Biliary Tract Disease: Biliary Tract Disease: Gallbladder Complications

0:00Welcome to Board Pearls. This is episode two of four of the Biliary Tract Disease chapter, in the Pancreatic and Biliary Disease module. This episode is the gallbladder beyond simple cholecystitis. The first patient is a septic man in the intensive care unit, ICU, and his case shows acalculous cholecystitis. A man with diabetes shows the gas-forming, emphysematous kind. The second patient is a woman with jaundice and an impacted stone, and her case shows what a stone does when it's left for years: Mirizzi syndrome and the porcelain gallbladder. An elderly woman with bowel obstruction shows gallstone ileus, and a man with vomiting shows Bouveret syndrome. The third patient is a man with a seven-millimeter polyp, and his case shows the four kinds of gallbladder polyp, why ten millimeters is the line, the risk factors that lower it, and how often to rescan. A woman with jaundice and weight loss shows why gallbladder cancer presents so late.

0:58Here's the first patient. A forty-six-year-old man is on day twelve in the trauma ICU after a motorcycle crash, with a pelvic fracture and a splenectomy. He's intubated and sedated, has been on total parenteral nutrition, TPN, since admission, and has been on norepinephrine for four days. Over the last day he's developed a fever of thirty-nine point two and a white count of twenty-one thousand. His lines, urine, and chest film explain nothing. His nurse noticed that he grimaces when his right upper abdomen is pressed. His bilirubin is two point one.

1:29Unexplained sepsis with right upper quadrant tenderness in a critically ill patient suggests acalculous cholecystitis, inflammation of the gallbladder without an obstructing stone. It accounts for about five to ten percent of acute cholecystitis, but its mortality is commonly cited at thirty to fifty percent in critically ill patients, for two reasons. It occurs in fasting, often intubated trauma, surgical, burn, or septic patients, where sedation, paralysis, and competing diagnoses delay recognition. And the gallbladder becomes ischemic in low-flow states, with prolonged TPN, sepsis, or vasopressors, while thick, inspissated bile functionally blocks the cystic duct, so the wall becomes gangrenous faster than in stone disease. He has every ingredient: fasting, TPN that removes the cholecystokinin signal to contract, and norepinephrine. New right upper quadrant tenderness, leukocytosis, and unexplained sepsis in an ICU patient call for early consideration, because delay drives the mortality, and his grimace is the closest thing to a Murphy sign he can give.

2:36His imaging is harder to read than in a well patient. Ultrasound can show wall thickening over three point five millimeters, pericholecystic fluid, striation of the wall or sloughed mucosa, and distension, but each is non-specific in ICU patients, who often have thick walls and sludge without cholecystitis. His shows a distended gallbladder, a six-millimeter wall, sludge, a thin rim of fluid, and no stones. A morphine-augmented hepatobiliary iminodiacetic acid, HIDA, scan can break the tie: morphine constricts the sphincter of Oddi, forcing tracer into the cystic duct if it's open, so persistent non-filling means obstruction. But prolonged fasting and TPN cause frequent false positives, so the result is weighed with everything else, and an unstable patient may be treated on clinical grounds. His HIDA shows no filling of the gallbladder.

3:26He needs decompression now, because his gallbladder is heading toward gangrene. Both the acalculous and emphysematous variants need rapid decompression with broad antibiotics covering enteric gram-negatives and anaerobes, such as piperacillin-tazobactam or a carbapenem. In the unstable ICU patient, percutaneous cholecystostomy is first line, because it's placed at the bedside, doesn't need the gallbladder to be apposed to the gut wall, and avoids the perforation risk of a transmural stent through a friable, ischemic wall. Cholecystectomy is preferred when the patient is stable enough for an operation, and gangrene, perforation, or peritonitis force an operation regardless of stability. He has a bedside cholecystostomy with piperacillin-tazobactam, his fever settles within forty-eight hours, and he's weaned off norepinephrine. In many ICU survivors, the catheter is the definitive treatment, because the ischemic insult has passed, and interval cholecystectomy is done if he becomes a surgical candidate.

4:27Gas in the gallbladder wall marks the other dangerous variant. A sixty-six-year-old man with long-standing diabetes and peripheral vascular disease has two days of right upper quadrant pain and fever. His ultrasound shows bright echoes rising in the gallbladder wall, the champagne sign, and his computed tomography, CT, shows a curved crescent of gas in the wall. He has emphysematous cholecystitis, in which Clostridium species, E. coli, or Klebsiella infect an ischemic gallbladder wall and produce gas in the lumen, the wall, or the surrounding tissue. The typical patient is a diabetic man, often with vascular disease. It progresses rapidly to gangrene and perforation, with a mortality of about fifteen to twenty-five percent, several times that of typical stone disease, because the wall is already ischemic before the infection and gas-forming organisms speed its necrosis.

5:20His treatment follows that speed, and one option is off the table. Antibiotics must cover enteric gram-negatives, anaerobes, and Clostridium, with piperacillin-tazobactam or a carbapenem, followed by cholecystectomy if he's stable or percutaneous cholecystostomy if he isn't. The twenty twenty-four American Society for Gastrointestinal Endoscopy guideline names emphysematous cholecystitis as a contraindication to gallbladder drainage with a lumen-apposing metal stent placed under endoscopic ultrasound. He's stable, starts a carbapenem, and goes to surgery that day. If he'd been hypotensive, he'd have had a bedside tube, and perforation would mean an operation regardless.

6:05The second patient shows what a stone can do when it's left for years. A sixty-eight-year-old woman has had intermittent right upper quadrant pain for years, and for a week she's been jaundiced and febrile, at thirty-eight point six, with worsening pain. Her bilirubin is six and her alkaline phosphatase four times normal. Her ultrasound shows a contracted gallbladder full of stones, a large stone impacted in its neck, and a dilated common hepatic duct above it, with a normal-caliber common bile duct below.

6:33Her jaundice comes from outside the duct. A duct dilated above a stone impacted in the gallbladder neck and normal below it, with the stone outside the duct, means extrinsic compression. She has Mirizzi syndrome: compression of the common hepatic duct by a stone impacted in the cystic duct or Hartmann's pouch at Calot's triangle, with chronic inflammation that can progress to a fistula between the gallbladder and the bile duct. It accounts for less than one percent of gallstone complications. About seventy percent of patients are women, typically over fifty, and they present with pain, fever, and jaundice, the Charcot triad in about seventy percent, with raised liver tests and sometimes pancreatitis from inflammation at the ampulla.

7:14Her surgery depends on how far a fistula has gone, so it's staged before the operation. The Csendes classification runs from type one, external compression alone, through fistulas of increasing depth: type two involves less than a third of the duct's circumference, type three up to two-thirds, and type four complete destruction of the duct wall. Type five is a fistula into the bowel. A deeper fistula needs a hepaticojejunostomy rather than a simple cholecystectomy. Magnetic resonance cholangiopancreatography, MRCP, is the study of choice, because it shows the relationship between stone and duct and any fistula without instrumentation. Hers shows a large stone in Hartmann's pouch compressing the common hepatic duct without a fistula, Csendes type one.

8:01Her endoscopy is temporizing, and her operation is planned around the danger. Endoscopic retrograde cholangiopancreatography, ERCP, with sphincterotomy and stenting decompresses the duct, but the stone usually can't be extracted, because it isn't in the duct lumen. Her stent relieves her fever and jaundice and buys time. Dense inflammation distorts Calot's triangle and dramatically raises the risk of bile duct injury at cholecystectomy, so these cases typically need open conversion, intraoperative cholangiography, and sometimes biliary reconstruction, and her surgeon is told the diagnosis beforehand. Gallbladder cancer accompanies Mirizzi syndrome in five to twenty-eight percent, from chronic transmural inflammation, so her specimen is examined carefully.

8:48Her years of stones left a second finding that changes the operation's urgency. Her CT also shows patchy calcification of the gallbladder wall, a porcelain gallbladder: calcium in a chronically inflamed wall, found in about two percent of cholecystectomy specimens, mostly with stones. The cancer risk depends on the pattern. Mucosal or incomplete calcification carries a higher cancer risk than complete calcification, because patchy calcification spares areas of mucosa where dysplasia can progress, while complete circumferential calcification is a burnt-out fibrotic wall. So incomplete calcification like hers is an indication for prophylactic cholecystectomy, while complete calcification can be observed in selected high-risk surgical patients with counseling, such as a frail ninety-year-old in whom it's found incidentally.

9:36A long-standing stone can also erode into the bowel. An eighty-one-year-old woman has three days of colicky pain, distension, and vomiting, with no biliary symptoms she remembers, and her CT shows dilated small bowel, gas in her bile ducts, and a three-centimeter calcified stone in her terminal ileum. She has gallstone ileus. Repeated pressure necrosis of the gallbladder wall against an adherent loop of bowel can erode through it, creating a fistula between the gallbladder and the bowel, most often the duodenum. Air then refluxes into the biliary tree, and a stone can migrate into the gut. The Rigler triad, pneumobilia, mechanical small bowel obstruction, and an ectopic radiopaque stone, makes the diagnosis, and stones larger than about two centimeters lodge at the ileocecal valve, the narrowest point. Elderly women with chronic gallstones are typical, often without a biliary history, because the fistula formed silently.

10:35Her operation is kept as small as possible because of her age. Treatment is enterotomy with stone extraction. Cholecystectomy and fistula repair at the same operation are reserved for fit patients, because adding biliary surgery raises mortality in elderly patients with comorbidities. A staged approach is often right, since the fistula may persist without symptoms and only a minority of patients have another stone migrate. She has an enterotomy alone.

11:01The same fistula can cause obstruction much higher up, where the treatment changes. A seventy-nine-year-old man has days of vomiting, and imaging shows a large stone lodged in his duodenal bulb with gastric outlet obstruction. He has Bouveret syndrome, the proximal variant, in which the migrated stone impacts in the duodenal bulb or second part of the duodenum. At that level, endoscopy can reach it, so endoscopic removal or fragmentation, by mechanical, electrohydraulic, or laser lithotripsy, comes first, with duodenotomy if that fails.

11:36The third patient's gallbladder finding was incidental, and the question is whether it's dangerous. A fifty-seven-year-old man of Indian ancestry had an ultrasound for fatty liver that showed a single seven-millimeter gallbladder polyp, smooth and isoechoic with the liver, on a broad base, with the wall beneath it thickened to five millimeters. He has no gallstones, no biliary pain, and no primary sclerosing cholangitis.

12:01He has a gallbladder polyp, and its type matters before its size. Polyps appear on about five percent of ultrasounds, and ninety-five percent are benign. Cholesterol polyps, sixty percent, are small, two to ten millimeters, often multiple, and brighter than liver, because they're focal cholesterolosis with lipid-laden macrophages in the lamina propria. Adenomyomatosis, twenty-five percent, is diffuse or segmental wall thickening with Rokitansky-Aschoff sinuses, almost always in the fundus, five to twenty millimeters, with a comet-tail artifact. Inflammatory polyps, ten percent, look like cholesterol polyps. Adenomatous polyps, five percent, are homogeneous, often solitary, isoechoic with liver, and smooth, and they aren't benign, because they're the precursor in the adenoma-carcinoma sequence for a subset of gallbladder cancers. His looks adenomatous. Bright, multiple small polyps, or fundal thickening with a comet tail, would need no surgery.

13:01His size alone would mean watching, but his risk factors lower the line. About eighty-five percent of gallbladder cancers occur in polyps of ten millimeters or more, so a polyp that size is an indication for cholecystectomy. For polyps of six to nine millimeters, the twenty twenty-two joint European guidelines offer surgery when there's a risk factor: age over sixty, primary sclerosing cholangitis, a sessile shape, including focal wall thickening over four millimeters, Asian ethnicity, or growth of two millimeters or more on serial imaging. His sessile base with five-millimeter thickening and his Indian ancestry are two risk factors, so he's offered cholecystectomy. Without risk factors, a polyp of five to nine millimeters is rescanned in three to six months, and one under five millimeters at twelve months, watching for growth, the highest-yield sign of malignancy.

13:52Primary sclerosing cholangitis lowers the line further, because its baseline cancer risk is higher. Its lifetime gallbladder cancer risk is about one to four percent, so the twenty twenty-two American Association for the Study of Liver Diseases guidance advises cholecystectomy for polyps over eight millimeters and ultrasound every six months for polyps of eight millimeters or less, with annual ultrasound for everyone with the disease.

14:16The polyp rules exist because gallbladder cancer is found late. A seventy-two-year-old woman of Native American ancestry had years of right upper quadrant discomfort attributed to her gallstones. Over a month she's turned yellow and lost six kilograms, and her CT shows a mass replacing the gallbladder, invading the liver and porta hepatis, with stones inside it. She has gallbladder adenocarcinoma, the most common biliary tract cancer, more common in women and faster-growing than cholangiocarcinoma, with a five-year survival of zero to ten percent because most patients present when it's unresectable. Early cancer mimics biliary colic and chronic cholecystitis, so it declares itself only when it invades the bile duct, causing jaundice, the porta hepatis, or the peritoneum.

15:00Her stones were part of her risk. Gallstones accompany seventy to ninety percent of gallbladder cancers, and stones of three centimeters carry about ten times the risk of stones under one centimeter, from chronic mechanical irritation. Pancreaticobiliary maljunction, a common channel of eight millimeters or longer joining above the sphincter of Oddi, lets pancreatic enzymes reflux into the biliary tree. With cystic dilation, present in seventy-five percent of cases, biliary cancer risk rises, and without dilation, gallbladder cancer occurs in about thirty-five percent, because the gallbladder takes the brunt of the stagnant refluxate.

15:34The other risks act through chronic inflammation or exposure. They are porcelain gallbladder, adenomatous polyps, chronic Salmonella typhi carriage, Native American, South American, or Indian or Pakistani ethnicity, Lynch syndrome, familial adenomatous polyposis, Peutz-Jeghers syndrome, inflammatory bowel disease, obesity, and radon, cigarettes, and industrial chemicals. Radical cholecystectomy with hepatic segmentectomy and lymphadenectomy is the only cure, and only for early disease. She's unresectable. Biliary tumor staging is covered in chapter twenty-four.

16:11Here are the traps the boards set in the acute variants. Acalculous cholecystitis is considered in any fasting, sedated ICU patient with unexplained sepsis. Treatment doesn't wait for a perfect test. Ultrasound findings in ICU patients are non-specific, and fasting and TPN cause false-positive HIDA scans. A transmural stent isn't placed through an ischemic wall, and a gangrenous or perforated gallbladder is operated on rather than drained. And emphysematous cholecystitis needs Clostridium coverage.

16:42For the long-standing stone, the traps are these. A duct dilated only above an impacted neck stone is Mirizzi syndrome. ERCP decompresses but doesn't remove the stone. The surgeon is warned before the operation. Mirizzi syndrome carries a cancer association. Not every porcelain gallbladder is removed, but an incompletely calcified one is. Pneumobilia in an elderly woman with bowel obstruction is gallstone ileus. A frail patient gets enterotomy alone. And Bouveret syndrome gets endoscopy before surgery.

17:14For polyps and cancer, the traps are these. Cholesterol polyps and adenomyomatosis aren't operated on. A polyp of ten millimeters, or a six-to-nine-millimeter polyp with a risk factor, isn't watched. A sessile shape or wall thickening over four millimeters, Asian ethnicity, and growth of two millimeters all count as risk factors. In primary sclerosing cholangitis, the threshold is eight millimeters. Chronic right upper quadrant pain with stones isn't always benign. And maljunction without dilation is a major gallbladder cancer risk.

17:50So, start to finish. Think of acalculous cholecystitis in any critically ill patient on TPN or vasopressors with unexplained sepsis, use a morphine-augmented HIDA scan as a tiebreaker while knowing its false positives, and decompress quickly with a percutaneous tube when the patient is unstable. Emphysematous cholecystitis progresses to gangrene quickly, so cover Clostridium, operate when possible, drain percutaneously when not, and never place a transmural stent.

18:18Suspect Mirizzi syndrome with jaundice and a duct dilated above an impacted neck stone, confirm it with MRCP, decompress with ERCP, and plan the operation around the Csendes type. Remove incompletely calcified porcelain gallbladders. The Rigler triad means gallstone ileus, treated by enterotomy, and Bouveret syndrome gets endoscopy first.

18:42Remove polyps of ten millimeters or more, and six to nine millimeters with a risk factor, and otherwise rescan. In primary sclerosing cholangitis, operate above eight millimeters. Gallbladder cancer presents late, and its main risks are large stones, maljunction, porcelain gallbladder, typhoid carriage, and ethnicity.

19:04Episode three is bile duct stones and acute cholangitis.

19:09For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode two of four of chapter twenty-seven, and I'll see you in the next one.