17. Biliary Colic

Question 1

Gall bladder Arterial supply

Answer 1

cystic artery, branch of right hepatic artery

Question 2

Gall bladder Venous drainage

Answer 2

part portal, part visceral surface of the liver

Question 3

Gall bladder Nervous supply

Answer 3

sympathetic coeliac plexus, parasympathetic vagus nerve, sensory phrenic nerve and hepatic plexus.

Question 4

Biliary tract

Answer 4

right and left hepatic ducts → CBD → penetrates pancreas for the biliary duct with the pancreatic duct

Question 5

Two sphincters involved in movement of bile:

Answer 5

1) Choledochal sphincter = allows bile storage
2) Sphincter of Oddi = controls secretion of BOTH bile and pancreatic juices

Question 6

Biliary pain

Answer 6

Upper abdominal pain

Penetrating tightness

typically severe

located in the epigastrium

Question 7

pathophysiological basis of biliary pain

Answer 7

distension of the biliary lumen

due to obstructed flow of bile

pain receptors in right phrenic nerve

supplying T5-T9

giving a central upper abdominal pain

Question 8

Gallstones which obstruct the gall-bladder leads to 2 further types of pain:

Answer 8

• Referred right shoulder tip pain, due to dermatomes C3-C5
• Peritonism, pain throughout the abdomen, and guarding locally

Question 9

Aetiological factors in development of gallstones

Answer 9

• ↑ cholesterol in the bile = obesity
• ↓ bile acids in bile = malabsorption
• ↑ bilirubin pigments
• ↑ stone formation from bacterial foci
• Lack of terminal ileum = Crohns + CF

Question 10

Gallstones are more common in:

Answer 10

1) Women
2) Older age
3) Diabetes and obesity

Question 11

Cause of Jaundice

Answer 11

Gall-stones block CBD can lead to cholestasis → conjugated hyperbilirubinaemia → presents as jaundice

Question 12

Cause of Pruritus

Answer 12

Itch associated with jaundice → due to irritation from bilirubin

Question 13

Cause of sepsis

Answer 13

Secondary infection of the static bile salts → “ascending cholangitis”

Question 14

Cause of Shock, pain through to the back, vomiting

Answer 14

Pancreatitis, inflammation of the pancreas, secondary to blocked CBD, if stone is impacted at the sphincter of Oddi

Question 15

Cause of Chronic weight loss

Answer 15

Malabsorption of fat, due to lack of bile salts in D2 Also need to consider another cause, such as pancreatic cancer causing an obstruction

Question 16

Acute Pancreatitis symptoms

Answer 16

acute onset of persistent, severe epigastric abdominal, sometimes localised to the right upper quadrant. This can radiate to the back

Question 17

Gallstone pancreatitis symptoms

Answer 17

pain is well localised onset of pain is rapid, reaching maximum intensity in 10 to 20 minutes 90% have associated nausea and vomiting

Question 18

Pancreatitis signs:

Answer 18

• Abdominal tenderness
• Abdominal distension and hypoactive bowel sounds
• Jaundice
• Systemic inflammatory response
• Evidence of retroperitoneal bleeding: Cullen’s sign / Grey Turner sign)

Question 19

Radiological investigations

Answer 19

1) Ultrasound abdomen 2) MRCP – magnetic resonance cholangio-pancreatography 3) ERCP – Endoscopic retrograde cholangio-pancreatography 4) CT abdomen

Question 20

White cell count

Answer 20

Very raised, in keeping with SIRS

Question 21

pH

Answer 21

Acidotic, likely metabolic, associated with SIRS from the pancreatitis. This is pretty severe.

Question 22

Serum albumin

Answer 22

Low, reverse acute phase reactant, and reduced synthetic function of the liver

Question 23

Serum bilirubin

Answer 23

Bilirubin moderately raised, again an obstructive marker.

Question 24

Alanine aminotransferase

Answer 24

Raised, evidence of hepatic damage.

Question 25

Alkaline phosphatase

Answer 25

“Obstructive” marker, released from hepatocyte and cell death in the bile ducts and biliary tree. Evidence of obstruction.

Question 26

Amylase

Answer 26

Evidence of pancreatitis, intracellular amylase released due to pancreatic cell damage/lysis.

Question 27

Cons of ultrasound abdomen

Answer 27

difficult if fat, or of lots of bowel in the way results are operator dependent

Question 28

Cons of MRCP

Answer 28

loud, cramped, need contrast

Question 29

Cons of ERCP

Answer 29

invasive, uncomfortable, difficult and operator dependent Risks of bleeding, infection, perforation and pancreatitis.

Question 30

Cons of abdomen CT

Answer 30

not very good at looking at the CBD or for gallstones