Biliary Disease

Key Definitions

  • Cholestasis: blockage to the flow of bile
  • Cholelithiasis: gallstone(s) present
  • Choledocholithiasis: gallstone(s) in the bile duct
  • Biliary colic: Intermittent right upper quadrant pain caused by gallstones irritating bile ducts
  • Cholecystitis: Inflammation of the gallbladder
  • Cholangitis: Infection and obstruction of the biliary system
  • Gallbladder empyema: Pus in the gallbladder
  • Cholecystectomy: Surgical removal of the gallbladder
  • Cholecystostomy: inserting a drain into the gallbladder


Gallstone Risk Factors (4 Fs)

  • Fat
  • Fair
  • Female
  • Forty


Investigating / Managing Gallstone Disease (Stepwise Process)

  1. Liver function tests and ultrasound
    • Indicated for investigating symptoms of gallstone disease (i.e. abdominal / right upper quadrant pain, jaundice)
    • Ultrasound is the most sensitive initial test for gallstones (CT scans are not good at identifying gallstones/biliary disease)
    • Ultrasound is limited by the patient’s weight, gaseous bowel obstructing the view and patients discomfort with probe.
  2. MRCP (Magnetic Resonance Cholangio-Pancreatography)
    • Indicated if USS doesn’t show ductal stones but the is bile duct dilitation or raised bilirubin
    • An MRI scan that produces detailed image of the biliary system
    • Very sensitive and specific for biliary tree diseases (e.g. ductal stones / malignancy)
  3. ERPC (Endoscopic Retrograde Cholangio-Pancreatography)
    • Indicated for established CBD stones / obstructing ductal tumours on USS or MRCP
    • An endoscopy (via mouth) down to the sphincter of Oddi (CBD opening)
    • Allows for treatment of CBD stones / stricture dilitation / biopsy of malignant areas
  4. Cholecystectomy
    • Indicated where symptomatic / problematic gallbladder stones are established in a patient fit for surgery
    • Removal of the gallbladder
    • If stone/s in the bile ducts, they must be removed prior to cholecystectomy


Ultrasound Findings

  • Acute cholecystitis: thickened gallbladder wall, stones / sludge in gallbladder and fluid around the gallbladder
  • Gallstones in the gallbladder
  • Gallstones in the ducts
  • Bile Duct Dilatation (Upper limit of normal is 6mm plus 1mm for every decade after 60)


Liver Function Tests Relating the Biliary Tree

  • Raised bilirubin (jaundice)
    • Represents an obstruction to flow along the bile duct
    • May be gallstone in the bile duct or an obstructing mass (e.g. cholangiocarcinoma / head of pancreas tumour)
  • Raised Alkaline Phosphatase (ALP)
    • Non-specific marker
    • Consistent with cholestasis in presence of RUQ pain and/or jaundice
    • Can also be cause by liver or bone metastasis, primary biliary cirrhosis, Paget’s disease or many other things
  • Raised aminotransferase (ALT/AST)
    • Markers or hepatocellular injury
    • Expect a slight rise in obstructive jaundice but if very high vs ALP more indicative of hepatocellular process
    • Consider a full liver screen if rise greater than ALP


Acute Cholecystitis

  • Murphy’s sign:
    • RUQ tenderness exacerbated by deep inspiration
    • Place hand in RUQ and apply pressure
    • Ask patient to take deep breath in
    • Gallbladder will move downwards under your hand and cause pain
  • Inflammation of the wall of the gallbladder
  • Majority caused by gallstones (calculous cholecystitis)
  • Minority have other causes e.g. injury during surgery or septicaemia (acalculous cholecystitis)
  • Treatment with fasting, fluids, antibiotics (if evidence of infection) and eventual laparoscopic cholecystectomy


Gallbladder Empyema

  • Infected tissue and pus in gallbladder
  • Treatment by cholecystectomy: inserting a drain into the gallbladder to drain an gallbladder empyema


Acute Cholangitis

  • Infection Biliary Obstruction
  • Diagnosis based on Charcot’s triad: Right Upper Quadrant Pain, Fever, Jaundice
  • High mortality due to sepsis / septicaemia
  • Requires antibiotics, treatment of sepsis and mechanical intervention
  • Mechanical intervention to relieve obstruction
    • ERCP
    • PTC (see below)


ERCP Procedure

  • Colangio-Pancreatography: retrograde injection of contrast into duct through sphincter of Oddi and xray images to visualize biliary system
  • Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal
  • Stone removal: a basket can be inserted and pulled through the CBD to remove stones
  • Balloon dilatation: a balloon can be inserted and inflated to treat strictures
  • Biliary stenting: a stent can be inserted to maintain a patent bile duct (if strictures or tumours)
  • Biopsy: a small biopsy can be taken to diagnose obstructing lesions
  • Notable complications: bleeding, pancreatitis, infection.


Percutaneous Transhepatic Cholangiography (PTC)

  • Involves radiologically guided insertion of a needle / drain through the skin and liver into the bile ducts
  • Contrast can be injected into the biliary system to get xray images to visualize the system
  • Internal bile duct stents can be inserted to relieve strictures
  • An external drain can be left in to allow bile to drain externally and bypass a biliary obstruction



  • Removal of the gallbladder
  • Offered to people with symptomatic / problematic gallstones
  • Most frequently done laparoscopically unless difficult procedure
  • Day case procedure
  • Not usually done “hot” – usually wait 6 weeks or so after cholecystitis for inflammation to reduced prior to removing
  • Notable complications: chronic diarrhoea
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