Skip to content

Biliary Disorders

I. Background

Biliary disorders (cholelithiasis, cholecystitis, choledocholithiasis, pancreatitis, and cholangitis) are some of the more common reasons for Emergency General Surgery consultation and need for operative management.

II. Guideline

A. Initial Evaluation with Concern for Biliary Pathology

  • Labs

    • CBC
    • CMP
    • Lipase

  • Imaging

    • Right Upper Quadrant Ultrasound is the preferred imaging modality
    • CT Abdomen/Pelvis with IV Contrast
      • If diagnostic uncertainty
      • If concern for severe pancreatitis
    • HIDA Scan
      • If concern for acalculous cholecystitis
      • If diagnostic uncertainty for cholecystitis and high risk for laparoscopic cholecystectomy
    • MRI/MRCP should be considered only:
      • When IOC and/or EUS/ERCP are a prohibitive risk
      • When there is a potential malignancy and MRCP findings will impact management

  • Emergency General Surgery Consultation

    • Patients with gallstone-related disease who will require cholecystectomy should be preferentially admitted to EGS
    • Patients with prohibitive operative risk factors should be admitted to a medical team
    • Patients referred for bile duct injury should be evaluated by Hepatobiliary Surgery
    • Patients with cirrhosis who are listed for liver transplant should be evaluated by Hepatobiliary Surgery

  • Considerations for Gastroenterology (Advanced Endoscopy) Consultation

    • High risk for choledocholithiasis
    • Postoperative bile leak (see below)

  • Considerations for Radiology (Image-Guided Procedures) Consultation

    • Prohibitive modifiable surgical risk (e.g. recent MI, multisystem organ failure)

B. Antibiotic Therapy

  • Without Sepsis

    • First Line: Ceftriaxone + Metronidazole
      • Only need Metronidazole if biliary-enteric anastomosis
    • Severe PCN allergy: Levofloxacin + Metronidazole
      • Only need Metronidazole if biliary-enteric anastomosis

  • Sepsis / MDR Risk

    • First Line: Piperacillin/Tazobactam
    • Severe PCN allergy: Cefepime + Metronidazole + Vancomycin

  • Duration

    • Stop postoperatively if cholecystectomy performed
    • 4 days if cholecystostomy tube placed

C. Indications for Laparoscopic Cholecystectomy

  • Cholelithiasis with intractable pain
  • Acute cholecystitis
  • Gallstone pancreatitis
  • Choledocholithiasis

D. Risk Assessment for Choledocholithiasis

  • High Risk

    • Choledocholithiasis identified on imaging
    • Clinical signs of ascending cholangitis
    • Total bilirubin > 4 mg/dL with CBD dilation on imaging

  • Intermediate Risk

    • Abnormal liver biochemical tests
    • Dilated CBD (> 6 mm) on imaging

  • Low Risk

    • None of the above risk factors

  • Indication for Intraoperative Cholangiogram

    • Intermediate or high risk for choledocholithiasis

E. Management After Subtotal Cholecystectomy

  • Surgical drain placement in gallbladder fossa
  • Evaluate drain for bilious output
    • If bilious, consult Gastroenterology for ERCP
    • If nonbilious, discharge patient. Drain management to be determined by rounding attending

F. Special Considerations

  • Prior Roux-en-Y Gastric Bypass with possible choledocholithiasis

    • Laparoscopic cholecystectomy with intraoperative cholangiogram
    • Consider common bile duct exploration vs laparoscopic-assisted ERCP
    • Coordinate OR timing with GI

  • Gallstone Pancreatitis

    • Early laparoscopic cholecystectomy if mild or moderate
    • Defer cholecystectomy in severe cases

  • Pregnancy

    • Symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, or cholangitis warrants cholecystectomy during hospital admission

G. Management of Postoperative Bile Leaks

  • Early presentation, bilious drain output

    • If low volume and reliable follow-up, consider discharge and expectant management
    • Otherwise consult GI for ERCP

  • Delayed presentation, no drain in place

    • If noninvasive imaging suggests biloma or drainable fluid collection, consult IR for percutaneous drain prior to ERCP

  • Role of HIDA scan

    • Limited to low- or intermediate-suspicion cases where other diagnostics are equivocal

  • Endoscopic therapy

    • Temporary biliary endoprosthesis with or without biliary sphincterotomy
    • Plastic stents are appropriate — no strong evidence for metal stents even in subtotal/fenestrated cases

  • If leak persists despite endoscopic therapy

    • Consider source from duct not in continuity (e.g., right posterior sectoral duct)

  • If common bile duct or hepatic duct injury

    • Consult Hepatobiliary Surgery

III. References

  1. Bosley ME, et al. Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration. Surg Endosc. 2023;37(5):3994–3999. doi:10.1007/s00464-022-09571-6
  2. Loozen CS, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE). BMJ. 2018;363:k3965. doi:10.1136/bmj.k3965
  3. Bosley ME, et al. Antegrade balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration for the acute care surgeon. J Trauma Acute Care Surg. 2022;92(3):e47–e51. doi:10.1097/TA.0000000000003478
  4. Gallaher JR, Charles A. Acute Cholecystitis: A Review. JAMA. 2022;327(10):965–975. doi:10.1001/jama.2022.2350
  5. Okamoto K, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55–72. doi:10.1002/jhbp.516
  6. Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy (ACDC study). Ann Surg. 2013;258(3):385–393. doi:10.1097/SLA.0b013e3182a1599b
  7. Narula VK, et al. Clinical spotlight review for the management of choledocholithiasis. Surg Endosc. 2020;34(4):1482–1491. doi:10.1007/s00464-020-07462-2
  8. Pearl JP, et al. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc. 2017;31(10):3767–3782. doi:10.1007/s00464-017-5637-3
  9. Yachimski P, Orr JK, Gamboa A. Endoscopic plastic stent therapy for bile leaks following total vs subtotal cholecystectomy. Endosc Int Open. 2020;8(12):E1895–E1899. doi:10.1055/a-1300-1319

IV. Authors

  • Michele N. Fiorentino, MD
  • Rachel D. Appelbaum, MD
  • Michael C. Smith, MD
  • Patrick S. Yachimski, MD

January 22, 2024