Biliary Tract Disease

Question 1

Know the 3 main factors that lead to gallstone formation.

Answer 1

• Hepatic secretion of bile supersaturated with cholesterol (lithogenic bile)
• Nucleation of cholesterol molecules (mucin, α1-acid glycoprotein, IgG/IgM)
• Stasis of bile within the GB

Question 2

What are the compositions of the 2 major forms of gallstones?

Answer 2

Cholesterol and calcium bilirubinate

Question 3

What are the 2 types of gallstones?

Answer 3

1) Brown Cholesterol stones- 75%
- Biliary infection
- Stricture
- Post-sphincterotomy

2) Pigmented Black/Brown stones (Bilirubinate) – 25%
- Chronic hemolysis
- Cirrhosis

Question 4

What are the risk factors for cholelithiasis?

Answer 4

Age, obesity, female, rapid wt loss, fertile, forties, fair

Question 5

What is biliary colic and what is the typical time course of the symptoms?

Answer 5

Biliary colic is typically a steady ache in the epigastrium or right upper quadrant, of sudden onset, reaching a plateau of intensity over a few minutes, which subsides gradually over 30 minutes to several hours.

It is associated with a gallstones passage through the biliary tract or against the cystic duct.

Question 6

What are the most effective procedures for diagnosing cholelithiasis and acute cholecystitis?

Answer 6

RUQ Abdominal U/S (cholesterol stones in GB), MRCP, HIDA Scan

Question 7

What is choledocholithiasis?

Answer 7

Gallstone lodged in common duct (CBD)

Pathogenesis:

• Originate in gallbladder or form de novo
• Retained stone after cholecystectomy

Question 8

How does choledocholithiasis manifest?

Answer 8

Asymptomatic (50%)

Biliary pain, jaundice

Question 9

What techniques can be used to diagnose a CBD stone?

Answer 9

RUQ U/S

Question 10

What labs can be used to determine the location of the stone?

Answer 10

Typical labs: transaminases >500, bilirubin >4

Question 11

What is the best method to remove it?

Answer 11

ERCP with sphincterotomy and stone extraction

Question 12

What is acute cholangitis?

Answer 12

Acute ascending cholangitis occurs when bacteria become trapped behind a gallstone that is lodged in the CBD;

Question 13

What constitutes Charcot’s triad and Reynold’s pentad?

Answer 13

Charcot’s triad is fever, jaundice and pain; Reynold’s pentad also includes shock and AMS

Question 14

What is the best medical management of this condition?

Answer 14

Cholecystectomy and ERCP/drainage of BT to remove stone after treating with antibiotics.

Best medical management:

• Broad-spectrum antibiotics
• – Amp/Gent, extended-spectrum
• – 3rd gen. cephalosporin
• Mandatory biliary drainage
• – Emergent if fevers >40 C, peritoneal signs, septic shock or bilirubin > 10

Question 15

What are the causes of an obstruction leading to cholangitis?

Answer 15

• CBD stone / stricture

- Neoplasm

Question 16

What is cholecystitis?

Answer 16

Inflammation of the gallbladder caused by an obstruction by a stone in the cystic duct, distention and inflammation, infection by bowel flora

Question 17

What is the clinical picture for cholecystitis?

Answer 17

RUQ pain, fever, leukocytosis

Pain is steady, unremitting, may radiate to right scapula
Nausea and vomiting, Dehydration

Question 18

What are the physical exam findings in a patient with cholecystitis?

Answer 18

• RUQ tenderness, decreased bowel sounds, guarding, tachycardia
• Positive Murphy’s sign

Question 19

What labs would you check in a patient with cholecystitis and what would the results be?

Answer 19

• Increased WBC with a left shift
• Increased bilirubin and alkaline phosphatase
• U/S- look for thick gall bladder wall, sludge, and stones

Question 20

What is the treatment for cholecystitis?

Answer 20

Antibiotics: Ampicillin-sulbactam and Metronidazole
Surgery: Cholecystectomy