Diseases of the Biliary Tree

Question 1

What is cholelithiasis?

Answer 1

Gallbladder stones.

Question 2

What is choledocolithiasis?

Answer 2

Bile duct stones.

Question 3

What is biliary colic?

Answer 3

(1) Rapid onset, severe, steady RUQ or epigastric pain.
(2) Radiation to the R shoulder or R scapula.
(3) Duration is 15 min to several hours.
(4) Not relieved by position change, antacids, or flatus.
(5) Associated with fatty food intolerance.

Question 4

What is the clinical presentation of acute cholecystitis?

Answer 4

(1) RUQ pain
(2) fever
(3) leukocytosis

Question 5

What are complications of acute cholecystitis?

Answer 5

(1) gangrene
(2) perforation
(3) sepsis

Question 6

What is the pathophysiology of acute cholecystitis?

Answer 6

(1) Obstruction of the cystic duct.

(2) Irritant factor leads to inflammatory mediator response and the propagation of inflammation in the gallbladder.

Question 7

How is acute cholecystitis treated?

Answer 7

Cholecystectomy.

Question 8

What is the pathogenesis of bacterial cholangitis?

Answer 8

(1) Bile duct obstruction leads to stasis, raising intrabiliary pressure.
(2) This promotes migration and colonization of bacteria from the portal circulation into the biliary tract.

Question 9

What is Charcot’s triad?

Answer 9

(1) fever
(2) RUQ pain
(3) jaundice

Question 10

What is the clinical presentation of bacterial cholangitis?

Answer 10

(1) Charcot’s triad
(2) confusion
(3) hypotension

Question 11

How is bacterial cholangitis treated?

Answer 11

(1) antibiotics

2) duct clearance (often using ERCP

Question 12

What is the surgical procedure for the removal of stones from the bile duct?

Answer 12

An ERCP is performed, followed by an endoscopic sphincterotomy, cutting the sphincter of Oddi. A catheter with a basket or balloon tip is inserted into the bile duct to retrieve the stones.

Question 13

What factors increase the risk of gallstone pancreatitis in a patient with cholelithiasis?

Answer 13

(1) wide cystic duct

(2) multiple, small gallstones

Question 14

What risk factors for biliary sludge?

Answer 14

(1) pregnancy
(2) TPN
(3) starvation
(4) weight loss

Question 15

How are patients with asymptomatic common bile duct stones managed?

Answer 15

Removal of stones, due to the risk of bacterial cholangitis and gallstone pancreatitis.

Question 16

How are patients with asymptomatic gallbladder stones managed?

Answer 16

Monitor.

Question 17

How are biliary strictures treated?

Answer 17

Insertion of a fixed-diameter plastic stent or self-expanding metallic stent into the bile duct. Balloon dilatation can also be performed in some cases.

Question 18

What is the primary complication with fixed-diameter plastic stents?

Answer 18

Occlusion with:

(1) bacteria
(2) bacterial glycocalyx
(3) calcium bilirubinate
(4) calcium palmitate
(5) insoluble dietary fiber

Question 19

What are causes of biliary strictures?

Answer 19

(1) mass effect from tumor
(2) bile duct injury (trauma, post-operative, post-liver transplant)
(3) chronic pancreatitis
(4) PSC

Question 20

What is the pathogenesis of PSC?

Answer 20

Unknown.

Question 21

What test is performed in order to diagnose PSC?

Answer 21

Cholangiogram.

Question 22

How does PSC appear on cholangiogram?

Answer 22

Multifocal stricturing of varying lengths and dilation of intrahepatic and/or extrahepatic bile ducts.

Question 23

How is PSC treated?

Answer 23

(1) ursodiol and antimicrobials
(2) stenting or dilation of strictures
(3) liver transplant