Biliary Tract Disease

Question 1

Presentation of gallstones?

Answer 1

Most are asymptomatic, with impacted gallstones presenting:
Biliary colic
Cholecystitis
Jaundice
Pancreatitis 
Bowel obstruction

Question 2

Causes of gallstones?

Answer 2

Abnormal bile composition
Bile stasis
Infection
Excess cholesterol or bilirubin

Question 3

Types of gallstones?

Answer 3

Mixed (80%)
Cholesterol (10%)
Pigment (black - 10%)
Primary bile duct stones (rare)

Question 4

Risk factors for gallstones?

Answer 4

Age >40 
Female
High fat diet
Obesity
Pregnancy
Hyperlipidaemia

Bile salt loss, e.g: in Crohn's
Diabetes
Dysmotility of GB
Prolonged fasting
TPN

Question 5

What are the five Fs?

Answer 5

Female, fair, fat, fertile, forty

Question 6

Why does biliary colic occur and describe the pain?

Answer 6

Stone impacts in cystic duct and spasm occurs; there is gradual build-up pain in the RUQ that radiates to the back or shoulder

This may last for 2-6 hours; it is associated with indigestion/nausea

Question 7

Causes of acute severe epigastric pain?

Answer 7

Biliary colic
Peptic ulcer disease
Oesophageal spasm
MI
Acute pancreatitis

Question 8

What is acute cholecystitis?

Answer 8

Inflammation in the gall bladder, usually due to obstruction of the cystic duct; this is initially sterile, then becomes infected

Presents with fever and positive Murphy’s sign

Question 9

Diagnosis of gallstones?

Answer 9

Ultrasound 
CT scan
MRCP (diagnosis) / ERCP (remove gallstones)
HIDA
EUS

Question 10

Treatment of acute cholecystitis?

Answer 10

IV antibiotics and IV fluids

Urgent cholecystectomy
Sometimes, surgeon, will do an interval cholecystectomy (antibiotics and then, 6 months later, elective admission - allows inflammation to settle)

Question 11

Complications of gallstones?

Answer 11

Stones may migrate into common bile duct, potentially causing:
Jaundice
Itching
Anorexia 
Cholangitis
Acute pancreatitis

Gallstone ileus - gallstones can enter small intestine and reach ileum, causing bowel obstruction

Question 12

Diagnosis of common bile duct pathology?

Answer 12

MRCP is used

Abnormal LFTs

Question 13

Treatment of gallstones?

Answer 13

Give patient pain killers; tell them to follow a low-fat diet and lose weight, if they are obese. Observe them for 3-6 months; if still symptomatic:

ERCP (ES + stone removal)
Symptomatic gallstones treated by removal of the gallbladder (laparascopic cholecystectomy)

For those who are unfit for surgery, ursodeoxycholic acid (10 mg/kg/day) to bind bile salts

Question 14

Main causes of acute pancreatitis?

Answer 14

Alcohol

Gallstones

Question 15

Mechanism of acute pancreatitis?

Answer 15

Auto-digestion of peri-pancreatic tissue by activated enzymes

Question 16

How does a gallstones ileus occur?

Answer 16

Fistula from the gallbladder to the duodenum allows a large gallstone to pass into the small intestine

This moves down small bowel causing intermittent colic; presents with distal small bowel obstruction

Question 17

Treatment of gallstone ileus?

Answer 17

Urgent laparotomy - small bowel enterotomy to remove stone (hole made in small bowel to squeeze gallstone out; hole is sealed up)

Interval cholecystectomy in 3 months

Question 18

What is cholangiocarcinoma?

Answer 18

Malignancy of the cholangiocarcinoma; second most common hepatobiliary cancer

Question 19

Presentation of cholangiocarcinoma?

Answer 19

Jaundice
Weight loss
Anorexia
Lethargy

Lymph node metastases
Peritoneal metastases at diagnosis

Question 20

Methods of staging/assessing cholangiocarcinoma?

Answer 20

Duplex ultrasound
Spiral CT / ERCP / PTC

MRI / MRCP / MRA

Question 21

Treatment of cholangiocarcinoma?

Answer 21

Surgical resection is the only
curative option

For palliation - a biliary stent can be placed

Question 22

Describe Murphy’s sign

Answer 22

Patient breathes out and doctor gently places hand below the costal margin, on the right side at the mid-clavicular line (the approximate location of the gallbladder); patient is then instructed to inspire.

Normally, during inspiration, the abdominal contents are pushed downward, as the diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s fingers) and winces with a ‘catch’ in breath, the test is considered positive

In order for the test to be considered positive, the same maneuver must not elicit pain when performed on the left side