Biliary meaning - relating to bile or the bile duct)
- Liver produces 500-600ml of bile daily
* Bile is mostly water and electrolytes but also bile salts, phospholipids, cholesterol, bilirubin and metabolites.
Function on the gallbladder
Stores bile (aids in breaking down fat after a meal)
Choleithiasis
Cholelithiasis
• Presence of 1 or more calculi (gallstones) in the gallbladder
• Blockage of bile ducts can cause inflammation including bacterial infection
Acute cholecystitis
• Gallbladder inflammation developing over hours due to complete obstruction of the cystic duct
Chronic cholecystitis
• Long standing gallbladder inflammation without complete obstruction but usually associated with gallstones
Choledocholithiasis
• Presence of stones in the bile ducts
Cholangitis
• Bile duct inflammation and infection
Cholelithiasis
80% asymptomatic
85% are cholesterol stones
• Supersaturated bile with cholesterol (western diet)
• Precipitation from solution accelerated by protein mucin • Aggregation (grow) of micro crystals
Black pigment stones are calcium based and commonly associated with alcoholic liver disease, aging and chronic haemolysis – tend to be small and hard
Brown pigment stones are fatty acid based, form during
infection and inflammation – tend to be soft and greasy
Cholelithiasis
- Gallstones grow 1-2 mm per year
- Takes 5-20 years to be big enough to be problematic
- Most form in the gallbladder but can form in bile ducts
- Main symptom when present is colic pain, biliary colic
- RUQ pain (right shoulder)
- Can be life threatening with infection
- Some stones get through cyctic duct without issue
- Most lead to cystic duct obstruction
Acute cholecystitis
- Most common complication of cholelithiasis – 95%
- Develops over hours due to cystic duct obstruction (stone impaction) = acute inflammation
- RUQ pain, fever, nausea
- 5-10% acalculous – surgery, sepsis, burns, trauma, prolonged fasting, shock, vasculitis
- Damaged mucosa secretes more fluid than absorbed so worsens inflammation, worsening mucosal damage, causing ischaemia
- Bacterial infection a risk
- Same pain as biliary coloc but lasts longer
- Resolves within 1 week in 85% of patients without treatment
Chronic cholecystitis
- Almost always due to gallstones
- Can be mild outcome, fibrosis, chronic inflammation and atrophy
- Extensive calcification due to fibrosis is called a porcelain gallbladder
- Intermittent flow restriction so recurrent colic
- Inflammation relates to extent and frequency of colic
- Once an episode occurs, recurrence is common
- Can have concurrent acute cholecystitis
- Fever is usuall acute
- Ultrasound shows stones and sometimes atrophy or fibrosis
- Scintigraphy differentiates acute from chronic
Signs and symptoms
- RUQpain
- R shoulder pain
- Tenderness
- Nausea
- Fever
Ultrasound
- Modality of choice for gallstones
- Sensitivity and specificity both 95%
- Can also detect sludge
Benefits:
• It is fast, real-time, non-invasive, and does not utilise ionizing radiation.
• High sensitivity for detection of acute cholecystitis.
• Diagnosis based on presence of cholelithiasis, gallbladder wall thickening, pericholecystic fluid.
Limitations:
• Limited by skill of operator, and patient’s body habitus.
X-ray
- This was used in the past, but has been widely replaced by the ultrasound.
- Can be used to visualise calcified stones, emphysematous cholecystitis (gas within the wall of the gallbladder), biliary fistula (gas within the biliary system), porcelain gallbladder.
OCG (oral cholecystography)
Replaced by ultrasound
CT
- The diagnosis of AC requires the presence of 2 major criteria or 1 major and 2 minor criteria.
- This classification is particularly helpful in the diagnosis of acalculous AC.
- Major criteria include the following:
- GB wall thickening of greater than 3 mm
- A halo surrounding the GB, resulting from edema of the GB • Extension of inflammation to the GB fossa
- Pericholecystic fluid in the absence of ascites
- GB mucosal sloughing
- Intramural GB gas
- Minor criteria include GB dilatation, with the transverse diameter being greater than 5 cm, and sludge in the GB.
MRCP (magnetic resonance cholangiopancreatography)
- MRCP is becoming a more viable imaging technique, as MRI technology improves.
- However, CT and ultrasound are faster, easier, and more readily available, so they are used more frequently than MRCP.
- MRCP is emerging as a new tool for non- invasive evaluation of the pancreatic and biliary ductal systems.
Treatment
Gallstones (uncomplicated):
• Laparoscopic cholecystecomy
• Stone dissolution using ursodeoxycholic acid
• Non symptomatic rarely opt for surgery
• Recurrence of pain means most symptomatic patient elect to have cholycystectomy
Acute cholecystitis: • Hydration • Antibiotics • Analgesics • Cholecystectomy • Percutaneous cholecystostomy for those with surgical risk and acalculous
