Biliary Tract Disease

Question 1

What is meant by ‘Biliary colic’ in regard to gallstones

Answer 1

Term used for pain associated with the temporary obstruction of the cystic or common bile duct by a stone migrating from the gall bladder.

Question 2

Describe the pain of stone-induced ductular obstruction

Answer 2

Of sudden onset, severe but constant and has a crescendo characteristic

Question 3

What is Cholecystitis

Answer 3

Gallbladder inflammation

Question 4

What does bile contain?

Answer 4

Cholestrol
Bile pigments (broken down Hb)
Phospholipids

Question 5

Epidemiology of gall stones

Answer 5

Unusual before age of 30
More common in females
More common ethnic groups include Scandinavians, South Africans, Native North Americans
Less common in Asian and African groups

Question 6

Where do most gall stones form

Answer 6

Gallbladder

Question 7

Main causes of gall stones

Answer 7

Obesity and rapid weight loss
Diet high in animal fat and low in fibre
Diabetes M
Contraceptive pill
Liver cirrhosis

Question 8

Risk factors of gall stones

Answer 8

Female
Fat
Fertile (more kids increases risk)
Smoking

Question 9

What are 2 types of gall stone

Answer 9

Cholesterol

(Bile) Pigment

Question 10

Pathophysiology of Cholesterol gall stones

Answer 10

Cholesterol is held in solution by the detergent action of bile salts and phospholipids, with which it forms MICELLES and VESICLES.
When there is an excess of cholesterol (LITHOGENIC BILE), there is a relative lack of bile salts and phospholipids.
-> Formation of cholesterol crystals and gall stones.
This is further promoted by lack of gall bladder motility, as well as nucleation factors (Calcium and mucus)

Question 11

What are 2 types of Pigment gall stones

Answer 11

Black pigment gallstones

Brown pigment stones

Question 12

What are Black pigment gallstones

Answer 12

Calcium biliurbinate composition and a network of mucin glycoproteins that interlace with salts e.g. calcium bicarbonate
Grass-like cross-sectional surface

Question 13

What are Brown pigment gallstones

Answer 13

Composed of calcium salts e.g. calcium bicarbonate, fatty acids and calcium bilirubinate
Muddy hue with an alternating brown and tan layer on cross-section

Question 14

Which pigment gall stones would be seen in a lot of patients with haemolytic anaemias e.g. spherocytosis, sickle cell and thalassaemia - chronic excess of bilirubin

Answer 14

Black pigment gall stones

Question 15

Which pigment gallstone is a common cause of recurrent bile duct stones following cholecystectomy

Answer 15

Brown pigment gall stones

Question 16

Which pigment gall stone is almost always found in the presence of bile stasis and/or biliary infection

Answer 16

Brown

Question 17

Pathophysiology of pigment gallstones

Answer 17

Bilirubin polymers and calcium bilirubinate

Caused by excess of bilirubin

Question 18

What % of Gall stones are asymptomatic at the time of diagnosis

Answer 18

70%

Question 19

Where is most common symptomatic gallstone and what symptoms would you see

Answer 19

Biliary Colic - right upper quadrant
Sudden, nausea and vomitting.
Caused by gallstone impacting on the cystic duct or the ampulla of vater

Question 20

What is second most common symptomatic gallstone condition

Answer 20

Acute Cholecystitis

Question 21

What is acute cholecystitis

Answer 21

Inflamed gallbladder leading to fever, peritonitis and raised WCC
Distension of the gall bladder leads to necrosis and ischaemia

Question 22

Aetiology of Cholesterol gallstones

Answer 22

Multifactorial

Cholesterol super saturation, nucleation factors and reduced gallbladder motility

Question 23

Aetiology of Pigment gallstones

Answer 23

Chronic haemolysis (sphereocytosis and sickle cell), in which bilirubin production is increased.
Also cirrhosis. Possible as complication of cholecystectomy and with duct strictures.

Question 24

What % of population are affected by gall-stones

Answer 24

10-20%

Question 25

Epidemiology of gallstones

Answer 25

Most common in women

Preveleance increases with age

Question 26

What % of Western world’s gallstones are cholesterol gallstone

Answer 26

80%

Question 27

Diagnosis of gallstone

Answer 27

Ultrasound (Trans-abdominal)

Also blood tests e.g. Raised serum bilirubin, serum alkaline phosphatase, ESR and CRP

Question 28

Treatment of gallstone

Answer 28

Non-surgical = Pain relief; IV antibiotics if necessary (e.g. Cefotaxime)
Surgical = Laparoscopic cholecystectomy (gall bladder removal in symptomatic cases)

Stone dissolution for pure cholesterol stones - give oral Ursodeoxycholic acid

Question 29

Complications of gallstones

Answer 29

Jaundice - if biliary obstruction
Acute cholecystitis - cystic duct impaction
Pancreatitis - blocks pancreatic duct
Gallstone ileus - occludes intestinal lumen
Empyema - obstructed gallbladder fills with pus
Cholangitis - Inflammation of the GB or bile duct as a result go bile duct blockage

Question 30

What is a Cholangiocarcinoma?

Answer 30

Cancer of the biliary tree (in or out of the liver)

Question 31

Cholangiocarcinoma clinical presentation

Answer 31

Fever, Malasie, Weight loss
Right Upper Quadrant pain, jaundice (early)
Hepatomegaly, ascites

Question 32

Cholangiocarcinoma Pathophysiology

Answer 32

90% ductal adenocarcinoma

10% are squamous cell carcinoma

Question 33

Cholangiocarcinoma aetiology

Answer 33

Caused by flukes, primary sclerosing cholangitis, HBV, HCV, DM, Caroli’s

Question 34

Cholangiocarcinoma epidemiology

Answer 34

mostly >60

Question 35

Cholangiocarcinoma diagnosis

Answer 35

Contrast MRI - optimal imaging for diagnosis

ERCP - can obtain samples for biopsy

Question 36

Cholangiocarcinoma Treatment

Answer 36

Complete surgical resection

Stent (or surgical bypass) to relieve symptoms

Question 37

Is CRP or ESR better

Answer 37

CRP as more sensitive and accurate reflection of acute phase of inflammation

Question 38

What does ERCP stand for

Answer 38

endoscopic retrograde cholangiopancreatogram