Biliary Disorders

Bile

  • Bile pigments (bilirubin & biliverdin) + cholesterol + phospholipids, ions, amino acids ➔ bile acid

    • Primary bile acids are produced in liver and stored in gallbladder

    • Secondary bile acids are produced in intestine by bx

  • Fat absorption (and fat soluble vitamins)

  • Cholesterol and bilirubin excretion

Gall Stones

Cholesterol stones (MC)

  • Excess cholesterol or ↓ bile secretion

  • Female, Fat, Fertile, Forty, Fibrates, Family hx

  • Pregnancy (↑progesterone) ➔ ↓ gallbladder contraction ➔ stasis

  • Mostly radiolucent

Black pigment stones

  • Hemolytic anemia ➔ ↑ bilirubin

  • Radiolucent

Brown (mixed) pigment stones

  • Biliary infxn ➔ bilirubin and bile breakdown

  • Radiopaque

Cholelithiasis

Calculous (MC) - gallstone obstruction in cystic duct

SSX - Usually incidental finding or ASX

  • Biliary colic - dull but intense RUQ discomfort that stops after ~ 6hrs

    • Biliary colic is not colicky... it's constant

  • Boas sign - Irritated phrenic nerve ➔ referred right shoulder blade pain

  • Belching, nausea, fullness (especially after high fat food)

TX

  • Avoid HFF, elective cholecystectomy

Acute Cholecystitis

  • Calculous (MC) - gallstone obstruction in cystic duct ➔ infection (MC E. coli, or other Gram NEG)

    • Acute cholecystitis ➔ chronic cholecystitis - calcification (radiopaque) ➔ porcelain GB , ↑↑ RF for GB cancer

  • Acalculous - really sick inpt ➔ NPO ➔ GB stasis ➔ inflammation & distention ➔ infxn

  • Emphysematous - infxn with Clostridium or other gas forming bx ➔ air in GB wall

SSX

  • RUQ pain (especially after HFF) ± radiation to right scapula (Boas sign)

  • Fever & ↑ WBC

  • Positive Murphy sign: Deep palpation of RUQ during inspiration ➔ ↑ pain & cessation of inspiration

DX

  • RUQ US first, shows distended GB with double-wall (edema hyperechoic inner and outter wall, hypoechoic in between)

  • HIDA scan (gold standard) Hepato-imino-diacetic Acid Scintigraphy

    • Within 4 hours (or 30 min with morphine)

      • Radiotracer should be visualized in normal GB within 30 mins - 4 hours

      • Morphine ➔ ↑ sphincter of Oddi pressure ➔ more tracer entering GB quicker

TX

  • NPO & empiric ABX (metronidazole and cephalosporin)

  • Cholecystectomy (laparoscopic > open; open if hx of ABD surgeries)

  • Cholecystostomy (percutaneous drainage) if too sick for surgery

Choledocholithiasis

  • Primary: stones formed in common bile duct

  • Secondary (MC): GB stone ➔ common bile duct obstruction ➔ stasis of biliary tract

  • Complication 2-3yrs s/p cholecystectomy

SSX

  • RUQ pain/tenderness, N/V

  • ± Jaundice & enlarged GB (Courvoisier's sign) MC in neoplasm blocking CBD

DX/TX

  • Obstruction ➔ ↑ ALP, ↑ GGT, ↑AST/ALT, ↑ bilirubin

  • RUQ US first

  • MRCP (magnetic resonance cholangiopancreatography) low-int risk

  • ERCP (endoscopic retrograde cholangiopancreatography) with stone removal

  • Cholecystectomy if GB dz

Cholangitis

  • Choledocholithiasis ➔ infection (MC E. coli, or other Gram NEG)

  • Can be from other obstruction (acute pancreatitis, PSC, post-ERCP)

SSX

  • Charcot triad: RUQ pain, fever (↑ WBC) , jaundice

  • Reynold's pentad: add AMS and hypotension

DX

  • Obstruction ➔ ↑ ALP, ↑ GGT, ↑AST/ALT, ↑ bilirubin, ↑ CRP

  • RUQ US first, shows dilated CBD and thick bile duct walls

  • CT with IV contrast or MRCP if US inconclusive

TX

  • Get blood cultures then empiric ABX (metronidazole and cephalosporin)

  • Biliary drainage within 24hrs

    • ERCP guided trans-papillary biliary drainage with sphincterotomy or stent

      • Don't have to wait for afebrile

    • Percutaneous transhepatic biliary drainage

    • Open choledochotomy with T-tube drains if ERCP fails

Don't forget: Gallstones MCC ➔ Acute pancreatitis

  • Gallstones > etOH > idiopathic