Pathology of the Biliary System

Question 1

Post-cholecystectomy

Answer 1

The gallbladder is a reservoir for bile, which is stores until fatty food and CCK trigger it to contract and release bile into the duodenum

• CHD up to 4mm
• CBD up to 6mm, or 1mm for each decade of life after 60

Post-cholecystectomy changes:
If recent surgery, could have residual hematoma or seroma
Enlargement of CHD and CBD – can be up to 10mm
Can still get cholelithiasis and pneumobilia (see later in this lecture for both of these)

Question 2

Choledocholithiasis

Answer 2

Calculi within the bile duct
Can be anywhere in the biliary tree – RHD, LHD, CHD, CD, CBD

Primary choledocholithiasis:
Calculi form within the bile ducts

Secondary choledocholithiasis:
Calculi moved into biliary tree from the gallbladder

Question 3

Bile duct obstruction

Answer 3

• Most common cause is a calculus or mass within the biliary tree or at the end of the biliary tree, blocking the flow of bile
• Dilatation can be intrahepatic, extrahepatic, or both, depending on where the blockage is
• Also seen in pancreatic conditions – pancreatitis, tumours, etc.
• Diagnosis of bile duct obstruction is made using sonography – train track / shotgun sign

Question 4

Cholangitis

Answer 4

Inflammation of the bile ducts / biliary tree

Acute (ascending) cholangitis:

• Bacterial infection rising up along biliary tree as a result of biliary stasis and an obstruction
• Most commonly from calculi, but can be from stricture or malignancy
• Strictures – congenital, post-infectious (AIDS cholangitis), or inflammatory (primary sclerosing cholangitis)
• Malignancies – gallbladder, bile duct, ampulla, duodenum, pancreas
• Charcot’s Triad&raquo_space; Reynold’s pentad

Question 5

Cholangiocarcinoma

Answer 5

Bile duct cancer
Usually arises in extrahepatic bile duct
Rare, but aggressive – 5 yr. SR 30%
Comprise of about 10-20% of 1o liver cancers
Increased risk with history of chronic liver diseases and PHx choledochal cyst

S&S:
Abdo pain, jaundice, weight loss, generalised itching, fever

Question 6

Pneumobilia

Answer 6

• The presence of air in the biliary tree
• Common finding in people who have recently undergone either biliary surgery or an endoscopic biliary procedure

Other causes: incompetent sphincter of Oddi, emphysematous cholecystitis (why would this be a cause?), fistula between the bowel and the biliary tree (recurrent bouts of acute cholecystitis or peptic ulcer disease).

Question 7

Choledochal cysts

Answer 7

• Rare congenital anomalies involving a cystic distention of the bile ducts
• Different classifications
• Inflammatory&raquo_space; can lead to cholangitis or pancreatitis
• Treatment – surgical removal

Question 8

Caroli’s disease

Answer 8

• Rare congenital anomalies involving cystic dilatation of the intrahepatic biliary tree
• Cystic dilatation of the intrahepatic bile ducts
• Inflammatory&raquo_space; can lead to cholangitis or pancreatitis
• Treatment – surgical removal

Question 9

Ascariasis

Answer 9

• Ascariasis is caused by a round worm, Ascaris lumbricoides
• Come up through the Sphincter of Oddi into the biliary tree
• Worms may be 20-30cm long, and 6cm in diameter!