Biliary Tract Disease

Question 1

What are the symptoms of gallstones?

Answer 1

Mostly asymptomatic

Colic

Question 2

What ar the complications of gallstones?

Answer 2

Cholecystitis 
Jaundice 
Cholangitis 
Acute Pancreatitis 
Gallstone Ileus = Bowel Obstruction

Question 3

What are the risk factors for Gallstones?

Answer 3

Over 40 
Female 
High fat diet
Obesity 
Pregnancy 
Hyperlipidaemia
Bile salt loss (Crohn's) 
Diabetes
Dysmotility of GB 
Prolonged fasting 
Total parenteral nutrition

Question 4

What is the pathogenesis of gallstones?

Answer 4

Abnormal bile composition

Bile stasis and infection

Question 5

What are the different types of gallstones?

Answer 5

Cholesterol stones
Pigment stones (excess billirubin due to haemolysis)
Mixed stones (most common)
Primary bile duct stones (very rare)

Question 6

What are the features of biliary colic due to gallstones?

Answer 6

Stones impact in cystic duct 
Gradual build up of RUQ pain 
Radiates to back/shoulder 
May last 2-6 hours 
Associated with indigestion/nausea

Question 7

What is the differential for several acute epigastric pain?

Answer 7

Biliary colic 
Peptic ulcer disease 
Oesophageal spasm 
MI 
Acute pancreatitis

Question 8

What are the key steps for investigating gallstones?

Answer 8

Ultrasound

MRCP

Question 9

What is the treatment for biliary colic?

Answer 9

Pain killers
Low fat diet, lose weight if obese
Observe for 3-6 months
Consider surgery referral of pain/colic is still recurrent

Question 10

Which elective surgery may be performed for symptomatic gallstones?

Answer 10

Laparoscopic cholecystectomy

Question 11

What is acute cholecystitis?

Answer 11

Inflammation in the gallbladder due to obstruction of the cystic duct
Initially sterile, then becomes infected

Question 12

What is the treatment of acute cholecystitis?

Answer 12

IV antibiotics and IV fluids
Nil by mouth
US to confirm
Urgent cholecystectomy (usual) or interval cholecystectomy

Question 13

How does a gallstone ileus occur?

Answer 13

Big gallstone gets into the intestine, blocks distal ileum and causes bowel obstruction
Generally due to the existence of a fistula between the ileum and duodenum

Question 14

When might gallstones cause jaundice?

Answer 14

When they block the common bile duct

Question 15

How might gallstones be removed from the CBD?

Answer 15

ERCP

Surgical if very large

Question 16

What is the difference between an MRCP and ERCP?

Answer 16

MRCP = diagnosis
ERCP = treatment

Question 17

What is the treatment for gallstone ileus?

Answer 17

Urgent laparotomy

Interval cholecystectomy in 3 months (not in elderly or frail)

Question 18

What is cholangitis?

Answer 18

Bile duct infection

Question 19

What is cholangiocarcinoma?

Answer 19

Second most common hepatobiliary cancer

Question 20

What is the clinical presentation of cholangiocarcinoma?

Answer 20

Jaundice
Weight loss
Anorexia 
Lethargy 
Often late, and so lymph node and distant metastases present

Question 21

How is a cholangiocarcinoma staged?

Answer 21

US
CT/ERCP/PTC
MRI/MRCP/MRA

Question 22

What curative surgery exists for cholangiocarcinoma?

Answer 22

Surgical resection of bile duct and liver

Question 23

What palliative treatment exists for cholangiocarcinoma?

Answer 23

Biliary stent

Question 24

Charcot’s Triad

Answer 24

Associated with acute cholangitis
Fever
Jaundice
Abdominal pain

Question 25

What are the symptoms of acute cholangitis?

Answer 25

Continuous epigastric or right upper quadrant pain
Vomiting 
Fever 
Peritonism 
Gall Bladder Mass