Biliary

Question 1

Indication ercp?

Answer 1

Diagnosis AND treatment choledocholithiasis

Question 2

Symptoms cholangitis? (5)

Answer 2

Charcot triad always
• fever intermittent with chills
• jaundice
• RUQ pain

Sometimes Reynald Pentad.
• hypotension (haemodynamic instability)
• altered level of consciousness

Question 3

Name and classify causes of obstructive jaundice (9)

Answer 3

Intraductal causes
• choledocholithiasis (stones common bile duct) = #1 cause
• foreign bodies eg blocked biliary stent
• ascaris worms

Intramural
• malignant strictures: cholangiocarcinoma
• benign strictures: chronic pancreatitis, primary sclerosing cholangitis, HIV associated cholangiopathy, iatrogenic bile duct injury, anastomotic strictures

Extraductal
• peri-ampullary malignancies: head pancreas cancer, ampullary carcinoma, duodenal cancer
• pancreatic pseudocysts
• malignant portal lymphadenopathy: lymphoma, metastasis from git and rarely breast and lung
• benign portal lymphadenopathy: Tb most common

Liver failure is NOT a cause, but in advanced cirrhosis biliary stasis occurs at level of sinusoids.

Question 4

Name 3 signs obstructive jaundice

Answer 4

• Yellowing (icterus) skin, corneas, mucosal membranes (eyes more than skin)
• white (acholic) stool
• dark Coca-Cola coloured urine
Pruritis

Question 5

Name 4 complications obstructive jaundice

Answer 5

• Acute cholangitis (bacterial bile infection and obstructed biliary tree)
• pruritis (bilirubin deposit in dermis )
• coagulopathy (absent it K absorption- and all other fat soluble kade)
• acute renal failure (bilirubin deposited renal tubules)
NOT hepatic encephalopathy (complication of liver failure which in some causes are due to biliary cirrhosis due to chronic obstructive jaundice)

Question 6

What does raised AST indicate? (4)

Answer 6

• Liver injury
• muscle injury (also found in mm) eg mi, rhabdomyolysis,
• hemolysis (found in rbc)
• biliary disease eg choledocholithiasis, cholecystitis

Question 7

What does lowered AST indicate? (2)

Answer 7

• B12 deficiency
• pregnancy

Question 8

Normal diameter common bile duct?

Answer 8

7 mm or less

Question 9

Diagnosis if GGT and alp raised more than AST and alt values but AST and alt still raised? (2)

Answer 9

• Acute cholangitis
• chronic obstructive jaundice

Question 10

Diagnosis if GGT and alp raised more than AST and alt values with high white cell count and CRP?

Answer 10

Acute cholangitis until proven otherwise

Question 11

Initial imaging investigation for all patients jaundice?

Answer 11

Ultrasound

Question 12

Further imaging investigation for obstructive jaundice if intra-mural or extra-ductal cause suspected?

Answer 12

Triphasic abdominal CT or mrcp

Question 13

Further imaging investigation for obstructive jaundice if intra-ductal cause suspected?

Answer 13

Endoscopic retrograde cholangiopancreaticogram and treat cause endoscopically

Question 14

Name 4 indications for urgent biliary tree drainage (decompress)

Answer 14

• Moderate-severe acute cholangitis (classified as per Tokyo guidelines)
• non-resolving acute renal dysfunction
• intractable pruritis
• bleeding despite vitamin K therapy

Question 15

Name 4 biliary drainage procedures

Answer 15

•Endoscopically using retrograde cholangiopancreaticogram
• percutaneous cholangiogram PTC then percutaneous biliary duct drainage PTBD
• percutaneous using transhepatic cholecystostomy tube
• surgically: bilio-enteric anastomosis- hepaticojejunostomy or cholecystojejunOstomy

Question 16

Tokyo guidelines criteria for acute cholangitis diagnosis?

Answer 16

A systemic inflammation
• fever > 38 or shivering
• lab pattern of inflammation: leukocytes <4000 or >10000 / L, CRP raised

B cholestasis
• icterus (bilirubin > 17 micro mol / L )
• raised cholestasis parameters and transaminases (alp, GGT, AST, alt > 1,5 times upper limit)

C imaging (initially transabdominal ultrasound, then endoscopic ultrasound or mrcp)
• bile duct dilatation >7 mm
• evidence stone or obstruction

A, B and C = definitely
A and b or C = urgent suspicion

Question 17

Define cholelithiasis

Answer 17

Gallstones in gallbladder

Question 18

Name 4 types of gallstones

Answer 18

• Cholesterol (85%)
. Pigmented black (sterile): calcium salts - hard stones
• pigmented brown (infected): calcium salts and bacterial cell bodies - soft
• mixed (majority)

Question 19

Which gall stones are radio-opaque?

Answer 19

Pigmented stones.
Cholesterol stones, which is 85% of all gallbladder stones, are radio-lucent (not visible)

Question 20

How are cholesterol gall stones formed? Risk factors? (8)

Answer 20

Disruption in solubility equilibrium of bile:
1. Increased cholesterol secretion in bile (risk factors = 4 fs):
• Forty (elderly)
• fat
• female
• fertile
• hyperlipidaemia

2. Decreased emptying of gallbladder
   • gallbladder malignancy.
   • Gallbladder hypomotility: truncal vagotomy, spinal cord injury
   • pregnancy
   • fasting, TPN

Question 21

How are black (sterile) pigmented gallstones formed? Etiology? (6)

Answer 21

• increased secretion unconjugated bilirubin into bile, usually due to haemolytic disorders:
  • chronic haemolysis, hereditary spherocytosis
  • most commonly g6pd deficiency
  • cirrhosis, chronic liver disease
  • tpn
• decreased bilirubin solubility and gallbladder stasis

Leads to precipitation of calcium. Small, brittle, spiculated stones.

Question 22

How are brown (infected) pigmented gallstones formed?

Answer 22

• Infection (especially klebsiella, e coli ) with bacterial degradation of biliary lipids
• biliary stasis causes bac infection (stasis may be due to stricture, other CBD stones, post cholecystectomy primary duct stones, gallbladder dysfunction)

Usually <1cm, soft, can form in GB or bile ducts primarily

Question 23

What is biliary sludge and what does it signify?

Answer 23

• Microlithiasis suspended in bile
• seen on ultrasound as layering in biliary tree
• pre-stone condition
• 20% disappear, 60% recur, 10% form stones

Question 24

Symptoms of gallstones? (7)

Answer 24

• 85% asymptomatic. Symptoms caused by impaction of stone at gallbladder outlet
• colicky pain: distinct attacks lasting 30 minutes to several hours, often resolve spontaneously (if > 6 hours, consider complication like cholecystitis) (biliary colic)
• Epigastric pain 70%, or right hypochondrium
• radiate to inferior angle right scapula or tip of right shoulder
• intense pain
• pain within hours of eating, especially after fatty meal, often wake patient from sleep
• back pain, LUQ pain, bloating
• nausea and vomiting which relieves the pain

Question 25

Name 4 complications of cholelithiasis

Answer 25

• Porcelain gallbladder/ chronic cholecystitis → increased risk malignancy - “limey” bile
• gallbladder cancer
• acute calculus cholecystitis! → empyema and hydrops of gallbladder, may cause perforation
• mirizzi syndrome → obstructive jaundice (gallstone impacted in cystic duct of neck gallbladder in Hartmann’s pouch causing compression CBD or common hepatic duct. Rare)
Liver or gallbladder abscess
Bouveret syndrome: gallstone erodes through fundus into intestine, may cause gallstone ileus!
Obstructive jaundice
Acute pancreatitis

Question 26

Name 4 complications choledocholithiasis

Answer 26

• Obstructive jaundice
• ascending cholaengitis
• secondary biliary cirrhosis
• gallstone pancreatitis

Question 27

Name 3 complications cholelithiasis in the gut

Answer 27

• gallbladder inflammation > adhesions > Cholecystoenteric fistula → intestinal obstruction
. Bouveret syndrome → gastric outlet obstruction (rare direct erosion large gallstone through gallbladder into GIT)
• gallstone dyspepsia: fatty food intolerance, dyspepsia and flatulence not due to other causes

Question 28

Treatment asymptomatic cholelithiasis?

Answer 28

• No surgery unless indications:become symptomatic, risk of gallbladder carcinoma, choledocholithiasis, gallstones >3 cm, patient live far, sickle cell disease, transplant or immunosuppressed, young
• expectant management and close follow up
• counsel patient about symptoms: biliary colic, acute cholecystitis, obstructive jaundice etc

Question 29

Treatment symptomatic cholelithiasis? (3)

Answer 29

• Open or laparoscopic cholecystectomy best

All other methods 50% recurrence:
• shockwave lithotripsy: only work for cholesterol stones, expensive, bile salt therapy necessary following lithotripsy to dissolve gallstone fragments. Contraindicated if > 3 stones, large or calcified stones, non-functioning gallbladder,
• Medical treatment if: radiolucent gallstones, < 15 mm, moderate obesity, mild symptoms
- chemodissolution:oral bile acid - ursodeoxycholic or chenodeoxycholic acid. Expensive, need lifelong maintenance
-Liver diet: moderate carbs, low fat and cholesterol, high fibre

Question 30

Define cholecystitis

Answer 30

Obstruction of cystic duct by gallstone → inflammation, distension gallbladder

Question 31

Symptoms cholecystitis? (3)

Answer 31

• Constant! Unremitting severe RHC pain due to inflammation spreading to parietal peritoneum (less commonly epigastric )
• radiate to inferior angle scapula, interscapular
• anorexia, vomiting

Question 32

Clinical presentation findings cholecystitis? (6)

Answer 32

•Tachycardia, low grade fever !, dehydration
• RHC tenderness with guarding
• Murphy sign positive! (Inspiratory arrest during deep palpation ruq)
• Boas’s sign: hyperaesthesia below right scapula
• 30% palpable gallbladder
• may have mild jaundice, if severe consider other causes

Question 33

Investigation for cholecystitis? (4)

Answer 33

• Ultrasound: thickened gallbladder wall, sonographic Murphy’s positive, pericholecystic fluid, gallstones in biliary system, controlled gallbladder
• CT: fat stranding around gallbladder
• FBc: leukocytosis!
• uce: dehydration

May have mildly raised amylase (but if >1000= pancreatitis) , mild transaminitis AST alt on LFT
Cxr, axr: radio-opaque gallstones, aerobilia due to fistula; exclude lower lobe pneumonia, perforated viscus (bowel), abnormal right thorax…

Question 34

Name 5 features on ultrasound of acute cholecystitis

Answer 34

• Thickened gallbladder wall
• sonographic Murphy’s positive
• pericholecystic fluid (oedema gallbladder wall)
• presence gallstones in biliary system
• contracted gallbladder from chronic gallstone disease

Question 35

Management acute cholecystitis? (5)

Answer 35

• ATLS resuscitation
• empirical iv antibiotics: ceftriaxone and metronidazole, septic workup, careful monitoring for signs of failure (peritonism, non-resolving fever or pain)
• analgesia
• definitive treatment = cholecystectomy
• alternative treatment = percutaneous cholecystostomy for moribund patients unfit for surgery, or when early surgery difficult due to inflammation. Resolves acute episode by draining gallbladder. Elective cholecystectomy 4-6 weeks later

Question 36

Name 2 complications cholecystectomy

Answer 36

• Reflux disease and biliary gastritis (loss concentrating action of gallbladder → increased flow of bile)
• abdominal pain and diarrhoea (disturbed micelles formation → fat intolerance and malabsorption)

Question 37

Name 5 local complications acute cholecystitis

Answer 37

• Hydrops : cystic duct obstruction → tense gallbladder filled with mucous. May → gallbladder wall necrosis if pressure exceeds capillary blood pressure
• empyema: infection of stagnant bile. Do urgent surgery
.Gangrene and perforation: localised perforation → abscess confined by omentum. Free perforation → generalised peritonitis and sepsis, emergency
• cholecystoenteric fistula: after repeated attacks. Aerobilia on AXR. Usually asymptomatic
• gallstone ileus: symptoms of small bowel obstruction. Most common site is terminal ileum

Question 38

Treatment gallstone ileus? (3)

Answer 38

• Exploratory laparotomy with enterolithotomy via small bowel enterotomy proximal to point of obstruction
• search entire bowel for other stones
• cholecystectomy

Question 39

Define choledocholithiasis

Answer 39

Common bile duct obstruction by gallstones causing proximal inflammation, obstructive jaundice and dilated hepatic bile ducts

Question 40

Symptoms choledocholithiasis (3)

Answer 40

• RUQ or epigastric pain (pain more prolonged than in biliary colic, but not constant)
• Nausea vomiting
• obstructive jaundice: dark urine, pale stool, yellow sclera, prunitis

Question 41

Name 2 complications choledocholithiasis

Answer 41

• acute cholangitis
• acute pancreatitis

Question 42

Blood investigations for choledocholithiasis? (4)

Answer 42

• LFT
-Early biliary obstruction: elevated alt/ast
- later alp / direct bilirubin / GGT more elevated (cholestatic pattern)
• FBC: leukocytosis (may suggest cholangitis)
• serum amylase: CBD stone may cause pancreatitis

Question 43

Imaging investigations for choledocholithiasis?

Answer 43

Ultrasound HBS, look for
• cholelithiasis
• gallstone CBD
• dilated CBD > 7 mm

Other modalities: mrcp, eus

Question 44

Management choledocholithiasis? (2)

Answer 44

• best = ercp with sphincterotomy and stone removal. Interval laparoscopic cholecystectomy and intra-op cholangiography
• if patient not suitable, lap surgery

Question 45

Name 7 indications for operative removal of stones in choledocholithiasis (instead of ercp)

Answer 45

• Stone > 25mm
• intrahepatic stone
• many stones
• impacted stone
• ductal pathology
• tortuous duct
• Previous billroth 2 gastrojejunostomy (unsuitable anatomy for ercp )

If prior cholecystectomy or acute cholangitis: do ercp.

Question 46

Define cholangitis

Answer 46

Life-threatening bacterial infection of biliary tree associated with complete or partial obstruction of ductal system.
(Choledocholithiasis + infection)

Question 47

Causes cholangitis? (9)

Answer 47

Memorize Cholangitis , Become First CHAMP

• Most commonly choledocholithiasis!
• benign strictures (instrumentation)
• malignancy (pancreatic, biliary)
• foreign body (previous instrumentation)
.Psc primary sclerosing cholangitis
• choledochal cysts
• mirizzi
• haemophilia
• biliary enteric anastomosis

Question 48

Common causative organisms of cholangitis? (4)

Answer 48

Gram negative bacteria and anaerobes
• klebsiella
• e Coli
• enterobacter
• enterococcus

Question 49

Name 4 complications cholangitis

Answer 49

• Sepsis and mods
• electrolyte abnormality (dehydration)
• infection
• coagulopathy (vitamin k)

Question 50

Diagnosis cholangitis by investigations? (3)

Answer 50

• Ultrasound → dilated bile ducts
• LFT → cholestatic picture (alp/GGT > AST/ALT )
• blood/bile culture → isolation of causative organism

Question 51

Emergency treatment cholangitis? (3)

Answer 51

• resuscitation: septic shock
• iv antibiotics: ceftriaxone and metronidazole, imipenem if patient in shock
• emergency biliary decompression
-Usually deferred until 24-48 hours after admission when patient stable. Emergency if deteriorating or antibiotics not improving infection
- ercp: endoscopic sphincterotomy and stenting or external drainage (nasobiliary drain)
- other methods: percutaneous transhepatic drainage, operative decompression.

Question 52

Definitive treatment options cholangitis? (3)

Answer 52

•Open cholecystectomy with CBD exploration
• laparoscopic cholecystectomy with or without CBD exploration

CBD exploration = cholangiogram or choledochoscopy with stone removal (manual, flush out, dredging or scooping with balloon catheter or dormia basket, or lithotripsy) with or without biliary stent or t-tube insertion (pressure release valve )

Question 53

Name 3 indications biliary bypass

Answer 53

• Multiple stones
• CBD > 2cm
• strictures

Question 54

Define mirizzi syndrome

Answer 54

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder.

Question 55

Define cholangiocarcinoma

Answer 55

Arise from ductular epithelia of the biliary tree either within the liver or more commonly from the extrahepatic bile ducts

Question 56

Define periampullary tumour

Answer 56

Arise within 2 cm of the ampulla of vater in the duodenum

Question 57

Name 4 types periampullary tumours

Answer 57

• Pancreatic head/uncinate process carcinoma
• lower CBD cholangiocaronoma (elderly)
• periampullary duodenum carcinoma (Thomas sign: silver stools)
• ampulla of vater carcinoma (intermittent jaundice)