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

Cholecystectomy

• 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