Case Discussion
Case Takeaways
Case of a 15-year-old male with right upper quadrant abdominal pain, nausea, vomiting, and subjective jaundice, likely because of gallstones and gallbladder disease. The patient's labs showed elevated liver function tests and a normal lipase, while ultrasound revealed a distended gallbladder with mobile sludge, stones, and mild pericoloccystic fat. The presenter noted the increasing prevalence of gallstone disease in obese teenagers and the decision to treat with antibiotics due to the patient's tender abdomen and common bile duct dilation. The group discussed whether additional imaging, such as MRCP, or interventional procedures before surgery would be necessary for this patient, emphasizing the importance of access to reliable ERCP services.
Laparoscopic Management of Bile Duct Stones
The team discussed a laparoscopic approach for managing common bile duct stones, combining a cholangiogram with transcystic common bile duct exploration. This method avoids unnecessary duct exploration and surgery-first approaches, especially in patients without acute cholangitis, potentially reducing the need for ERCP. The procedure involves decompressing the gallbladder, achieving the critical view of safety, and using a Fogarty catheter under fluoroscopy to dislodge stones. The success of this method was highlighted, noting that it has not been needed to perform an ERCP after this procedure in several cases.
Choledocholithiasis Management in Pediatrics and Adults
The team focused on the management of choledocholithiasis, discussing differences in approach between pediatric and adult hepatobiliary surgery. They highlighted the controversy surrounding ERCP and the surgery-first approach, emphasizing the importance of center-dependent practices and effective communication with partners in biliary surgery. Also discussed was the use of hemlock clips for secure closure and the training of residents in both GI and surgical approaches. A detailed review of the pathology of a gallbladder case was presented, that focused on the characteristics of a "strawberry gallbladder" and the underlying metabolic abnormalities.