What are the implications of a calculus (cholelithiasis) in the neck of the gallbladder causing obstruction?

From the Guidelines

Gallbladder calculi (gallstones) in the neck with obstruction typically requires surgical intervention through cholecystectomy, preferably laparoscopic if the patient is a suitable candidate. This approach is supported by the 2020 World Society of Emergency Surgery guidelines, which emphasize the pivotal role of surgery in the management of acute calculus cholecystitis, including in high-risk patients 1. While waiting for surgery, pain management with NSAIDs like ketorolac (10-30mg IV/IM) or opioids such as morphine (2-4mg IV) may be necessary. Antibiotics are indicated if cholecystitis is present, typically with a regimen of piperacillin-tazobactam (3.375g IV every 6 hours) or a combination of ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours) for 5-7 days.

Some key points to consider in the management of gallbladder calculi in the neck with obstruction include:

• The importance of prompt treatment to prevent complications such as acute cholecystitis, gallbladder empyema, perforation, or pancreatitis if the stone migrates to the common bile duct.
• The use of abdominal ultrasound as the preferred initial imaging technique for diagnosing acute cholecystitis, especially in elderly patients 1.
• The consideration of endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction in non-surgical candidates.
• The need for patients to fast to reduce gallbladder stimulation and receive IV fluids for hydration.
• The recommendation for patients to follow a low-fat diet to prevent recurrence of symptoms while awaiting definitive treatment.

It's also important to note that age alone is not a contraindication to cholecystectomy, and laparoscopic cholecystectomy is safe and feasible in elderly patients with acute cholecystitis 1. The evaluation of the risk for elderly patients with acute calculus cholecystitis should include mortality rate, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation.

In terms of specific treatment options, early laparoscopic cholecystectomy should be performed as soon as possible, but can be performed up to 10 days of onset of symptoms 1. Percutaneous cholecystostomy can be considered in the treatment of acute calculus cholecystitis patients who are deemed unfit for surgery.

Overall, the management of gallbladder calculi in the neck with obstruction requires a comprehensive approach that takes into account the patient's overall health, age, and other factors, with the goal of preventing complications and improving outcomes.

From the Research

Calculus in the Neck of the Gallbladder with Obstruction

• Calculus in the neck of the gallbladder can cause obstruction, leading to symptoms such as biliary colic and acute cholecystitis 2.
• The management of calculus gallbladder disease involves early laparoscopic cholecystectomy, which is the recommended treatment for biliary colic and acute cholecystitis 3, 2.
• In cases where the calculus is causing obstruction, endoscopic or surgical relief of the obstruction and clearance of stones from the bile duct may be necessary 2.
• The use of intraoperative cholangiography is not routine, but may be useful in certain situations, such as when there is a high suspicion of choledocholithiasis 4.

Treatment Options

• Laparoscopic cholecystectomy is the standard operation for gallstone disease and is considered the gold standard for treatment 3, 4.
• Open cholecystectomy and small-incision cholecystectomy are safe alternatives, but the superiority of one technique over the others has not been proven 3.
• Emerging techniques, such as single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery, may be used in highly selected patients 2.
• In cases where the calculus is retained in the gallbladder or cystic duct remnant, treatment options include laparotomy and resection, extracorporeal shock-wave lithotripsy, and endoscopic biliary holmium laser lithotripsy 5.

Diagnosis and Management

• Ultrasound is the initial imaging modality of choice for diagnosing gallbladder disease 2.
• Additional diagnostic and therapeutic studies, such as computed tomography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography, may be used in specific situations 2.
• The management of gallbladder disease should be timely and evidence-based, and the choice of procedure should be influenced by facility and surgeon factors 2.