Biliary Disease

Question 1

Definitions in biliary disease

Answer 1

• Cholestasis - blockage to the flow of bile
• Cholelithiasis - gallstones
• Choledocholithiasis - gallstones in the bile duct
• Biliary colic - intermittent RUQ pain caused by gallstones irritating bile duct
• Cholecystitis - inflammation of the gallbladder
• Cholangitis - infection and obstruction of the biliary system
• Gallbladder empyema - pus in the gallbladder
• Cholecyetectomy - surgical removal of the gallbladder
• Cholecystostomy - inserting a drain into the gallbladder

Question 2

Risk factors for gallstones (remember the 4 F’s)

Answer 2

• Fat
• Fair
• Female
• Forty
• Fertile (one or more children)

Question 3

Investigation and management of gallstone disease

Answer 3

• LFTs and US
  
  • US is most sensitive initial test for gallstones but it limited by patients weight, bowel obstructing the view and patient discomfort
  • Bile duct dilatation (>6mm plus 1mm for every decade after 60 years)
• MRCP
  
  • Indicated if USS doesn’t show ductal stones but there is bile duct dilatation or raised bilirubin
• ERCP
  
  • Indicated in established CBD stones/obstructing ductal tumours
  • Allows for treatment with stricture dilatation/biopsy
• Cholecystectomy
  
  • Indicated where symptomatic/problematic stones are established in patient fit for surgery

Question 4

LFTs in biliary disease

Answer 4

• Raised bilirubin
  
  • Represents an obstruction to flow in the bile duct
• Raised ALP
  
  • Consistent with cholestasis in presence of RUQ pain and/or jaundice
  • Can also be caused by liver or bone metastasis, PBC, Paget’s disease
• Raised aminotranferase (ALT/AST)
  
  • Markers of hepatocellular injury
  • Slight rise in obstructive jaundice but if very high vs ALP suggest hepatocellular process

Question 5

Acute cholecystitis

Answer 5

• 90% secondary to gallstones
• Murphy’s sign - RUQ tenderness exacerbated by deep inspiraton as gallbladder is pushed down onto hand
• Inflammation of the wall of the gallbladder
• Treat with fasting, fluids, antibiotics and eventually laparoscopic cholecystectomy

Question 6

Ascending cholangitis

Answer 6

• Infected biliary obstruction
• Charcots triad (fever, jaundice, RUQ pain)
• Reynolds pentad includes mental confusion and septic shock
• Requires broad spectrum antibiotics and ERCP/PTC

Question 7

What is the importance of obstructive jaundice as a presentation of carcinoma of the extrahepatic bile ducts?

Answer 7

• 66% in head of pancreas
• Ductal adenocarcinoma
• Pre-malignant pain asymptomatic
• Signs include painless obstructive jaundice
• Abdominal pain due to pancreatic insufficiency or nerve invasion
• Tumours in head may obstruct pancreatic and bile duct (‘double duct sign’ on radiology)
• Whipple’s resection for head of pancreas tumours

Question 8

ERCP treatments

Answer 8

• Colangio-Pancreatography: retrograde injection of contrast into duct through sphincter of Oddi and xray images to visualize biliary system
• Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal
• Stone removal: a basket can be inserted and pulled through the CBD to remove stones
• Balloon dilatation: a balloon can be inserted and inflated to treat strictures
• Biliary stenting: a stent can be inserted to maintain a patent bile duct (if strictures or tumours)
• Biopsy: a small biopsy can be taken to diagnose obstructing lesions
• Notable complications: bleeding, pancreatitis, infection.