Biliary disease

Question 1

Biliary colic: aetiology/epidemiology

Answer 1

Presence of gallstones
More common in females
Obesity
Hyperlipidaemia

Question 2

Biliary colic: signs/Sx

Answer 2

Sudden onset, severe pain with crescendo characteristic
Can be related to eating high fat content food
Initial pain is epigastric but can have RUQ component
N+V with severe episodes
May terminate spontaneously or with administration of opioids

Question 3

Biliary colic: pathology

Answer 3

Temporary obstruction of the cystic or common bile duct by a stone, usually migrating from the gall bladder

Question 4

Biliary colic: investigations

Answer 4

Obs: afebrile, no abnormal vitals (cf. cholangitis etc.)
FBC, LFTs (rule out cholecystitis + cholangitis)
RUQ abdominal US to visualise stones

Question 5

Biliary colic: treatment (initial and definitive)

Answer 5

Initial: analgesia, rehydrate, NBM
Definitive: elective lap chole

Question 6

Acute cholecystitis: aetiology/epidemiology

Answer 6

Same as in biliary colic: presence of gallstones, more common in women, obesity + hyperlipidaemia

Question 7

Acute cholecystitis: signs/Sx

Answer 7

Inflammatory component in addition to biliary colic: local peritonism, ↑WCC, fever etc.
Murphy’s sign: lay 2 fingers over the RUQ, ask pt to breathe in - causes pain and arrest of inspiration as an inflamed GB impinges on your fingers

Question 8

Acute cholecystitis: pathology

Answer 8

Happens due to obstruction of GB emptying

Results in ↑ glandular secretion → progressive distension → (+/-) compromised vascular supply to GB

Question 9

Acute cholecystitis: investigations

Answer 9

FBC (moderate leukocytosis), inflammatory markers (↑), LFTs (↑)
Abdominal US

Question 10

Signs on US suggesting acute cholecystitis

Answer 10

Gallstones within the GB, particularly if obstructing neck of GB or cystic duct
Focal tenderness over underlying GB
Pericholecystic fluid
Thickening of the GB wall

Question 11

Eponymous sign associated with acute cholecystitis

Answer 11

Murphy’s sign: lay 2 fingers over the RUQ, ask pt to breathe in - causes pain and arrest of inspiration as an inflamed GB impinges on your fingers

Question 12

Acute cholecystitis: treatment

Answer 12

Immediate: NBM, analgesia, ABx e.g. cefuroxime 1.5g/8h IV
Definitive: lap chole (acute or delayed)

Question 13

Ascending cholangitis: aetiology/pathology

Answer 13

Same as biliary colic: Presence of gallstones
More common in females
Obesity
Hyperlipidaemia

Question 14

Ascending cholangitis: signs/Sx

Answer 14

Classically presents with Charcot’s triad: RUQ pain, fever + jaundice - in reality only a minority of patients have this
Abdo pain is most common Sx and has typical features of biliary colic
Jaundice is almost always preceded by abdo pain
Level of jaundice can fluctuate
Fever is present in only a minority of cases: indicates biliary sepsis

Question 15

Eponymous triad associated with ascending cholangitis

Answer 15

Charcot’s triad: RUQ pain, fever and jaundice

Question 16

Ascending cholangitis: pathology

Answer 16

Gallstone/other mass causing obstruction of the common bile duct

Question 17

Ascending cholangitis: investigations

Answer 17

FBC (↑ neutrophils), ↑ inflammatory markers, ↑LFTs
Abdominal US is initial technique of choice: look for dilatation of intrahepatic biliary radicles
Stones in distal CBD are often poorly visualised and can be missed
MRCP
CT
EUS
ERCP: invasive with recognised risks; usually used therapeutically after stones have been identified by above investigations

Question 18

Ascending cholangitis: treatment

Answer 18

Urgent IV ABx + bile duct drainage (usually by ERCP)

If pt found to have stones in CBD + GB, can both be resolved at the time of laparoscopic cholecystectomy