Lecture 38: Diseases of the Biliary Tree

Question 1

What are the complications of gallstones?

Answer 1

1. Asymptomatic stone if in the gallbladder
2. Stone intermittently obstructing cystic duct, causing intermittent biliary colic if it is at the mouth of the gallbladder
3. Stone impacted in cystic duct, causing acute cholecystitis
4. Stone in cystic duct compression common bile duct causing MIRIZZI syndrome
5. Stone impacted in distal common bile duct, causing jaundice, biliary colic-type pain, and risk of ascending cholangitis or acute biliary pancreatitis
6. Stone eroding through gallbladder into duodenum, resulting in cholecystenteric fistula
7. . Long-standing cholelithiasis, resulting in gallbladder carcinoma

Question 2

What is the epidemiology of gallstones?

Answer 2

8-10% of adult population

More females

Question 3

What are the two types of gallstones?

Answer 3

1. cholesterol stones
   
   • risks = the 4 F’s
2. pigment stones
   
   • infection, cirrhosis and hemolytic anemia

Question 4

What is cholelithiasis?

Answer 4

Gallbladder stones

Question 5

Out of the adult population that has gallstones, how many are symptomatic?

Answer 5

10-20%

Question 6

What is biliary colic?

Answer 6

Colic = a crampy pain that comes and goes
But this is actually a steady pain
-crescendos
-at the right upper quadrant or epigastric
Rapid onset, severe, steady pain
Radiation ot R shoulder or scapula
Remember that this is NOT RELIEVED by position change, antacids, flatus, etc.

Question 7

What is the pathophysiology of biliary colic?

Answer 7

Pain is caused by gallstone that is wedged at the neck of the gallbladder and the junction of the cystic duct and hepatic ducts

Question 8

When is CCK secreted?

Answer 8

When fatty food is ingested

Question 9

What is suggestive of biliary colic?

Answer 9

Fatty food intolerance is suggestive

Question 10

What are the characteristics of Acute cholecystitis?

Answer 10

An uncommon complication of cholelithiasis

Obstructed cystic duct + some other irritant factor that leads to inflammatory release

Question 11

What is the classic presentation of acute cholecystitis?

Answer 11

1. RUQ pain
2. Fever
3. Leukocytosis
   Is emergent because gallbladder can progress to risk of gangrene, perforation and sepsis

Question 12

How do you diagnose acute cholecystitis?

Answer 12

Use HIDA radioscans
Radiolabeled technesium compound is injected to see where the bile is taken up (you will not see shit to go into the gallbladder if you have blocked cystic duct)

Question 13

What is the pathophysiology of bacterial cholangitis?

Answer 13

Stasis due to biliary obstruction raises intrabiliary pressure
Intrabiliary pressure promotes migration and colonization nof bacteria from the portal circulation into the biliary tract

Question 14

What is cholangitis?

Answer 14

Inflammation of the COMMON BILE DUCT ninjaaaa

Question 15

What are the presentations of cholangitis?

Answer 15

1. Charcot’s triad
   i. fever
   ii. RUQ pain
   ii. Jaundice
   Can progress to confusion and HYPOtension
   You don’t get jaundice unless you block the common bile duct

Question 16

What is the treatment for bacterial cholangitis?

Answer 16

Antibiotics and duct clearance

Question 17

What is ERCP?

Answer 17

Endoscopic Retrograde CholangioPacreatography

Used to access biliary and pancreatic ducts for diagnostic AND therapeutic procedures

Question 18

What is better for diagnostic study?

Answer 18

MRCP rather than ERCP
MRCP has 0 risk of pancreatitis
ERCP may cause pancreatitis

Question 19

What are the characteristics of gallstone pancreatitis?

Answer 19

When the stone blocks the pancreatic duct
This makes pancreas become inflamed because the shit builds up in pancreas
Common cause of severe aucte pancreatitis
Need to ultimately have a cholecystectomy to prevent future complications

Question 20

What is the risk of pancreatitis with gallstones?

Answer 20

Small stones = higher risk

Bigger risks = smaller risk (cuz wont go through cystic duct)

Question 21

What is biliary sludge?

Answer 21

Mucoprotein and cholesterol cystals
Precursor of gallstones
Cause of indiopathic pancreatitis
Formed when stasis is present

Question 22

What are the types of biliary strictures (malignant)?

Answer 22

1. pancreatic head carcinoma
2. Cholangiocarcinoma (bile duct cancer)
3. ampullary tumor
4. Nodal compression
5. Gallbladder carcinoma

Question 23

What is double duct sign?

Answer 23

When there are two ducts going into a mass (the common bile and pancreatic duct) and emerging from the other side of the mass
Indicative of pancreatic head carcinoma

Question 24

What are the types of benign biliary strictures?

Answer 24

1. trauma
2. postoperative
3. post-liver transplant
4. bile duct leaks
5. chronic and pancreatitis
6. PSC

Question 25

How do you prevent a bile leak?

Answer 25

By putting in a stent that opens the sphinter of Oddi and reverse pressure gradient so less flows into the small intestin

Question 26

By putting in a stent that opens the sphinter of Oddi and reverse pressure gradient so less flows into the small intestine

Answer 26

Associated with IBD (UC>CD) | -inflammation of the common bile duct, fibrosis, structuring

Question 27

What are the genetics of PSC?

Answer 27

HLA-B8

Question 28

What are the immunological characteristics of PSC?

Answer 28

P-ANCA is often found

Question 29

What are the symptoms of PSC?

Answer 29

Abnormal LAEs (cholestatic) Fatigue, pruritus, fever, RUQ pain ONION SKINNING

Question 30

What is choledocolithiasis?

Answer 30

Gallstones in the bile duct

Question 31

What are the key points about choledocolithiasis?

Answer 31

should be cleared ideally with ERCP due to risk of complications (cholangitis, biliary pancreatitis…these complications refer to complications of disease not ERCP

Question 32

What are the potential complications of gallstones?

Answer 32

i. cholecystitis (cystic duct obstruction, requires urgent attention, cholecystectomy) ii. cholangitis (bacterial infection of the bile duct due to lodged stone, medical emergency, antibiotics and ERCP iii. Biliary pancreatitis (ampullary stone causing transient obstruction of PD, CysticBileDuct must ultimately be cleared as well)

Question 33

What is the treatment for cholangitis?

Answer 33

Cholycystectomy should follow an episode of cholangitis or biliary pancreatitis to prevent future complications

Question 34

What are the key points for Primary Sclerosing Cholangitis?

Answer 34

A. Progressive cholestatic biliary STRICTURING disease with classic appearance on cholangiography (alternating areas of stricture and dilation) B. Has an association with IBD C. Increased risk of bile duct cancer (cholangiocarcinoma) D. Can lead to cirrhosis (end stage liver disease) requiring liver transplant E. biliary strictures and episodes of cholangitis can be treated endoscopically