Biliary Tract disease

Question 1

What are the 3 biliary tract diseases?

Answer 1

Gall stones
Cholecystitis
Ascending cholangitis

Question 2

What are gall stones made of?

Answer 2

Made of Cholesterol (80%), pigment or mixed

Question 3

What are the RF for biliary tract diseases?

Answer 3

The 4 Fs
Fat (BMI 30+)
Female
Forty (40)
Fertile (pregnant/many children)
(fair)

fHx, T2DM, NAFLD, haemolytic condition

Question 4

Sx of gall stones?

Answer 4

RUQ ‘biliary colic’ pain - constant severe episodes of pain 30+ mins
Worse after fatty meal

Question 5

Why is biliary colic different to typical colic?

Answer 5

renal colic eg. often comes and goes

Question 6

What is cholecystitis?
Sx of cholecystitis?

Answer 6

Inflammation of GB due to obstruction

RUQ pain, fever, tender GB
May have referred pain to tip of right shoulder - PHRENIC
MURPHY SIGN +VE = press on GB and ask Px to inhale, either wince or stop

Question 7

What is ascending cholangitis?
Sx?

Answer 7

Infection and inflammation of bile duct due to obstruction or infection - bacteria (eg. E.COLI)

RUQ pain, fever, Jaundice (Charcot triad)
Obstructive = dark urine + pale stool

Question 8

Charcot triad + altered mental state =

Answer 8

Reynold’s pentad
Also used to diagnose ascending cholangitis Sx

Question 9

What does MRCP + ERCP stand for?

Answer 9

magnetic resonance cholangio pancreatography

endoscopic retrograde cholangio pancreatography

Question 10

Gall stones
Dx? 1st line?
Tx?

Answer 10

1st line = abdo Uss (ID gall stones)

Tx=Elective laparoscopic cholecystectomy if Sx
(until then, mild pain = NSAIDs, severe pain = IM Diclofenac (strong NSAID) + lifestyle change)

Question 11

Cholecystitis
Dx?
Tx?

Answer 11

FBC = High leukocytes and neutrophils
LFT = Normal
Abdo USS = Thickened GB wall >3mm

Tx = surgery within 1 week (MUST, by NICE)
Typically done within 72 hours (laparoscopic cholecystectomy)
Till then IV fluids, analgesia and Abx if necessary

Question 12

Ascending Cholangitis
Dx? 1st line? GS?
Tx?

Answer 12

FBC = Leukocytosis + neutrophilic (high)
LFT = High conj bilirubin
1st = Abdo USS - CBD (bile duct) + gall stones
GS - MRCP = Diagnostic + best pre intervention management

Tx = ERCP (Bile duct clearance) them laparoscopic cholecystectomy once stable to prevent reoccurrence

Consider risk of sepsis

Question 13

How can ascending cholangitis cause sepsis?

Answer 13

Biliary obstruction increases back flow of ‘biliary sludge’, ‘stasis is the basis’, bacteria (esp E.COLI) from intestines can climb up through Ampulla of vater + colonise biliary tree