Gallstone/biliary tree disease

• The medical term for gall stones is cholelithiasis
• The presence of gall stones in the gallbladder is cholecystolithiasis
• The term for gallstones in the common bile duct is choledocholithiasis
• Biliary colic is a sudden painful spasms of the gall bladder wall triggered by a gallstone
• Patients with biliary colic present with:

  • Sudden onset severe RUQ/epigastric pain - pain may radiate to the right shoulder
  • Nausea and vomiting
  • Patients will not have a fever
  • An episode of isolated biliary colic lasts about 6 hours and subsides once the stone is dislodged
  • Attacks are often precipitated by eating fatty or spicy foods
• Acute cholecystitis is the acute inflammation of the gallbladder - most commonly due to gall stones

  It occurs when a gallstone impacts the cystic duct

  In a lot of cases, a bacterial infection also develops within the stagnant bile
• A positive murphy's sign indicates acute cholecystitis
• Acute cholangitis is caused by an acute bacterial infection within the biliary tree - almost always caused by gallstones
• Acute cholangitis classically presents with Charcot’s triad, which consists of RUQ pain, jaundice and fever, usually associated with rigors
• Gallstone pancreatitis is the sudden onset of acute inflammation within the pancreas secondary to gallstones
• Gallstone pancreatitis typically presents with a sudden onset of constant, excruciatingly severe epigastric or upper abdominal pain, which often radiates to the back or shoulders and may be relieved by sitting forwards or curling up into a ball
• A gallstone ileus is a form of obstruction that occurs when a gallstone blocks the ileum

  A gallstone from the gallbladder erodes into the duodenum

  This causes air to enter the biliary system
• Gallbladder cancer is almost always an adenocarcinoma. It develops due to accumulated oncogenic mutations induced by a prolonged inflammatory process such as chronic cholecystitis
• Patients may have longstanding symptoms of gallstones but are usually otherwise asymptomatic until the late stages of the disease. Advanced gallbladder cancer presents with the insidious onset of atypical or constant RUQ pain and a RUQ mass, along with other red-flag symptoms such as loss of appetite, weight loss, fatigue or jaundice.
• Cholangiocarcinoma is cancer of the bile ducts. Like gallbladder cancer, cholangiocarcinoma progresses rapidly and is usually asymptomatic until it is too late. Patients often have longstanding background symptoms related to gallstones or CBD stones, suddenly developing jaundice when the tumour obstructs the bile duct. The jaundice is classically painless but may be associated with upper abdominal or back pain. Systemic symptoms such as anorexia, weight loss and fatigue are common
• Risk factors for gallstones can be remembered with the four F's:

  • Fat
  • Fair
  • Female
  • Forty
• In most cases of biliary colic, inflammatory markers and LFTs will be normal
• Acute cholecystitis is acute inflammation of the gallbladder, usually caused by a gallstone being stuck in the neck of the gallbladder or the cystic duct. Prolonged bile stasis leads to chemical irritation of the gallbladder. Most patients will develop a bacterial infection.
• Acute cholecystitis normally begins as an attack of biliary colic but the pain lasts more than 6 hours and worsens.
• Presentation of acute cholecystitis:

  • RUQ pain that radiates to the right shoulder (irritation of the phrenic nerve)
  • Fever
  • Nausea and vomiting
  • Tachycardia
  • Murphy's sign positive - painful inspiratory catch
• Acalculous cholecystitis is usually caused by long periods of fasting when the gallbladder hasn't been stimulated. It has a higher mortality rate that gallstone cholecystitis
• Investigations for acute cholecystitis:

  • Raised inflammatory markers
  • Raised ALP due to gallstone obstruction
  • 1st line imaging is abdominal ultrasound
  • CT scan if ultrasound not readily available
• Management of acute cholecystitis:

  • Nil by mouth
  • IV fluids
  • Oral/IV antibiotics
  • NG tube for vomiting
  • Analgesia
  • Cholecystectomy - within 7 days of symptom onset
• Complications of acute cholecystitis:

  • Gangrenous cholecystitis - becomes ischaemic and necrotic and can perforate
  • Empyema - systemic sepsis - cholecystostomy (drain)
• Acute cholangitis is an acute bacterial infection within the biliary tree, usually from a stone stuck in the common bile duct that completely obstructs the flow of bile

  The stagnant bile becomes contaminated with gut organisms (E.coli and klebsiella)

  The bile duct fills with pus and ascends towards the liver
• Patients with acute cholangitis present with "charcot's triad"

  • RUQ pain
  • Fever
  • jaundice

  They may also have signs of systemic sepsis - tachycardia, hypotension, tachypnoea, new O2 requirement and confusion
• Main 2 risk factors for acute cholangitis are gallstones and recent ERCP
• Investigations for acute cholangitis:

  • Very raised ALP
  • Raised bilirubin
  • Signs of end organ dysfunction - AKI, lactate, coagulopathy and thrombocytopenia
  • Blood cultures
  • Abdominal ultrasound (CT if not immediately available)
• Management of acute cholangitis:

  • Immediate ABCDE approach and management of sepsis
  • IV fluids
  • IV antibiotics
  • Nil by mouth
  • Urgent decompression of the biliary tree via ERCP within 24 hours
  • PTC biliary tree drainage if patient too unwell or ERCP failed
  • Surgical drainage is the last result
• Patients with acute cholangitis should have a cholecystectomy once they are stable enough
• The gallbladder:

  • blood supply is from the cystic artery, which is a branch of the right hepatic artery
  • the right hepatic artery originates from the celiac trunk
  • sits just under the 9th costal cartilage in the mid-clavicular line
  • stores and concentrates bile
• The cystic artery is within calots triangle. Borders of calots triangle:

  • inferior surface of the liver
  • common hepatic duct
  • cystic duct
• Bile salts are produced in the liver and stored in the gallbladder until needed to emulsify fats during digestion.
• The common bile duct joins the pancreatic duct to form the ampulla of vater which then enters the descending duodenum via the major duodenal papilla. The sphincter of oddi closes the ampulla of vater to prevent reflux of bile into the duodenum.
• A gallstone ileus occurs when a gallstone from the gallbladder erodes into the duodenum

  Allows air to enter the biliary system

  A chest x-ray will show pneumobilia, small bowel obstruction (stacked coin appearance) and a stone in the terminal ileum
• Intra-abdominal sepsis is treated with triple IV antibiotic therapy:

  • Gentamicin
  • amoxicillin
  • metronidazole
• Procedures that can be done during an ERCP:

  • cholangio-pancreatography = injection of dye and X-rays taken
  • Sphincterotomy - allow stone removal
  • stone removal
  • balloon dilation
  • biliary stenting for strictures or tumours
  • biospy
• Reynolds pentad is a combination of clinical signs found in acute cholangitis

  • Charcot triad - fever, RUQ pain and jaundice
  • PLUS
  • Delirium or lethargy and
  • Shock
• Percutaneous transhepatic cholangiography is considered if a patient with acute cholangitis is too unwell for ERCP or if ERCP is unsuccessful.

  PTC allows placement of a biliary drain (PTBD) to decompress the biliary tree from above. This is performed by passing a needle through the skin and into the bile ducts. It is more likely to be successful when the intrahepatic bile ducts are sufficiently dilated. Contrast material is injected and the anatomy of the biliary tree is defined. A drain (the PTBD) can then be inserted and fixed to the skin.
• Risk factors for the development of cholangitis:

  • Gallstone disease (e.g. Mirizzi syndrome: where a stone-containing gallbladder extrinsically compresses the common bile duct; choledocholithiasis: gallstones in the common bile duct).
  • Iatrogenic biliary injury (e.g. during cholecystectomy or ERCP)
  • Tumours (pancreatic, cholangiocarcinoma, hepatic)
  • Sclerosing cholangitis (primary and secondary)
  • Primary biliary cholangitis
  • Biliary strictures (benign or malignant)
  • Parasitic infections (roundworm, liver fluke)