Diseases of the Biliary Tree

Question 1

What does cholelithiasis refer to?

Answer 1

Stones in the gallbladder

Question 2

What does choledocolithiathis refer to?

Answer 2

Stones in the ducts

Question 3

What should you do if you see some stones in a gallbladder of an asymptomatic patient?

Answer 3

Leave them alone.

Question 4

Describe biliary colic? (Location, radiation, duration, etc.)

Answer 4

Rapid onset, severe, steady RUQ pain.
Radiation to R shoulder or scapula common.
Duration >15 up to several hours.
(Provoked by fatty foods is suggestive but not specific.)

Question 5

What do you do with a patient who comes in with the first occurrence of symptomatic gallstones?

Answer 5

Watch and wait - because the pain might never come back, and delaying surgery doesn’t cause problem.
(note - only if these stones are definitely just in the gallbladder)

Question 6

What is cholecystitis?

Answer 6

Inflammation of gallbladder with obstructed cystic duct, +/- infection.

Question 7

What is the classic presentation of acute cholescystitis? (it’s a triad)

Answer 7

RUQ pain
Fever
Leukocytosis

Question 8

What feature on imaging is highly suggestive of cholecystitis?

Answer 8

Thickened gallbladder wall.

Question 9

What should you do for a patient with acute cholecystitis?

Answer 9

Cholecystectomy right away.

Don’t just watch and wait when there’s fever and leukocytosis.

Question 10

Imaging test for cystic duct obstruction?

Answer 10

99-Tc labeled “HIDA” radioscan….

Liver takes up stuff, should see it see fill up gallbladder. Non-filling gallbladder shows cystic duct obstruction.

Question 11

Can gallstones kill you?

Answer 11

Yes, They can cause cholangitis that leads to sepsis.

Question 12

Where do the bacteria that cause cholangitis tend to come from?

Answer 12

Portal circulation.

Question 13

What is Charcot’s triad for cholangitis?

Answer 13

Fever
RUQ pain
Jaundice
(Can progress to confusion and hypotension

Question 14

What’s the treatment for cholangitis?

Answer 14

ABx and duct clearance, usually via ERCP.

Question 15

Why is MRCP preferable to ERCP if you’re just doing diagnostic imaging?

Answer 15

Injection of the ERCP contrast into the pancreatic duct can cause pancreatitis.

Question 16

What does ERCP removal of a bile duct stone involve?

Answer 16

Sphincterotomy - widen the sphincter of Oddi.

Remove the stone - either grab with basket, or snake catheter past it then inflate balloon and pull out.

Question 17

Most gallstone pancreatitis resolves with supportive care. But what are 2 circumstances must you do ERCP right away?

Answer 17

Severe acute pancreatitis.

“Evidence of ongoing biliary obstruction” (meaning… it doesn’t clear on its own.)

Question 18

Even if a stone causing gallstone pancreatitis clears, what must be done later?

Answer 18

Cholecystectomy, because the stones will recur.

Question 19

Which are more likely to cause pancreatitis: large stones or small stones in the gallbladder?

Answer 19

Small stones - they’re more able to get out and cause trouble.

Question 20

What’s a surgical way to prevent sequelae of biliary sludge?

Answer 20

Sphincterotomy - make it easier for any stuff formed to get out.

Question 21

Should you take out asymptomatic common bile duct (CBD) stones?

Answer 21

Yep.

Question 22

What’s the double-duct sign?

Answer 22

Both CBD and pancreatic duct occluded - strongly suggestive of cancer.

Question 23

What palliative treatment can be done for duct occlusions caused by malignancy?

Answer 23

Stents placed in the ducts.

Plastic ones can clog… self-expanding metallic stents are perhaps better.

Question 24

Treatment for benign biliary strictures?

Answer 24

Balloon dilatation.

Question 25

Say a gun shot wound causes a bile leak seen on ERCP. What’s the treatment? Why does that work?

Answer 25

Stent and/or sphincterotomy.
By creating a path of least resistance, bile will drain into the duodenum instead of into the peritoneum and cause peritonitis.

Question 26

Review: What’s primary sclerosing cholangitis? How do you diagnose it?

Answer 26

Autoimmune-mediated inflammation, fibrosis, and stricturing of biliary tree.
Cholangiogram will show “beads on a string.”

Question 27

Main treatments for PSC? Goal of treatment?

Answer 27

Ursodiol, ABx (if necessary)
Dilation, stenting.
Liver transplant
Goal = Keep patient alive until transplantation.

Question 28

What do you want to rule out if you think something looks like PSC?

Answer 28

Cholangiocarcinoma - and note that PSC increases the risk for it.

Question 29

Review: With what other autoimmune disease is PSC strongly associated?

Answer 29

IBD, especially UC.