Biliary Conditions

Biliary Colic

This is writhing right upper quadrant pain which occurs due to the gallbladder contracting to clear a stone stuck in the cystic duct or gallbladder neck.

Pain usually occurs after a fatty meal when the gallbladder contracts to release bile.

If left untreated this can lead to inflammation causing acute cholecystitis.

Symptoms

Right upper quadrant pain (can radiate to the right shoulder and scapula)

Nausea and vomiting

No fever or jaundice

Key tests

Ultrasound to detect stone

LFTs are usually within normal limits

Management

Small stones can pass spontaneously with resolution of the symptoms

If persistent, may require a cholecystectomy

Acute Cholecystitis

This refers to acute inflammation of the gallbladder.

It is usually secondary to a stone in the cystic duct which causes dilation, bacterial (E. coli) growth and inflammation.

Symptoms

RUQ pain, nausea/vomiting, fever

No jaundice

Murphy’s sign positive – palpating the RUQ causes pain during inspiration, as the inflamed gallbladder touchers fingers 

Key tests

Ultrasound shows stones

Blood tests show raised inflammatory markers (WBC, CRP) and raised alkaline phosphatase (from cystic duct damage)

Management

Provide analgesia and IV fluids

Broad spectrum antibiotics, e.g., co-amoxiclav

Once the infection settles, elective cholecystectomy

Choledocholithiasis

This is a stone in the common bile duct, which causes an obstructive jaundice

Symptoms

RUQ pain, nausea/vomiting and jaundice but no fever

Murphy’s sign negative as the gallbladder is not inflamed

If left untreated, this can lead to infection leading to ascending cholangitis

Key tests

Blood tests show raised ALP raised conjugated bilirubin

Urine dipstick shows elevated bilirubin

Imaging – ultrasound is gold standard

MRCP can be used if US is negative

Management

Removal of stone using ERCP followed by elective cholecystectomy

If ERCP is unsuccessful, percutaneous transhepatic cholangiography (PTC) can be done.

This is a tube which enters through the hepatic duct and allows the drainage of bile. It relieves pressure and can be used to remove the stone.

Ascending Cholangitis

This is a bacterial infection of the bile ducts, which often occurs after a stone gets stuck in the common bile duct.

It is usually due to an ascending infection secondary to enteric bacteria E. coli.

Symptoms

Charcot’s triad: RUQ pain, jaundice, fever

Reynold’s pentad: Charcot’s triad with hypotension and confusion

Key tests

Bloods show high ALP, raised bilirubin, raised inflammatory markers

Imaging – ultrasound and MRCP

Management

Sepsis 6 protocol with IV fluids with broad spectrum antibiotics

Removal of stone via ERCP, followed by elective cholecystectomy later

If ERCP unsuccessful, consider PTC or surgical exploration of the bile ducts

Gallstone Ileus

A condition caused by fistula formation between the gallbladder and duodenum.

This allows a gallstone to pass into the duodenum and cause small bowel obstruction, which commonly occurs near the distal ileum.

Duodenal obstruction is much rarer and known as Bouveret’s syndrome.

Symptoms

Usually preceded by history of cholecystitis that then gives obstruction

Bowel obstruction symptoms – nausea, vomiting, abdominal pain and distension

Key tests

Abdominal X-ray/CT scan shows small bowel obstruction with presence of pneumobilia and stone in right iliac fossa

Management

“Drip and suck,” IV fluids and decompression (NG tube) to treat bowel obstruction

Surgery may be required to remove the gallstone, with elective cholecystectomy

Cholangiocarcinoma

This is an adenocarcinoma arising from the epithelium lining the bile ducts.

The major risk factor is primary sclerosing cholangitis as well as hepatitis B/C.

Symptoms

Abdominal pain, itching and weight loss

Palpable RUQ mass (Courvoisier’s sign) due to gallbladder dilation

Obstructive jaundice, with changes in the colour of stool and/or urine

Key tests

Bloods show high ALP, bilirubin, raised cancer markers CA 19-9, CEA, CA-125

CT/MRI and MRCP show biliary tree dilation.

Biopsy may be required for histology

Management

Mainly involves palliative chemotherapy with biliary stenting