Biliary Tract Disease
Biliary Tract Disease
Biliary Tract Disease
Overview
• Gallstones
• Other conditions
• Acute acalculous cholecystitis
• Mirizzi’s syndrome
• Primary Biliary Cirrhosis
• Primary Sclerosing Cholangitis
• Biliary tract cysts
• Biliary strictures
Biliary Tract
Part of the digestive system.
Made up of:
• Intra hepatic ducts
• Exta hepatic ducts
• Gallbladder
• Common Bile Duct
The Gallbladder
The gallbladder concentrates and stores bile.
Bile:
• Secreted by the liver
• Contains cholesterol, bile pigments and
phospholipids
• Flows from the liver, through the hepatic ducts,
into the gallbladder
• Exits the gallbladder via the cystic duct
• Flows from the cystic duct into the common
bile duct, into the small intestine
• In the small intestine, aids digestion
by breaking down fatty foods and
fat-soluble vitamins
Gallstones – Pathophysiology
• Cholesterol, ordinarily insoluble in water, comes into
solution by forming vesicles with phospholipids
• If ratio of cholesterol, phospholipids, and bile salts altered,
cholesterol crystals may form
• Gallstone formation involves a variety of factors:
• Cholesterol supersaturation
• Mucin hypersecretion by the gallbladder mucosa creates a
viscoelastic gel that fosters nucleation.
• Bile stasis
• Occurs in diabetes, pregnancy, oral contraceptive use, and prolonged
fasting in critically ill patients on total parenteral nutrition.
Gallstones – Frequency
• Gallstone disease is one of the most common and costly
of all digestive diseases
• 9% of those > 60 years
• In USA, 6.3 million men and 14.2 million women aged 20-
74 years have gallbladder disease
• Incidence of gallstones is 1 million new cases per year
• Prevalence is 20 million cases in USA
Gallstones
Sex
• Higher among females than males (lifetime risk of 35% vs
20%, respectively)
• Due to endogenous sex hormones (enhance cholesterol secretion
and increase bile cholesterol saturation)
• Progesterone may contribute by relaxing smooth muscle and
impairing gallbladder emptying.
Age
• Increased age is associated with lithogenic bile and
increased rate of gallstones
Gallstones – Types
• Two main types:
• Cholesterol stones (85%):
• 2 subtypes—pure (90-100% cholesterol) or mixed (50-90%
cholesterol).
• Pure stones often are solitary, whitish, and larger than 2.5 cm in
diameter.
• Mixed stones usually are smaller, multiple in number, and occur in
various shapes and colors.
• Pigment stones (15%) occur in 2 subtypes—brown and black.
• Brown stones are made up of calcium bilirubinate and calcium-soaps.
Bacteria involved in formation via secretion of beta glucuronidase and
phospholipase
• Black stones result when excess bilirubin enters the bile and
polymerizes into calcium bilirubinate (patients with chronic hemolysis)
Gallstones – Natural History
• 80% of patients, gallstones are clinically silent
• 20% of patients develop symptoms over 15-20
years
• About 1% per year
• Almost all become symptomatic before
complications develop
• Biliary-type pain due to obstruction of the bile
duct lumen
• Predictive value of other complaints (eg,
intolerance to fatty food, indigestion) too low to
be clinically helpful
Gallstones – Diverse symptoms
• Abdominal pain
• Aching or tightness, typically severe and located in the epigastrium
• May develop suddenly, last for 15 minutes to several hours, and then resolve
suddenly
• Referred pain – posterior scapula or right shoulder area
• Nausea and vomiting
• Jaundice
• Pruritus:
• Itching, typically worse at night.
• Fatigue
• Weight loss
• Miscellaneous:
• Fatty food intolerance
• Gas
• Bloating
• Dyspepsia
Complications of Gallstones
• In the gallbladder
• Biliary colic
• Acute and chronic cholecystitis
• Empyema
• Mucocoele
• Carcinoma
• In the bile ducts
• Obstructive jaundice
• Pancreatitis
• Cholangitis
• In the Gut
• Gallstone ileus
Biliary Colic
• Symptoms
• Right upper quadrant pain
• Signs
• Usually none
• Investigations
• Bloods – U&E, FBC, LFT, Amylase, CRP
• Ultrasound of abdomen
• OGD (Oesophagogastroduodenoscopy)
• Treatment
• Analgesia
• Cholecystectomy
Acute Calculous Cholecystitis
• Inflammation of the gallbladder that develops in the
setting of an obstructed cystic or bile duct
• Most patients have complete remission within 1-4 days.
• 25-30% of patients either require surgery or develop
some complication
• Perforation occurs in 10-15% of cases.
Acute Calculous Cholecystitis
• Symptoms
• Right upper quadrant pain – continuous, longer duration
• Signs
• Fever, Local peritonism.
• Murphy’s sign
• 2 fingers on RUQ, ask patient to breathe in. Positive if pain and arrest of inspiration
• Investigations
• Bloods – U&E, FBC, LFT, Amylase, CRP
• Ultrasound of abdomen
• Thickened gallbladder wall, pericholecystic fluid and stones
• OGD (Oesophagogastroduodenoscopy)
• Treatment
• Nil by mouth
• Analgesia
• Intravenous antibiotics
• Cholecystectomy
Empyema / Mucocoele
• Empyema refers to a gallbladder filled
with pus due to acute cholecystitis
• Symptoms
• Pain, Jaundice, dark urine, pale stools
• Signs
• Jaundice.
• Investigations
• Bloods – U&E, FBC, LFT, Amylase, CRP, Hepatitis screen,
Coagulation screen
• Ultrasound of abdomen
• Treatment
• Endoscopic Retrograde CholangioPancreatogram
Ascending Cholangitis
• Obstruction of biliary tree with bile duct infection
• Symptoms
• Unwell, pain, jaundice, dark urine, pale stools
• Charcot triad (ie, fever, right upper quadrant pain, jaundice) occurs in
only 20-70% of cases
• Signs
• Sepsis (Fever, tachycardia, low BP), Jaundice.
• Investigations
• Bloods – U&E, FBC, LFT, Amylase, CRP, Coagulation screen
• Ultrasound of abdomen
• Treatment
• Intravenous antibiotics
• Endoscopic Retrograde CholangioPancreatogram
Acute Pancreatitis
• Acute inflammation of pancreas and other retroperitoneal
tissues.
• Symptoms
• Severe central abdominal pain radiating to back, vomiting
• Signs
• Variable – None to Sepsis (Fever, tachycardia, low BP), Jaundice,
acute abdomen
• Investigations
• Bloods – U&E, FBC, LFT, Amylase, CRP
• Ultrasound of abdomen
• MRCP
• CT Pancreas
• Treatment
• Supportive
• Endoscopic Retrograde CholangioPancreatogram
Gallstone ileus
• Obstruction of the small bowel by a large gallstone
• A stone ulcerates through the gallbladder into the duodenum and
causes obstruction at the terminal ileum
• Symptoms
• Small bowel obstruction (vomiting, abdominal pain, distension, nil pr)
• Signs
• Abdominal distension, obstructive bowel sounds.
• Investigations
• Bloods – U&E, FBC, LFT, Amylase, CRP, Hepatitis screen,
Coagulation screen
• Plain film of abdomen – Air in CBD, small bowel fluid levels and stone
• Treatment
• Laparotomy and removal of stone from small bowel.
Cholecystectomy
• Laparoscopic
cholecystectomy standard of
care
• Timing
• Early vs interval operation
• Patient consent
• Conversion to open procedure
10%
• Bleeding
• Bile duct injury
• Damage to other organs
Mirizzi Syndrome
• Refers to common hepatic duct obstruction caused by an
extrinsic compression from an impacted stone in the
cystic duct
• Estimated to occur in 0.7-1.4% of all cholecystectomies
• Often not recognized preoperatively, which can lead to
significant morbidity and biliary injury, particularly with
laparoscopic surgery.
Acute Acalculous Cholecystitis
• Presence of an inflamed gallbladder in the absence of an
obstructed cystic or common bile duct
• Typically occurs in the setting of a critically ill patient (eg,
severe burns, multiple traumas, lengthy postoperative care,
prolonged intensive care)
• Accounts for 5% of cholecystectomies
• Aetiology is thought to have ischemic basis, and gangrenous
gallbladder may result
• Increased rate of complications and mortality
• An uncommon subtype known as acute emphysematous
cholecystitis generally is caused by infection with clostridial
organisms and occlusion of the cystic artery associated with
atherosclerotic vascular disease and, often, diabetes.
Primary Sclerosing Cholangitis
• Chronic cholestatic biliary disease characterized by non-
suppurative inflammation and fibrosis of the biliary ductal
system
• Cause is unknown but is associated with autoimmune
inflammatory diseases, such as chronic ulcerative colitis and
Crohn colitis, and rare conditions, such as Riedel thyroiditis
and retroperitoneal fibrosis
• Most patients present with fatigue and pruritus and,
occasionally, jaundice
• Natural history is variable but involves progressive destruction
of the bile ducts, leading to cirrhosis and liver failure
• Clinical features of cholangitis (ie, fever, right upper quadrant
pain, jaundice) are uncommon unless the biliary system has
been instrumented.
Primary Sclerosing Cholangitis
Medical Care
• Chronic progressive disease with no curative medical therapy
• Goals of medical management are to treat the symptoms and
to prevent or treat the known complications
• Liver transplantation is the only effective therapy and is
indicated in end-stage liver disease.
Surgical Care
• Indications for liver transplantation include variceal bleed or
portal gastropathy, intractable ascites, recurrent cholangitis,
progressive muscle wasting, and hepatic encephalopathy.
• Recurs in 15-20% of patients after transplantation.
Primary Biliary Cirrhosis
• Progressive cholestatic biliary disease that presents with
fatigue and itching or asymptomatic elevation of the alkaline
phosphatase.
• Jaundice develops with progressive destruction of bile ductules
that eventually leads to liver cirrhosis and hepatic failure.
• Autoimmune illness has a familial predisposition
• Antimitochondrial antibodies (AMA) are present in 95% of
patients
• Goals of treatment are to slow the progression rate of the
disease and to alleviate the symptoms (eg, pruritus,
osteoporosis, sicca syndrome)
• Liver transplantation appears to be the only life-saving
procedure.
Biliary Tract Cysts
• Choledochal cysts
• Consist of cystic dilatations of the extra-
hepatic biliary tree
• Uncommon abnormality
• 50% present with combination of jaundice,
abdominal pain, and an abdominal mass.
• ? Due to anomalous union of the pancreatic
and biliary ductal system.
• Classified into 5 types
• Treatment for choledochal cysts is surgical
(excision of the cyst with construction).
Biliary Tract Tumours
Cholangiocarcinoma
Cancer of the Gall Bladder
Biliary Tree Neoplasms
• Clinical symptoms:
• Weight loss (77%) • Fever (21%)
• Nausea (60%) • Malaise (19%)
• Anorexia (56%) • Diarrheoa (19%)
• Abdominal pain (56%) • Constipation (16%)
• Fatigue (63%) • Abdominal fullness (16%).
• Pruritus (51%)
• Symptomatic patients usually have advanced disease,
with spread to hilar lymph nodes before obstructive
jaundice occurs
• Associated with a poor prognosis.
Cholangiocarcinoma
• Adenocarcinoma of the bile ducts
• May occur without associated risk factors
• Associated with chronic cholestatic liver disease such as:
• Primary Sclerosing Cholangitis
• Choledochal cysts
• Asbestos.
• Accounts for 25% of biliary tract cancers
• Presentation:
• Jaundice
• Vague upper or right upper quadrant abdominal pain
• Anorexia, weight loss
• Pruritus.
Cholangiocarcinoma
• Slow growing malignancy of biliary tract which tend to
infiltrate locally and metastasize late.
• Gall Bladder cancer = 6,900/yr
• Bile duct cancer = 3,000/yr
• Hepatocellular Ca = 15,000/yr
Cholangiocarcinoma
Diagnosis and Initial Workup
• Jaundice
• Weight loss, anorexia, abdominal pain, fever
The Endoscope is
positioned in the
duodenum at the
opening of the bile
duct.
Stent Placement -Endoscopic Approach
• A catheter is inserted through
the endoscope into the ostium
of the common bile duct.
• While maintaining the
endoscope position in the
duodenum, a wire is inserted
through the catheter into the
bile duct.
• The stent delivery system is
then inserted over the wire
to the site of obstruction, where
the stent is deployed.
Stent Placement – Endoscopic Approach
Success rate of ERCP 90-95%
Complication rate of approximately 3-5%.
Complications:
• Pancreatitis
• Bleeding
• Perforation
• Infection
• Cardiopulmonary depression from conscious sedation.
Biliary Stent - Percutaneous Approach
Transhepatic Approach