REFERRAL GUIDELINES: GALLSTONES

Transcription

1 REFERRAL GUIDELINES: GALLSTONES Document Purpose To ensure patients with gallstones disease are managed appropriately in primary/ secondary care Oxford Radcliffe Hospital Surgical Department Surgical Registrar on call at John Radcliffe Hospital Consultants contact details (for elective assessments, Churchill hospital) , bleep (secretary to HPB service) Change Control Input Approved by Mr Zahir Soonawalla Oxfordshire Clinical Commissioning Group Notes Date published Feb 2012 Review Date Feb 2014

2 GALLSTONES DIAGNOSIS Overview Gallstones are stones that form in the gallbladder. Gallstones are very common. It is estimated that, in England, 10-15% of the adult population have gallstones. In most cases, they are asymptomatic. Every year, it is estimated that 1-4% of people with asymptomatic gallstones develop uncomplicated or complicated gallstone disease. An abdominal ultrasound scan is the investigation of choice to diagnose gallstones. Gallstones can cause severe symptoms with repeated attacks of abdominal pain being the most common. The pain can be severe enough to need admission to hospital. If the stones move out of the gallbladder into the common bile duct, they can cause jaundice, cholangitis or acute pancreatitis. These complications can be very serious and rarely fatal. Once gallstones are symptomatic, cholecystectomy is usually advised. Gallstone disease forms a significant health care burden. Health care costs can be reduced by streamlining pathways for the management of gallstones. Delays in the pathway result in repeat visits to primary care and emergency hospital admissions whilst waiting for surgery. Management of asymptomatic gallstones MANAGEMENT Surgery is generally not advised for patients with asymptomatic gallstones, and such patients should not be referred to secondary care. Although patients with diabetes mellitus were felt to have an increased risk of gallstone related complications, the magnitude of the risk does not warrant prophylactic cholecystectomy. Incidental cholecystectomy at the time of another abdominal operation may occasionally be considered for asymptomatic gallstones. Some asymptomatic patients with an abnormal gallbladder warrant referral due to the increased risk for gallbladder carcinoma (porcelain gallbladder, synchronous large polyps or abnormal gallbladder wall suspicious for neoplasm).

3 REFER ONLY Referral to secondary care Urgent admissions The following patients should be considered for urgent referral to secondary care: Patients with jaundice, particularly if with fever or other systemic signs of illness Patients with suspected acute cholecystitis Patients who are highly symptomatic, requiring injectable analgesia Patients with an attack that lasts more than 4-6 hours and is failing to settle Urgent outpatient review Patients with frequent severe symptoms who do not warrant urgent admission should be referred to secondary care outpatient as urgent referrals. Urgent assessment is likely to reduce the need for repeated visits in primary care and may avoid the need for hospitalization. Patients referred urgently should be seen within 2 weeks of the referral. Routine Patients who suffer from symptoms of biliary colic may have symptoms due to stones in the gall bladder or due to small stones passing down the bile duct. The latter usually have abnormal liver biochemistry during or soon after and attack. Over 10% of patients harbor bile duct stones. These can be suspected preoperatively by a history of jaundice, abnormal liver chemistry or dilated bile duct on ultrasound. If suspected, a preoperative MRCP or operative cholangiogram can confirm or exclude bile duct stones. If not suspected, the patient could undergo laparoscopic cholecystectomy with a risk of leaving behind bile duct stones. Ultrasound scan sludge or thickening of the gall bladder are common findings in patients suffering from bilary colic. The US report should be available at the outpatient appointment and should comment on the thickness of the gall bladder and any dilation of the biliary tree. Late referrals Patients who present with a history of an attack many months/ years previously can be offered conservative management if the attack was solitary, mild, lasted only a few hours, and was not associated with jaundice. If such patients are being referred to secondary care: They do not need their liver biochemistry rechecked at time of referral They do not need routine ultrasound prior to referral, if a report is available from 1-2 years previously In a small proportion of patients a repeat ultrasound may be required in secondary care according to their symptomology

4 Painless obstructive jaundice Patients with painless obstructive jaundice are likely to have malignant bile duct obstruction. Initial investigations include blood tests and ultrasound scan. Most of these patients can be referred urgently to the gastroenterology outpatient clinic for review. It is not necessary to wait for the ultrasound scan to be performed prior to referral, as that would add several weeks delay to the investigative pathway. Blood tests, an urgent referral to gastroenterology and a request for urgent ultrasound can all be requested simultaneously. Emergency admission in this group of patients is indicated if: Patients with fever or other systemic signs of illness Patients with deep jaundice, bilirubin over 100, often associated with a history of jaundice of over a week s duration Patients who are nauseous or have poor oral intake, and are at risk of dehydration Gall bladder polyps Ultrasound may reveal gall bladder polyps rather than stones. Gall bladder polyps fall into two groups: 1. True polyps these are asymptomatic mucosal adenomas similar to polyps that occur in the colon. They may grow and have a small risk of turning malignant: this risk is usually only relevant if the polyp is over 1cm. There is a higher risk in patients with colonic polyposis syndromes, HNPCC and with primary sclerosing cholangitis/ ulcerative colitis. Patients with a polyp of 10mm or more should be referred to secondary care. Patients with a polyp of less than 10mm should undergo annual US to survey the polyps. Referral for cholecystectomy should be considered if the polyp is growing in size. There are no clear guidelines on the duration of surveillance though it is known that the risks are low. For polyps 5mm or less, if unchanged over 2-3 years, the patient can be reassured and surveillance stopped. For polyps of 6-9mm, a longer follow up period of 3-5 years is advisable. 2. False polyps sometimes what looks like small polyps on ultrasound simply represents cholesterolosis, adenomyomatosis or small stones sticking to the wall of the gall bladder. Therefore surgery may be considered for symptomatic patients if the ultrasound shows polyps rather than stones, particularly if the gall bladder wall is thickened. Patients who have a clear radiological diagnosis of adenomyomatosis also fall into this group: they should be referred to consider cholecystectomy if symptoms warrant referral and can otherwise be managed conservatively. Incidental bile duct dilatation Asymptomatic bile duct dilatation in patients with normal LFTs does not require referral or investigation. This is usually seen in elderly patients and sometimes in patients who have undergone previous cholecystectomy. Patients with a dilated bile duct should be referred if any of the below apply: They have symptoms that can be attributed to biliary/pancreatic pathology LFTs are abnormal Both the bile duct and pancreatic duct are dilated (possible asymptomatic early ampullary tumour) Evidence of stones present in the bile duct

5 Referral Letter Should include A clear indication of the grounds for referral Relevant medical history and current medication BP check ( undiagnosed or poorly controlled hypertension is a common cause of delays to patients booked for surgery) Abdominal ultrasound results (attach full report if not done at OUH) Liver biochemistry results References Focus on: cholecystectomy. A guide for commissioners. _product_info&products_id=186&cpath=71 Local funding policy Gallstones/ Cholecystectomy Abnormal Liver Function Tests Asymptomatic & Incidental Findings: Oxford Liver Unit Guidance for Referral, Oct 2010