operative report.
Twelve months later, she had severe pruruitis, nausea, and painless jaundice. She also reported a pound weight loss and acholic stools. On examination, her abdomen was soft and all her incisions were well healed. Laboratory evaluation demonstrated a total bilirubin of Computed tomographic scan of the abdomen was interpreted as cholelithiasis and cholecystitis despite a previous cholecystectomy , but was otherwise normal Figure 1. Some mild intrahepatic bile duct dilation was present.
On magnetic resonance cholangiopancreatography, thickening of the bile ducts was observed, which was suspicious for cholangiocarcinoma. Endoscopic retrograde cholangiopancreatography demonstrated a stenosis of the common hepatic duct and a stent was placed.
Living in or working at an institution with long-term residents, such as a mental health care facility, prison, or long-term care facility. During the physical examination, doctors look for signs of serious disorders such as fever, very low blood pressure, and a rapid heart rate and for signs that liver function is greatly impaired such as easy bruising, a rash of tiny dots or splotches, or changes in mental function.
They gently press on the abdomen to check for lumps, tenderness, swelling, and other abnormalities, such as an enlarged liver or spleen. Blood tests to evaluate how well the liver is functioning and whether it is damaged liver tests. Usually imaging tests such as ultrasonography Ultrasonography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography CT , magnetic resonance imaging MRI , endoscopic retrograde cholangiopancreatography Sometimes biopsy Biopsy of the Liver Doctors can obtain a sample of liver tissue during exploratory surgery, but more often they obtain a sample by inserting a hollow needle through the person's skin and into the liver.
This type Liver tests Liver Blood Tests Liver tests are blood tests that represent a noninvasive way to screen for the presence of liver disease for example, hepatitis in donated blood and to measure the severity and progress of These tests help doctors determine whether the cause is liver malfunction or a blocked bile duct.
If a bile duct is blocked, imaging tests, such as ultrasonography, are usually required. Other blood tests are done based on the disorder doctors suspect and the results of the examination and the initial tests.
They may include. Examination of a blood sample under a microscope to check for excessive destruction of red blood cells. If imaging is needed, ultrasonography of the abdomen is often done first. It can usually detect blockages in the bile ducts. If ultrasonography shows a blockage in a bile duct, other tests may be needed to determine the cause. Typically, magnetic resonance cholangiopancreatography MRCP Magnetic Resonance Imaging Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography CT , magnetic resonance imaging MRI , endoscopic retrograde cholangiopancreatography MRCP is MRI of the bile and pancreatic ducts, done with specialized techniques that make the fluid in the ducts appear bright and the surrounding tissues appear dark.
For ERCP, a flexible viewing tube endoscope is inserted through the mouth and into the small intestine, and a radiopaque contrast agent is injected through the tube into the bile and pancreatic ducts. Then x-rays are taken. When available, MRCP is usually preferred because it is just as accurate and is safer. But ERCP may be used because it enables doctors to take a biopsy sample, remove a gallstone, or do other procedures.
Occasionally, liver biopsy Biopsy of the Liver Doctors can obtain a sample of liver tissue during exploratory surgery, but more often they obtain a sample by inserting a hollow needle through the person's skin and into the liver.
It may be done when certain causes such as viral hepatitis, use of a drug, or exposure to a toxin are suspected or when the diagnosis is unclear after doctors have the results of other tests. Laparoscopy Laparoscopy Laparoscopy is an examination of the abdominal cavity using a fiberoptic instrument inserted through the abdominal wall.
This is a surgical procedure done in an operating room. People are given For this procedure, doctors make a small incision just below the navel and insert a viewing tube laparoscope to examine the liver and gallbladder directly. Rarely, a larger incision is needed a procedure called laparotomy. For a blocked bile duct, a procedure to open it such as endoscopic retrograde cholangiopancreatography [ ERCP Endoscopic Retrograde Cholangiopancreatography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography CT , magnetic resonance imaging MRI , endoscopic retrograde cholangiopancreatography The underlying disorder and any problems it causes are treated as needed.
If jaundice is due to acute viral hepatitis Overview of Acute Viral Hepatitis Acute viral hepatitis is inflammation of the liver caused by infection with one of the five hepatitis viruses. In most people, the inflammation begins suddenly and lasts only a few weeks. However, hepatitis may become chronic, even if the jaundice disappears. Usually, itching gradually disappears as the liver's condition improves.
If itching is bothersome, taking cholestyramine by mouth may help. However, cholestyramine is ineffective when a bile duct is completely blocked. If the cause is a blocked bile duct, a procedure may be done to open the bile duct. This procedure can usually be done during ERCP, using instruments threaded through the endoscope Endoscopic Retrograde Cholangiopancreatography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography CT , magnetic resonance imaging MRI , endoscopic retrograde cholangiopancreatography In older people, the disorder causing jaundice may not cause the same symptoms as it typically does in younger people, or the symptoms may be milder or harder to recognize.
For example, if older people have acute viral hepatitis, they often have much less abdominal pain than younger people. When older people become confused, doctors may mistakenly diagnose dementia and not realize that the cause is hepatic encephalopathy Hepatic Encephalopathy Hepatic encephalopathy is deterioration of brain function that occurs in people with severe liver disease because toxic substances normally removed by the liver build up in the blood and reach That is, doctors may not realize that brain function is deteriorating because the liver is unable to remove toxic substances from the blood as it usually does and, thus, the toxic substances can reach the brain.
In older people, jaundice usually results from a blockage in the bile ducts, and the blockage is more likely to be cancer. Doctors suspect that the blockage is cancer when older people have lost weight, have only mild itching, have no abdominal pain, and have a lump in the abdomen.
Jaundice is a yellow color of the skin and eyes caused by having too much bilirubin in the blood. Jaundice is caused by excess bilirubin, which is formed when hemoglobin the part of red blood cells that carries oxygen is broken down as part of the normal process of recycling old or damaged red blood cells. The gallbladder holds a digestive fluid called bile that's released into your small intestine.
Gallstones range in size from as small as a grain of sand to as large as a golf ball. Some people develop just one gallstone, while others develop many gallstones at the same time.
People who experience symptoms from their gallstones usually require gallbladder removal surgery. Gallstones that don't cause any signs and symptoms typically don't need treatment. Gallstones may cause no signs or symptoms. If a gallstone lodges in a duct and causes a blockage, the resulting signs and symptoms may include:.
Seek immediate care if you develop signs and symptoms of a serious gallstone complication, such as:. There is a problem with information submitted for this request. Subscribe for free and receive your in-depth guide to digestive health, plus the latest on health innovations and news.
You can unsubscribe at any time. Error Email field is required. Error Include a valid email address. Causes of gallstones 4. Diagnosing gallstones 5.
Treating gallstones 6. Complications of gallstones 7. Preventing gallstones. About gallstones Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. Some people with gallstones can also develop complications, such as inflammation of the gallbladder cholecystitis , which can cause: persistent pain jaundice a fever When gallstones cause symptoms or complications, it's known as gallstone disease or cholelithiasis. Read more about: symptoms of gallstones complications of gallstones The gallbladder The gallbladder is a small, pouch-like organ found underneath the liver.
What causes gallstones? You're more at risk of developing gallstones if you're: overweight or obese female, particularly if you've had children 40 or over the risk increases as you get older Read more about: causes of gallstones preventing gallstones Treating gallstones Treatment is usually only necessary if gallstones are causing: symptoms — such as abdominal pain complications — such as jaundice or acute pancreatitis In these cases, keyhole surgery to remove the gallbladder may be recommended.
Read more about: treating gallstones diagnosing gallstones Outlook Most cases of gallstone disease are easily treated with surgery. Symptoms of gallstones Most cases of gallstones don't cause any symptoms. Abdominal pain biliary colic Gallstones can cause sudden, severe abdominal pain that usually lasts 1 to 5 hours although it can sometimes last just a few minutes. The pain can be felt: in the centre of your abdomen tummy just under the ribs on your right-hand side — it may spread from here to your side or shoulder blade The pain is constant and isn't relieved when you go to the toilet, pass wind or are sick.
Some people also have periods where they sweat excessively and feel sick or vomit. Other symptoms In a small number of people, gallstones can cause more serious problems if they obstruct the flow of bile for longer periods or move into other organs such as the pancreas or small bowel. If this happens, you may develop: a high temperature of 38C When to seek medical advice If you think you may be experiencing biliary colic, you should make an appointment with your GP.
Contact your GP immediately for advice if you develop: jaundice abdominal pain lasting longer than eight hours a high temperature and chills abdominal pain so intense that you can't find a position to relieve it If it's not possible to contact your GP immediately, phone your local out-of-hours NHS 24 service.
Causes of gallstones Gallstones are thought to be caused by an imbalance in the chemical make-up of bile inside the gallbladder. It's still unclear exactly what leads to this imbalance, but gallstones can form if: there are unusually high levels of cholesterol inside the gallbladder about 4 in every 5 gallstones are made up of cholesterol there are unusually high levels of a waste product called bilirubin inside the gallbladder about 1 in every 5 gallstones is made up of bilirubin These chemical imbalances cause tiny crystals to develop in the bile.
Sometimes only 1 stone will form, but there are often several at the same time. Gallstones are more common if you: are female, particularly if you've had children, are taking the combined Pill, or are undergoing high-dose oestrogen therapy are overweight or obese are aged 40 years or older the older you are, the more likely you are to develop gallstones have a condition that affects the flow of bile — such as cirrhosis scarring of the liver , primary sclerosing cholangitis, or obstetric cholestasis have Crohn's disease or irritable bowel syndrome IBS have a close family member who's also had gallstones have recently lost weight from either dieting or weight-loss surgery are taking an antibiotic called ceftriaxone.
Diagnosing gallstones Gallstones may be discovered during tests for a different condition, as they often don't cause any symptoms. Seeing your GP Your GP will ask about your symptoms in detail and may carry out the Murphy's sign test to help determine if your gallbladder is inflamed. Further tests If your symptoms and test results suggest you may have gallstones, you'll usually be referred for further tests.
Ultrasound scan Gallstones can usually be confirmed using an ultrasound scan, which uses high frequency sound waves to create an image of the inside of the body. Cholangiography A procedure called a cholangiography can give further information about the condition of your gallbladder. CT scan A computerised tomography CT scan may be carried out to look for any complications of gallstones, such as acute pancreatitis.
CT scans are often done in an emergency to diagnose severe abdominal pain. Treating gallstones Your treatment plan for gallstones depends on how the symptoms are affecting your daily life. You may need treatment if you have a condition that increases your risk of developing complications, such as: scarring of the liver cirrhosis high blood pressure inside the liver — this is known as portal hypertension and is often a complication of alcohol-related liver disease diabetes Treatment may also be recommended if a scan shows high levels of calcium inside your gallbladder, as this can lead to gallbladder cancer in later life.
Keyhole surgery to remove the gallbladder If surgery is recommended, you'll usually have keyhole surgery to remove your gallbladder. Single-incision keyhole surgery Single-incision laparoscopic cholecystectomy is a newer type of keyhole surgery used to remove the gallbladder.
Open surgery A laparoscopic cholecystectomy may not always be recommended, for example if you: are in the third trimester the last three months of pregnancy are extremely overweight have an unusual gallbladder or bile duct structure that makes a keyhole procedure difficult and potentially dangerous In these circumstances, an open cholecystectomy may be recommended.
Endoscopic retrograde cholangio-pancreatography ERCP An endoscopic retrograde cholangio-pancreatography ERCP is a procedure that can be used to remove gallstones from the bile duct. Medication to dissolve gallstones If your gallstones are small and don't contain calcium, it may be possible to take ursodeoxycholic acid tablets to dissolve them.
However, these aren't prescribed very often because: they're rarely very effective they need to be taken for a long time up to 2 years gallstones can recur once treatment is stopped Side effects of ursodeoxycholic acid are uncommon and are usually mild.
Complications of gallstones A small number of people with gallstones may develop serious problems if the gallstones cause a severe blockage or move into another part of the digestive system. Inflammation of the gallbladder acute cholecystitis In some cases of gallstone disease a bile duct can become permanently blocked, which can lead to a build-up of bile inside the gallbladder. The medical term for inflammation of the gallbladder is acute cholecystitis.
Symptoms include: pain in your upper abdomen that travels towards your shoulder blade unlike biliary colic, the pain usually lasts longer than five hours a high temperature fever of 38C Jaundice If a gallstone passes out of the gallbladder into the bile duct and blocks the flow of bile, jaundice occurs.
Symptoms of jaundice include: yellowing of the skin and eyes dark brown urine pale stools itching Sometimes the stone passes from the bile duct on its own. Infection of the bile ducts acute cholangitis If the bile ducts become blocked, they're vulnerable to infection by bacteria. Symptoms of acute cholangitis include: pain in your upper abdomen that travels towards your shoulder blade a high temperature jaundice chills confusion itchy skin generally feeling unwell Antibiotics will help treat the infection, but it's also important to help the bile from the liver to drain with an endoscopic retrograde cholangio-pancreatography ERCP.
Acute pancreatitis Acute pancreatitis may develop when a gallstone moves out of the gallbladder and blocks the opening duct of the pancreas, causing it to become inflamed. Other symptoms of acute pancreatitis can include: feeling sick being sick diarrhoea loss of appetite a high temperature fever of 38C This usually involves admission to hospital so you can be given: fluids into a vein intravenous fluids pain relief nutritional support oxygen through tubes into your nose With treatment, most people with acute pancreatitis improve within a week and are well enough to leave hospital after days.
Cancer of the gallbladder Gallbladder cancer is a rare but serious complication of gallstones. The symptoms of gallbladder cancer are similar to those of complicated gallstone disease, including: abdominal pain high temperature fever of 38C Gallstone ileus Another rare but serious complication of gallstones is known as gallstone ileus.
Symptoms of gallstone ileus include: abdominal pain being sick swelling of the abdomen constipation A bowel obstruction requires immediate medical treatment. Preventing gallstones From the limited evidence available, changes to your diet and losing weight if you're overweight may help prevent gallstones.
Diet Because of the role cholesterol appears to play in the formation of gallstones, it is advisable to avoid eating too many foods with a high saturated fat content. Foods high in saturated fat include: meat pies sausages and fatty cuts of meat butter, ghee and lard cream hard cheeses cakes and biscuits food containing coconut or palm oil A healthy, balanced diet is recommended.
Read more about: high cholesterol how to lower your cholesterol healthy eating Losing weight Being overweight, particularly being obese, increases the amount of cholesterol in your bile, which increases your risk of developing gallstones.
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