Gallstone disease pathway
From 2016 RCSEng/AUGIS Commissioning Guide.
Welcome to the Right Decision Service (RDS) newsletter for April 2024.
Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May. If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.
Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.
Thank you for your patience and understanding while we achieve a full resolution.
A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.
The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.
The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.
Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.
These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.
Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.
Figure 1: Impact of RDS on direct delivery of care
Key figures
Figure 2 shows RDS impact to date on delivery of health and care services
Key figures
These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.
Saving time and money
Quality assurance and governance
Service innovation and workforce development
A few examples of toolkits published to live in the last month:
Some of the toolkits the RDS team is currently working on:
Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.
Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions. We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.
Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine. The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.
With kind regards
Right Decision Service team
Healthcare Improvement Scotland
10 to 15% of the adult population in the UK have gallstones, the majority of which are asymptomatic and require no treatment.
Presentation of symptomatic gallstones is usually with biliary colic or, less commonly, a complication of gallstone disease, most commonly cholecystitis.
The definitive treatment of symptomatic gallstones is cholecystectomy.
Stones may pass from the gallbladder into the CBD (common bile duct) and present with jaundice, cholangitis, pancreatitis.
Gallstones on abdominal USS
No treatment or referral
CBD stone
Routine referral due to the risk of potentially significant complications.
(If the patient is currently asymptomatic but there has been a history of jaundice or infection consider urgent referral)
Most patients with symptomatic gallstones present with a self-limiting attack of RUQ / epigastric pain, frequently radiating to the back +/- nausea/vomiting.
This can usually be controlled in primary care with appropriate analgesia +/- anti-emetics without hospital admission.
Consider checking LFTs and a routine referral for USS (although may be deferred until symptoms become recurrent – please see below)
When pain cannot be managed or if the patient is otherwise unwell (septic), refer as an emergency to the on-call surgical team
Further episodes of biliary colic are common (50% risk per annum with 1 to 2% risk per annum of complications).
If not done following the initial presentation, arrange for LFTs to be checked and request a routine USS (unless LFTs are significantly abnormal or the patient is clinically jaundiced. (See section: Clinical suspicion of biliary obstruction)
Recurrent episodes can be prevented in around 30% of patients by adopting a low-fat diet (fat in the stomach provokes release of cholecystokinin, which precipitates gallbladder contraction).
If gallstones (including the suggestion of gallbladder sludge) are confirmed on USS, and the patient is considered fit for and would desire surgery, refer routinely for consideration of cholecystectomy
If the gallbladder is normal with no gallstones identified, consider an alternative diagnosis e.g dyspepsia.
There is NO evidence to support the use of:
(with or without known gallstones)
Ideally patient with acute cholecystitis should have a cholecystectomy in the same admission but if the patient is clinically well and admission is not felt to be required based on clinical condition, management of cholecystitis in the community with analgesia and anti-emetics may be appropriate. If in doubt a discussion with the on-call surgical team would be appropriate.
In the case of management in Primary Care
If the patient cannot be managed in the community, refer the patient to the on-call surgeon with view to admission.
(with or without known gallstones)
If there is a clinical suspicion of acute pancreatitits or cholangitis, refer the patient to the on-call surgical team.
Patients with known gallstones and jaundice or clinical suspicion of biliary obstruction (e.g. significantly abnormal LFTs), not requiring same day admission (i.e not septic), should be referred urgently.