Disorders of the Biliary Tract

What are the borders of Calot's Triangle? It is oriented so the apex is directed at the apex?

1. Medial-common hepatic duct

2. Inferior-cystic duct

3. Superior-inferior surface of the liver

What is a yellow/green fluid secreted by liver, stored in gallbladder?

bile

The presence of lipids in the duodenum stimulates the release of _________________ which in turn stimulates gallbladder wall contraction and relaxation of Sphincter of Oddi. This results in the release of the bile into the cystic duct and common bile duct. Bile then flows into the second part of the duodenum and causes emulsification of large fat droplets into small ones (Micelles).

cholecystokinin (CCK)

What is the composition of bile?

water and electrolytes and other substances which include bile salts, cholesterol, bilirubin, lecithin, amino acids, drugs, toxins, heavy metals, and vitamins

What are the 5 main functions of the bile?

1. Aids in the digestion of fat via fat emulsification

2. Absorption of fat and fat-soluble vitamins

3. Excretion of bilirubin and excess cholesterol

4. Provides an alkaline fluid in the duodenum to neutralize the acidic pH of the chyme that comes from the stomach

5. It provides bactericidal activity against microorganisms present in the ingested food

Which 2 ducts come together to form the common bile duct?

common hepatic and cystic duct

When you eat, what releases bile into the common bile duct, where it's carried to the duodenum? This helps break down fat in food

the gallbladder

What is a hormone which is secreted by cells in the duodenum and stimulates the release of bile into the intestine and the secretion of enzymes by the pancreas? It also acts as a hunger suppressant

Cholecystokinin (CCK)

What is secreted by I-cells in the small intestine and induces contraction of the gallbladder?

CCK

What are some other effects of CCK on the GI tract?

1. Relaxes the sphincter of Oddi, increases bile acid production in the liver

2. Delays gastric emptying

3. Induces digestive enzyme production in the pancreas.

What can gallstones form from (cholelithiasis)?

1. Ratio of cholesterol too high

2. Ratio of bilirubin too high

3. Gallbladder not emptying bile enough

What is the MC type of gallstones?

Cholesterol gallstones - m/c

Calcium Bilirubinate (pigmented) gallstones

What are some risk factors for cholelithiasis?

-western culture diets

-genetics

-women

-obesity

-pregnancy

-advanced age

-rapid weight loss

-medical conditions

What genetics are associated with a higher risk for cholelithiasis?

-Caucasians, Hispanics, & Native Americans

-Genetics and diets

-LITH gene in NA that promote fat and cholesterol storage

Why are women at higher risk for cholelithiasis?

Increase cholesterol levels in bile and decrease emptying/movement:

-Excess estrogen from pregnancy

-Excess estrogen from hormone replacement

-OCPs

Why is obesity a risk factor for cholelithiasis?

Enhanced cholesterol synthesis

Why is pregnancy a risk factor for cholelithiasis?

Change in bile composition and delayed emptying

What medical conditions are risk factors for cholelithiasis?

-Hemolytic anemias

-Hyperlipidemia

-DM

-Cirrhosis

-Hypertriglyceridemia

What diet can help prevent gallstones?

1. A low-carb diet and a Mediterranean diet as well as physical activity and cardiorespiratory fitness may help prevent gallstones

2. Caffeinated coffee appears to protect vs. gallstones in women

What occurs when there are gallstones remaining in gallbladder that is asymptomatic and found incidentally on abd imaging?

asymptomatic cholelithiasis

What occurs when the gallbladder contracts in response to stimulation and forces gallstones to move blocking cystic duct opening/gallbladder outlet?

symptomatic cholelithiasis (biliary colic)

What happens when the gallbladder forces gallstones to move blocking cystic duct opening/gallbladder outlet?

causes increased intra-gallbladder pressure and back up of bile resulting in pain

What happens when the gallbladder relaxes?

stones often fall back from cystic duct, and pain slowly subsides

What is the hallmark of symptomatic cholelithiasis?

RUQ pain lasting 6 hours max and not ill-appearing-->no fever or tachycardia

What is the presentation of symptomatic cholelithiasis?

Intense, dull discomfort, often associated with diaphoresis, nausea and vomiting:

-Usually constant

-Often following "fatty" meals d/t gallbladder contraction

-Pain is often nocturnal

-May radiate to right shoulder blade

-The severe pain lasts about 30 minutes (plateaus in an hour, total attack about 6 hours)

What are the lab results of cholithiasis?

WNL: Cbc, LFTs, amylase/lipase, alkaline phosphatase

What type of pain is biliary colic?

visceral pain; no peritoneal signs because gallbladder not inflamed

What is the diagnostic of choice for cholelithiasis?

abd US (RUQ)

What is the treatment for cholelithiasis?

1. NSAID for pain

2. laparoscopic cholecystectomy

Do you need to treat asymptomatic cholelithaisis?

NO!

When can a cholecystectomy be performed in pregnant women?

2nd trimester preferably in pregnant women after conservative approach fails for repeated attacks

What does post-cholecystectomy look like for patients?

-Generally all patients can go home within 1 day of the procedure

-Return to work within days

What is an Xray of your bile ducts, usually done during a cholecystectomy where a small catheter is inserted into the cystic duct, draining bile from the gallbladder into common bile duct (CBD)? A dye is injected in common bile duct, then Xrays taken. This allows the surgeon to see the anatomy of the bile duct system from liver to small intestines. Viewing the bile ducts before removal of gallbladder helps ensure the surgeon does not accidentally cut or damage CBD

intraoperative cholangiogram

What is the treatment of cholelithiasis if not a candidate for surgery?

Ursodeoxycholic acid- A bile salt given PO for up to 2 years can dissolve some cholesterol stones and may be considered in patients who refuse cholecystectomy

What are some complications from cholelithiasis?

-Acute Cholecystitis

-Choledocolithiasis

-Cholangitis

-Acute Pancreatitis

-Gallstone Ileus

What is the MC complication of cholecystitis?

Acute Calculous Cholecystitis

What is acute calculous cholecystitis MC due to?

stone becomes lodged in cystic duct--> sudden onset and severe

What type of cholecystitis results from gallbladder stasis and ischemia, which then causes a local inflammatory response in the gallbladder wall and is generally seen in critically ill patients/post op after major surgery?

acute acalculous cholecystitis

What are the characteristics of acute acalculous cholecystitis?

-Most have multiple risk factors/comorbidities

-Patients with acalculous cholecystitis, endothelial injury, gallbladder ischemia, and stasis, leads to a concentration of bile salts, gallbladder distension, and necrosis of gallbladder tissue

-Once established, secondary infection is common (E. Coli m/c)

What type of cholecystitis is a result of mechanical irritation or recurrent attacks of acute cholecystitis that presents with episodes of biliary colic?

chronic cholecystitis

What happens when the stome becomes lodged in chronic cholecystitis?

-Stone becomes lodged, inflammation of gallbladder develops, stone moves, symptoms resolve

-Fibrosis and Chronic thickening of gallbladder

-Recurrent

What is acute cholecystitis MC due to?

gallstones become impacted at cystic duct

Where does inflammation occur when acute cholecystitis?

at and behind the stone and in the gallbladder

What is released in response to the inflammation in cholecystitis?

prostaglandins

What are the symptoms of acute cholecystitis?

RUQ pain for 18 hours with fever and tachycardia (ill-appearing!!!)

How do the patients present with acute cholecystitis?

Patients lie still on examining table

due to peritoneal irritation; aggravated by movement

What is a clinical sign of acute cholecystitis?

Murphy sign:

Inhibition of inspiration by pain on palpation of RUQ

Ask pt to inspire deeply, which makes gallbladder descend toward and press against examining fingers leading to discomfort

Associated with muscle guarding and rebound tenderness

What is a common lab finding of acute cholecystitis?

leukocytosis (left shift)

What is the first line diagnostic for acute cholecystitis?

US- gallbladder wall thickening greater than 4-5mm

What is a + response observed during palpation with ultrasound transducer that is more accurate than hand palpation b/c it can confirm it is indeed the gallbladder?

Sonographic Murphy's sign

What is the scan for acute cholecystitis is US is inconclusive? It is more sensitive and useful in showing an obstructed cystic duct.

HIDA scan

What utilizes IV injection of Technetium-labeled iminodiacetic acid with uptake by the liver from bile producing cells which then travels into the gallbladder and bile ducts? They will watch it move to gallbladder (15-30 minutes), biliary ducts, & duodenum (60 minutes).

HIDA scan

What is being visualized in a HIDA scan?

filling defects--> Nonvisualized gallbladder = acute cholecystitis

A HIDA scan can also measure gallbladder ejection fraction. This is useful for what?

-Chronic cholecystitis

-Acalculous cholecystitis

CCK is injected with a HIDA scan which does what?

stimulates contraction of the gallbladder

What is the normal range of a HIDA scan?

35-75%

< 35% is indicative of gallbladder disease and indication for cholecystectomy

What are the indications for a HIDA scan?

1. Gallbladder inflammation (cholecystitis)

2. Bile duct obstruction

3. Congenital abnormalities in the bile ducts, such as biliary atresia

4. Postoperative complications, such as bile leaks and fistulas

5. Assessment of liver transplant

What are the risks of a HIDA scan?

1. Allergic reaction to medications containing radioactive tracers used for the scan

2. Bruising at the injection site

3. Radiation exposure, which is small

4. NOT done in pregnancy

How should you educate your patient for a HIDA scan?

-Ordering doctor may want pt to fast for 4 hrs before - can have clear liquids

-Have list of current medications

What is a complication of acute cholecystitis that is continuous or progression of RUQ abd pain, tenderness, muscle guarding, fever, leukocytosis after 24-48 hours resulting from ischemia?

gangrenous gallbladder

What does a gangrenous gallbladder suggest?

severe inflammation and possible gangrene of the bladder

What is a complication of acute cholecystitis that results in delay in diagnosis and failure of treatment (10% of cases)?

gallbladder perforation

What is a complication of acute cholecystitis that results when acute cholecystitis subsides but cystic duct obstruction persists?

hydrops of the gallbladder

What does hydrops of the gallbladder produce?

distention of the gallbladder with a clear mucoid fluid

What is a complication of acute cholecystitis where a stone in neck of gallbladder may compress common hepatic duct and cause jaundice?

mirizzi syndrome

What is a complication of acute cholecystitis that is associated with cholelithiasis and is a calcification of gallbladder wall? There is also chronic inflammation due to gallstones (scarring and calcification).

porcelain gallbladder

What is the management of acute cholecystitis?

1. IV abx d/t possible secondary infection - link (Piperacillin/Tazobactam (Zosyn) OR

2nd or 3rd generation Cephalosporin or Cipro + metronidazole)

2. NPO; NG tube if vomiting

3. IV fluids

4. IV Meperidine (Demerol) for pain and or NSAIDS

5. Lap cholecystectomy within 24-48 hours

What is the treatment of chronic cholecystitis?

lap cholecystectomy

What is the newer management of acute cholecystitis for high risk patients (elderly, diabetic)?

-Gallbladder drainage an alternative to surgery

-Percutaneous cholecystostomy

-Drainage under radiologic guidance via a percutaneous cholecystostomy tube

-Decompressing the gallbladder allows both local inflammation and systemic illness to resolve

Allows drainage of infected bile or pus

-Tube left in place until resolved

What happens when there are gallstones in the common bile duct?

choledocholithiasis

Passes = "Uncomplicated" and may be asymptomatic

What is the MC presentation of choledocholithiasis?

RUQ pain

What presents with biliary pain d/t increase in CBD pressure where pain subsides when stone passes/removed?

choledocholithiasis

What occurs when gallstone becomes lodged and causes obstruction in CBD? It is considered "complicated".

cholangitis

What is the MC cause of bacterial infections in cholangitis?

E.coli--> they ascend from the duodenum

What can cholangitis result in?

Hepatic Injury

About 15% of patients with symptomatic gallstones will develop what?

choledocolithiasis; risk increases with age

What is the presentation of choledocholithiasis that results from rapid increases in bile duct pressure?

-Intermittent biliary colic symptoms (RUQ pain);

severe and persists for hours

-Jaundice

-Intermittent N/V

-Epigastric tenderness

What lab values are typically elevated with choledocholithiasis?

-AST/ALT typically elevated early in course, followed by Alkaline Phosphatase, Gamma-glutamyl Transpeptidase

-Hyperbilirubinemia also noted

What is another enzyme found in liver that raises in response to liver damage/bile duct damage?

GGT

Patients are often suspected of having what when they present with RUQ pain with elevated liver enzymes with elevation of alkaline phosphatase, gamma-glutamyl transferase, and bilirubin?

choledocholithiasis

What is the initial diagnostic for choledocholithiasis?

transabdominal US-->will show CBD dilation and impaired flow with stones

Has poor sensitivity for stones in the distal CBD b/c distal CBD is often obscured by bowel gas in imaging field

What is the treatment of choice for choledocholithiasis?

ERCP with sphincterotomy and stone extraction/stent replacement (cholecystectomy)

What is the intermediate risk for choledocholithiasis?

-Abnormal LFTs

-Age >55

-Dilated CBD on US

-Go to MRCP or EUS for confirmation (Endoscopic Ultrasound)

-Then removal with ERCP if stone noted

-If no stone noted, still proceed to laparoscopic cholecystectomy

What is caused by bacterial infection in pt with CBD obstruction (M/C- E.Coli) with translocation from duodenum (normally ascends)?

cholangitis

What are some mechanisms that help prevent entry causing cholangitis?

-Sphincter of Oddi (acts as mechanical barrier)

-Continuous flushing action of bile

-Bacteriostatic activity of bile salts

What occurs when there is inflammation of the bile duct due to bacteria enter biliary tract when normal barrier mechanisms are disrupted resulting in stasis and infection?

cholangitis

What is the clinical presentation of acute cholangitis?

Charcot Triad:

-RUQ Pain

-Fever (and chills)

-Jaundice

What is the clinical presentation of acute supppurative (severe) cholangitis?

Reynolds Pentad:

-RUQ Pain  

-Fever  

-Jaundice  

-Hypotension

-Mental Status Change

What is acute cholangitis?

medical emergency

What can be appeciated on PE with acute cholangitis?

-RUQ tenderness

-Hepatomegaly possible

What are the lab findings of acute cholangitis?

-CBC - Leukocytosis

-Elevated inflammatory markers (CRP)

-Blood cultures

-Hepatic panel - Elevated Alkaline phosphatase (ALP) and bilirubin

Can see mildly elevated AST/ALT

-ProThrombin Time

What is the most accurate imaging of cholangitis?

Endoscopic Retrograde Cholangiopancreatography (ERCP)- direct visualization and allows for stone extraction

What is a complication of ERCP due to mechanical injury of pancreatic duct and hydrostatic injury from contrast injection?

pancreatitis

What is the criteria for diagnosing cholangitis?

1 of the following:

●Fever and/or shaking chills.

●Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation).

and both of the following:

●Evidence of cholestasis: Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, or aspartate aminotransferase, to >1.5 times the upper limit of normal).

●Imaging with biliary dilation or evidence of the underlying etiology (eg, a stricture, stone, or stent).

What are some complications of cholangitis?

1. Liver damage

Cirrhosis & Liver failure if untreated

2. Septic shock with acute cholangitis if not treated promptly

How do you treat cholangitis?

1. ADMIT, IV fluids, pain control, NPO

2. ERCP with stone extraction & sphincterotomy is the procedure of choice for Acute Cholangitis within 48 hours

3. If patient still has gallbladder - lap chole performed AFTER ERCP

4. ABX with acute cholangitis

What are the abx used for mild-moderate cholangitis?

Cipro plus Metronidazole (Flagyl)

What are the abx used for severe (organ damage) cholangitis?

IV Zosyn plus Flagyl

What is a chronic inflammatory disease of the biliary tract that results from increased immune response to intestinal endotoxin?

primary sclerosing cholangitis

What is primary sclerosing cholangitis often closely associated with?

UC & CD, more so with UC

⅔ have IBD