BILIARY DISEASE.docx

BILIARY DISEASE: APPROACH & MANAGEMENT  What are gallstones? AKA cholethiasis: stones formed from cholesterol, bilirubin & bile Asymptomatic in most people Clinical presentation:  RUQ abdominal pain after eating greasy or spicy food, Nausea & vomiting Pain in epigastrium that radiates to...

BILIARY DISEASE: APPROACH & MANAGEMENT  What are gallstones? AKA cholethiasis: stones formed from cholesterol, bilirubin & bile Asymptomatic in most people Clinical presentation:  RUQ abdominal pain after eating greasy or spicy food, Nausea & vomiting Pain in epigastrium that radiates to R scapula or mid-back Murphy's sign: RUQ dee palpation under rib cage w/ deep inspiration = pain Why do gallstones form? Bile becomes too concentrated & substances precipitate into crystals Bile that does not fully drain from gallbladder precipitates into a sludge, which can turn into gallstones Can also occur from biliary obstruction (e.g. bile duct strictures or neoplasms) Most common cause: cholesterol precipitating from cholesterol-rich bile Second most common: black pigmented gallstones from breakdown of RBCs Third: mixed pigmented stones formed from calcium compounds, cholesterol & bile Fourth: calcium precipitating from hypercalcemia What are risk factors for gallstone disease? Older age, family history Pregnancy (progesterone decreases gallbladder contractility, leading to stasis) Dyslipidemia, obesity (increases biliary secretion of cholesterol) Rapid weight loss, prolonged fasting, parenteral nutrition (causes biliary stasis) Medication: fibrats, ceftriaxone, somatostatin analogues (octreotide), hormones & oral contraceptive Spinal cord injury, diabetes (causes decreased gallbladder motility & increased stasis) Cirrhosis (risk for pigment gallstones) Crohn's & ileal resection (alters enterohepatic cycling) Hyperbilirubinemia How can gallstones present? Cholelithiasis: Gallstones just hanging out, not causing any problems Biliary colic: happens after a fatty meal, the GB contracts and pushes stones into the cystic duct but when the duct relaxes the stone rolls back into the GB. The pain is entirely visceral and generally lasts <6h. There should be no fever or chills. Cholecystitis: inflammation of the GB. It’s biliary colic that just doesn’t go away. The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain. Choledocholithiasis: gallstones in the common bile duct. Usually secondary to cholelithiasis, but can be a primary stone in cases of bile stasis or recurrent infection of the biliary tree. Usually have abnormalities in liver enzymes and pain but no fever. Cholangitis: infection/inflammation of the biliary tree (infected bile or gallstone), secondary to an impacted stone or stricture(s). Can present w/ Charcot’s triad: fever, RUQ pain, jaundice Reynold’s pentad: Charcot’s triad + hypoperfusion, decreased level of consciousness Gallstone Pancreatitis: gallstone blocks your pancreatic duct causing inflammation and pain in your pancreas. Gallstone pancreatitis causes severe abdominal pain, nausea, vomiting, fever, chills, and/or jaundice How can we tell if stones are in gallbladder or in common bile duct? CBD: usually symptomatic, with jaundice, have dilated bile duct on CT (from downstream obstruction)  What investigations can help dx gallstones & acute cholecystitis? RUQ ultrasound: best diagnostic test 90% specificity, can potentially detect 2mm stones  However, advanced scarring & gallbladder contraction can lead to false negatives HIDA scan: helpful if dx is uncertain after u/s Radioactive tracer is injected IV, taken up by hepatocytes, excreted into bile High sensitivity & specificity Severe liver disease, fasting patients, hyperbilirubinemia can lead to false negatives What investigations can help dx choledocholithiasis?  Magnetic resonance cholangiopancreatography (MRCP): can assess for CBD stones & biliary strictures Non-invasive, no radiation, no anesthesia  Endoscopic retrograde cholangiopancreatogram (ERCP): gold standard for dx & tx Can also stent CBD in case of strictures & collect samples to r/o cancer Invasive, associated w/ surgical complications U/S: not very good, since CBD often obscured by bowel gas CT: can r/o other diagnoses, evaluate for complications (e.g. perforation) & cancer How are symptomatic gallstones treated? They’re taken out (cholecystectomy) Laparoscopic: gold standard for gallbladder gallstones ERCP: gold standard for CBD gallstones However, gallstones often recur after 1 year & risk for complication is 2-3% per year Take out gallbladder (cholecystectomy): Electively for biliary colic W/ early cholecystitis, for better outcome Electively for cholangitis (removing 1 duct) Pancreatitis  How does biliary malignancies arise? Gallbladder & intra and extrahepatic biliary tree are lined by epithelial cells called cholangiocytes Cholangiocyte malignancy = cholangiocarcinoma Rare but aggressive w/ poor prognosis, since they are often advanced & unresectable w/ diagnosed What are risk factors for biliary malignancies? Chronic inflammatory conditions Primary sclerosing cholangitis (PSC) from chronic IBD, particular UC, is closely associated w/ biliary cancers Colonization by liver flukes will also do you in (that’s why you shouldn’t have raw liver salad in Thailand!) Other: obesity, alcohol, T2DM How does cholangiocarcinoma present? Usually asymptomatic in early stages Symptoms arise due to obstruction by malignant growth: Abdominal pain or heaviness (usually RUQ) Jaundice, changes in stool & urine colour, generalized itching Fever, weight loss, generalized malaise How do we investigate for suspected cholangiocarcinoma? Labs: Baseline: CBC, electrolytes, kidney function, liver function Liver function tests: aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin Biliary excretion products: bile salts, gamma glutamyl transpeptidase (GGT), alkaline phosphatase (ALP) Tumour markers: CA 19-9, CEA, AFP Imaging: Assess pancreas: CT pancreas protocol Assess bile duct & relieve biliary obstruction: ERCP or percutaneous transhepatic cholangiogram (PTC) Histology: ERCP / PTC: brush bile duct to collect samples Endoscopic u/s (EUS): biopsy mass or lymph node Complete staging: CT chest, abdo, pelvis to assess for metastases +/- MRI liver for occult metastasis How are pancreatic & biliary cancers treated? All of them have really shitty prognoses & survival rates Resect if you can but mostly systemic therapy Look at the powerpoint for some great MCQs at the end