Biliary Tract

I. Chronic Cholecystitis

a. Pathology: imbalance of cholesterol, lechithin and bile salts; 75% are cholesterol stones in US; black pigment stones associated with hemolytic diseases; also associated with obesity, rapid weight loss (gastric bypass), estrogen, TPN

b. Diagnosis: RUQ pain that is constant and crampy for several hours before resolving … until the next meal; normal WBC and no fever; ultrasound is best test

c. Differential Diagnosis: angina, uretral obstruction, IBS

d. Sequellae: recurrence, acute cholecystitis, gallstone pancreatitis, gallstone ileus

e. Treatment: cholecystectomy; can be dissolved medically with ursodeoxycholic acid, but takes 6-12 months and works best for stones <5 mm; half will recur if medications are ceased

II. Acute Cholecystitis

a. Pathology: sustained obstruction leads to inflammation of gallbladder

b. Diagnosis: constant RUQ pain with fever and elevated WBC (12 – 15K); + Murphy’s; rebound tenderness and guarding; Ultrasound best test; HIDA might give false positive (failure to see gallbladder) if NPO

c. Differential Diagnosis: acute pancreatitis, peptic ulceration into pancreas, acute appendicitis

d. Sequellae: empyema, gangrene, perforation

e. Treatment: NPO; antibiotics for gut bugs; NG tube; cholecystectomy within 3 days

f. Others:

i. Acute gangrenous chole: 25% mortality rate; leukocytosis with left shift

ii. Acute emphysematous chole: gas-forming bugs cause gangrene; often in diabetics

iii. Acute acalculous chole: often TPN patients on vents after blood transfusions

III. Choledocholithiasis

a. Pathology: gallstone in the common duct

b. Diagnosis: jaundice; light-colored stool; tea-colored urine;

c. Differential Diagnosis: gallbladder cancer

d. Sequellae: acute cholangitis

e. Treatment: elective cholecystectomy and removal of stones from duct

IV. Acute cholangitis

a. Pathology: infection of common duct

b. Diagnosis: Charcot’s triad: jaundice, RUQ pain, fever with chills; normal bowel sounds and no rebound tenderness; elevated WBC with left shift; elevated liver enzymes and alk phos; also amylase

c. Differential Diagnosis:

d. Sequellae: acute suppurative cholangitis – Charcot’s plus hypotension and mental status change (now called Reynold’s pentad)

e. Treatment: NPO; antibiotics; emergent cholecystectomy;

V. Acute Biliary Pancreatitis

a. Pathology: obstruction of pancreatic duct by gallstone

b. Diagnosis: 60% of non-EtOH patients with pancreatitis; very high serum amylase (pancreas still works, as opposed to EtOH pancreatitis);

c. Differential Diagnosis: EtOH pancreatitis

d. Sequellae: pancreatic necrosis

e. Treatment: fluids; antibiotics; elective cholecystectomy

VI. Gallstone ileus

a. Pathology: fistula between gallbladder and small bowel allows large gallstone to enter small bowel, blocking it usually just proximal to iliececal valve

b. Diagnosis: plain x-ray films, ultrasound, barium enema, -- none of them really work;

c. Differential Diagnosis:

d. Sequellae: bad things to the bowel

e. Treatment: remove the stone from the intestines; repair the fistula in healthy patients

VII. Gallbladder cancer (extrahepatic biliary duct malignancy)

a. Pathology: mucin-producing adenocarcinomas

b. Diagnosis: very rare; associated with ulcerative colitis and sclerosing cholangitis; symptoms of biliary obstruction with jaundice;

c. Differential Diagnosis:

d. Sequellae: death (95% of the time, except for cancers in proximal duct that can be resected with a Whipple – then 30% survive 5 years)

e. Treatment: resection; stent to by-pass obstruction; prepare the living will