Biliary tract diseases

Question 1

What are the biliary tract diseases?

Answer 1

Diverse spectrum of diseases affecting the biliary system (gallbladder, bile ducts and liver).

Question 2

Basic anatomy: the common hepatic duct.

Answer 2

The right hepatic duct and left hepatic duct leave the liver and join together to become the common hepatic duct.

Question 3

Basic anatomy: the cystic duct.

Answer 3

The cystic duct from the gallbladder joins the common hepatic duct halfway along.

Question 4

Basic anatomy: the pancreatic duct.

Answer 4

The pancreatic duct from the pancreas joins with the common hepatic duct further along.

Question 5

Basic anatomy: the ampulla of Vater.

Answer 5

When the common bile duct and the pancreatic duct join, they become the ampulla of Vater, which then opens into the duodenum.

Question 6

Basic anatomy: sphincter of Oddi.

Answer 6

The sphincter of Oddi is a ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions into the duodenum.

Question 7

Describe the 3 types of gallstones and their causes.

Answer 7

Stones form from supersaturation of bile, meaning they are either made of:

1. Cholesterol - large, often solitary; obesity and fatty diets, age, female sex
2. Pigment - small, friable, irregular, seen in haemolytic anaemia
3. Mixed - faceted (calcium salts, pigment + cholesterol) - made of both of the above

Question 8

What is biliary colic?

Answer 8

Gallbladder attack:
Intermittent right upper quadrant (RUQ) pain caused by gallstones irritating/blocking the bile ducts and temporarily obstructing drainage of the gallbladder.

It is the name given to the pain experienced from gallstones, it is not a condition itself!!

Question 9

Explain the pathophysiology of biliary colic.

Answer 9

Gallstones lodged in bile ducts -> temporary severe abdominal pain.
After meal, gallbladder contracts.
Gallstone ejected into cystic duct -> lodged -> gallbladder contract against lodged stone -> severe abdominal pain.
Pain subsides when gallstone dislodged.

Question 10

Give 4 causes of biliary colic.

Answer 10

1. Gallstones
2. Narrow bile duct
3. Pancreatitis
4. Duodenitis
5. Oesophageal spasms

Question 11

What can trigger biliary colic?

Answer 11

Eating a heavy meal especially one that is high in fat.

Question 12

Why do fatty foods trigger biliary colic?

Answer 12

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum.
CCK triggers contraction of the gallbladder, which leads to biliary colic.
Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.

Exams may test this mechanism, so it is worth remembering!!

Question 13

Give the 5 risk factors for biliary colic.

Answer 13

The 5Fs:
1. Fat (obesity)
2. Fertile (- more kids = increased risk of gallstones)
3. Forty (age >40)
4. Female
5. FHx

Question 14

Describe the pain of biliary colic.

Any other symptoms may occur?

Answer 14

Sudden onset, severe but constant, crescendo characteristic.

Severe, colicky epigastric or RUQ pain - increases.

Can radiate to right shoulder/scapula (epigastrium/back).

Other symptom:
- Nausea and vomiting

Question 15

What exactly is meant by ‘colicky’ pain?

Answer 15

Colicky pain is pain that ‘comes and goes’.

Question 16

Differential diagnoses of biliary colic.

Answer 16

Think of other causes of RUQ pain:
1. Cholecystitis and cholangitis (often progressions from untreated gallstones anyway).
2. IBD.
3. Pancreatitis.
4. GORD.
5. Peptic Ulcers.

Question 17

Diagnosis of biliary colic - the diagnostic test?

Answer 17

Abdominal Ultrasound - most useful for gallstone disease diagnosis:

1.Stones
2.Gallbladder wall thickness (inflammation)
3.Duct dilation (suggests distal blockage)

Question 18

More investigations for biliary colic.

Answer 18

1. FBC and CRP → look for inflammatory response suggesting cholecystitis
2. LFTs: Raised ALP → ALP is associated with biliary pathology.
3. Bilirubin and ALT usually normal.
4. Amylase → Check for pancreatitis as it can also give RUQ.

These tests are more to rule out the cholecystitis and cholangitis than to confirm gallstones. They alone are unlikely to derange many tests. Ultrasound is the diagnostic test.

Question 19

Treatment of biliary colic.

Answer 19

1. NSAIDs/Analgesia.
2. Optional laparoscopic cholecystectomy (gallbladder removal): as gallstones often recur.

Question 20

How can gallstones be removed from the gall bladder?

Answer 20

Laproscopic cholecystectomy.

Question 21

Define acute cholecystitis.

Answer 21

Acute inflammation of the gallbladder - 95% of cases involve a gallstone.

Question 22

Explain the pathophysiology of cholecystitis.

Answer 22

1. Stone is blocking the ducts - obstruction to gallbladder emptying.
2. Bile builds up, distending the gallbladder.
3. Vascular supply may be reduced from this distension.
4. Inflammation follows these events secondary to the retained bile, inflaming the gallbladder.

Question 23

Describe the presentation of cholecystitis - give 2 symptoms.

Answer 23

Generalised epigastric pain migrating to severe RUQ pain.
Signs of inflammation like a fever or fatigue.
Pain associated with tenderness and guarding from inflamed gallbladder and local peritonitis.

Symptoms:
1. RUQ pain which may radiate to right shoulder
2. Fatigue - inflammation

Signs:
Fever - inflammation
Positive Murphy’s Sign → Severe pain on deep inhalation with examiners hand pressed into the RUQ
Tenderness and guarding

Question 24

Describe the presentation of cholecystitis - give 3 signs.

Answer 24

Signs:
1. Fever - inflammation

2. Positive Murphy’s Sign → Severe pain on deep inhalation with examiners hand pressed into the RUQ
3. Tenderness and guarding

Question 25

Investigations for acute cholecystitis.

Answer 25

1. Blood tests - inflammatory markers:
   - Raised WCC (due to inflammation) and CRP (c-reactive protein)
   - Raised serum bilirubin, alkaline phosphatase and
   aminotransferase levels
2. Abdominal ultrasound:
   - Thick walled, shrunken gallbladder (due to inflammation)
   - Pericholecystic fluid
   - Stones
3. Physical abdominal examination:
   - RUQ tenderness
   - Positive Murphy’s sign: severe pain on taking a deep breath when examiner places 2 fingers on RUQ (where gallbladder is)

Question 26

Treatment for acute cholecystitis.

Answer 26

Conservative management before surgery:
1. IV Antibiotics e.g. e.g. CEFUROXIME or CEFTRIAXONE
2. Heavy analgesia - opiates
3. IV fluids
4. Nil by mouth

5. Cholecystectomy, if needed

Question 27

What 3 bacteria are associated with acute cholecystitis?

Answer 27

1. Klebsiella
2. Enterococcus
3. Escheria coli (E.coli)

(Antibiotics as per trust guidelines but are likely to be ones that target the 3 main pathogens).

Question 28

What differentiates biliary colic from acute cholecystitis?

Answer 28

Acute cholecystitis: is an inflammatory response!
Biliary colic: no inflammation

Question 29

Define ascending/acute cholangitis.

Answer 29

Ascending/acute cholangitis is an infection of the biliary tree and most often occurs secondary to common billed duct obstruction by gallstones (choledocholithiasis).

Acute inflammation and infection of bile duct due to common bile duct obstruction.

Question 30

What structure is being obstructed by gallstones if a patient has developed acute cholangitis?

Answer 30

Common bile duct

Question 31

Describe the clinical presentation of acute cholangitis.

Answer 31

Charcot’s triad:
1. RUQ pain
2. Jaundice - common bile duct blocked, bilirubin builds up
3. Fever with rigors/chills

Septic presentation - Hypotension/altered mental state
Reynolds pentad → Charcot’s triad + confusion + septic shock

Patient may present as septic and/or have developed some level of pancreatitis.

Jaundice is cholestatic, thus there is dark urine, pale stools and skin may itch.

Question 32

What is the triad of symptoms for acute cholangitis?

Answer 32

Charcot’s triad - jaundice, fever, biliary colic.

Question 33

What is Charcot’s triad? And what condition is it related to?

Answer 33

Charcot’s Triad:
1. RUQ pain
2. Jaundice - common bile duct blocked, bilirubin builds up
3. Fever with rigors/chills

Acute cholangitis.

Question 34

What is Reynold’s pentad? And what condition is it related to?

Answer 34

Reynolds pentad → Charcot’s triad + confusion + septic shock

Acute cholangitis.

Question 35

How would you tell that a gallstone had moved to obstruct the common bile duct?

Answer 35

Obstructive jaundice and acute cholangitis.

Question 36

What special test would you do on examination to confirm acute cholecystitis?

Answer 36

Murphy’s sign - 2 fingers over RUQ + ask patient to breathe in - causes pain and arrest of inspiration as inflamed gallbladder hits your fingers

Question 37

What is the gold standard investigation in acute cholangitis?

Answer 37

Transabdominal ultrasound - measure CBD dilatation.

Question 38

Investigations for acute cholecystitis.

Answer 38

1.Blood tests
* Elevated neutrophil count
* Raised ESR and CRP
* Raised serum bilirubin - bile duct obstruction if very high
* Raised serum alkaline phospahtase
* Aminotransferase levels are elevated; ALTs are higher then ASTs
normally

2. Blood cultures/MC&S
   - To work out what the pathogen is so you can use the trust’s advised antibiotics
3. Transabdominal Ultrasound:
   - Initial imaging choice
   - Dilatation of common bile duct
   - May or may not show cause of obstruction
   - Distal common bile duct stones are easily missed
4. ERCP
   - Endoscopic Retrograde Cholangiopancreatography
   - Basically a biliary tree contrast X-ray
   - Clearly shows biliary tree making detection of common bile duct
   stones and presence or dilated duct
   - Much more clearer to see

Question 39

describe the clinical features of chronic cholecystitis

Answer 39

chronic inflammation ± colic. flatulent dyspepsia - vague abdo discomfort, distension, nausea, flatulence and fat intolerance.

Question 40

how would you treat acute cholangitis?

Answer 40

laparoscopic cholecystectomy with IV abx - cefuroxime and metronidazole

Question 41

Describe the management of acute cholangitis.

Answer 41

1. Treat sepsis
2. IV fluid
3. IV antibiotics e.g. cefotaxime and metronidazole
   - continued after biliary drainage until symptom resolution
4. Urgent ERCP
   - Urgent biliary drainage using ERCP with sphincterotomy (cutting of biliary sphincter)
5. Stenting
   - To mechanically clear the blockage, surgery/cholecystectomy possible
6. Surgery/cholecystectomy is required for large stones

Question 42

What is the difference between ascending cholangitis and acute cholecystitis?

Answer 42

A patient with acute cholecystitis would not have signs of jaundice!

Question 43

Give 4 potential complications of gallstones in the bile duct.

Answer 43

1. Biliary pain.
2. Obstructive jaundice.
3. Cholangitis (infection of the biliary tract).
4. Pancreatitis.

Question 44

Give a complication of gallstones in the gut.

Answer 44

Gallstone ileus.

Question 45

Give 3 complications of gallstones in the gallbladder and the cystic duct.

Answer 45

1. Biliary colic
2. Acute cholecystitis
3. Empyema - gallbladder fills with pus
4. Carcinoma
5. Mucocoele
6. Mirizzi’s syndrome - stone in gallbladder presses on bile duct, causing jaundice

Question 46

Compare the presentation of biliary colic, acute cholecystitis and acute cholangitis.

Answer 46