Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 474

As we age, the diameter of the common bile duct increases and the lithogenicity of bile increases, resulting in an increased tendency to form cholesterol and calcium bilirubinate stones.³³ It is estimated that up to 28% of men and 42% of women age 80–89 have gallstones.³⁴ In the general population, 6% of men and 9% of women have gallstones.³⁵ Asymptomatic cholelithiasis is a common occurrence in older patients, and only at most 30% of those with gallstones will become symptomatic. Symptomatic recurrent episodes of abdominal pain lasting 30–60 minutes are the usual clinical manifestation of biliary colic. Acute cholecystitis is persistent biliary pain that may be epigastric, right upper quadrant or right shoulder pain with fever, and signs of sepsis caused by gallstones, resulting in infection of the gallbladder or inflammation and infection of the gallbladder in the absence of stones (acalculous cholecystitis). The elderly frequently have atypical presentation of biliary disease and coexistent illnesses, and the increasing frailty of the elderly increases mortality. The elderly patient with cholecystitis often can present with delirium, and many have poorly localized abdominal pain. Physical diagnosis is more challenging as Murphy’s sign in older adults is poorly sensitive (48%) compared with a sensitivity of 90% in younger patients.³⁶ In a person presenting with a severe episodic or persistent epigastric right upper quadrant or right shoulder pain, or in the elderly presenting with fever or delirium, cholecystitis should be suspected. Choledocholithiasis (stones in the common bile duct) presents in a similar manner but is more likely to present with jaundice, and sepsis is more pronounced. Also, the passage of stones through the biliary tract that then obstruct the ampulla can trigger acute pancreatitis.

If gallbladder disease is suspected, the initial test is ultrasonography, with a sensitivity of 84% and a specificity of 99%.³⁷ CT scanning is less sensitive, ranging from 55 to 80%, as many gallstones do not contain calcium and are isodense with bile. As noted above, the elderly are more likely to have acalculous cholecystitis, and cholestintigraphy (HIDA) is useful in this situation and diagnosis of acute cholecystitis. Patients can be suspected of having a common bile duct stone (choledocholithiasis) given appearance on ultrasound, jaundice, and spiking liver enzymes with abdominal pain. An elderly patient who has had a previous cholecystectomy has a larger bile duct with stasis of bile, and therefore bile duct stones are more likely to form. Ascending cholangitis and pancreatitis are complications of choledocholithiasis. Patients suspected of having choledocholithiasis can be diagnosed by magnetic resonance cholangiopancretography (MRCP), endoscopic ultrasound, or endoscopic retrograde cholangiopancreatography (ERCP). ERCP can also remove stones, treat cholangitis, and prevent recurrent pancreatitis.

The treatment of gallstone disease depends on the symptoms, aetiology, and health of the patient. Recurrent (although not frequent) biliary colic may be observed, as complications such as acute cholecystitis develop in about 6.5% at 10 years, while asymptomatic gallstones are less likely to develop complications at a rate of 3% in 10 years.³⁸ If patients have recurrent biliary colic or acute cholecystitis and are in good condition, laparoscopic cholecystectomy is safe and effective even in patients over 90. In a study of 1007 cholecystectomies in those over 90 between 2005 and 2012, mortality was 5.5%, 3.7% for laparoscopic, and 12% for open.³⁹ If patients are too ill for cholecystectomy due to sepsis or coexistent illness, a percutaneous gallbladder drainage tube (cholecystostomy) can be placed. ERCP for choledocholithiasis is safe even in those over 80, who have about the same complication rate as those 70–79.⁴⁰