Biliary system disease

1. BILIARY SYSTEM DISEASE
KHADEEJA NOFAL

2. ACUTE CHOLECYSTITIS
DEFINITION AND TYPES
• Acute cholecystitis refers to inflammation of the gallbladder,
which is caused by a blockage of the cystic duct preventing the
gallbladder from draining.
• It is a key complication of gallstones, and the majority of cases
(around 95%) are caused by gallstones (calculous
cholecystitis). Gallstones may be trapped in the neck of the
gallbladder or in the cystic duct.

4. • In a small number of cases, the dysfunction in gallbladder
emptying is caused by something other than gallstones
(acalculous cholecystitis). One scenario where this may
occur is in patients on total parental nutrition or having long
periods of fasting (for example in ICU for other serious
conditions), where the gallbladder is not being stimulated by
food to regularly empty, resulting in a build-up of pressure.

5. PRESENTATION OF
THE DISEASE
• The main presenting symptom of cholecystitis is pain in
the right upper quadrant (RUQ). This may radiate to the right
shoulder.
• Fever
• Nausea
• Vomiting
• Murphy’s sign
• Right upper quadrant tenderness
• Raised inflammatory markers and white blood cells
• Tachycardia and tachypnoea

6. MURPHY’S SIGN
Murphy’s sign is suggestive of acute cholecystitis
• Place a hand in RUQ and apply pressure
• Ask the patient to take a deep breath in
• The gallbladder will move downwards during inspiration and
come in contact with your hand
• Stimulation of the inflamed gallbladder results in acute pain
and sudden stopping of inspiration

7. DIAGNOSIS
• Imaging
1. The first step is an abdominal ultrasound scan. Signs of acute
cholecystitis on ultrasound are:
• Thickened gallbladder wall
• Stones or sludge in gallbladder
• Fluid around the gallbladder
2. Magnetic resonance cholangiopancreatography (MRCP) may be
used to visualise the biliary tree in more detail if a common bile duct
stone is suspected but not seen on an ultrasound scan (e.g., bile duct
dilatation or raised bilirubin).

8. MANAGEMENT
Patients with suspected acute cholecystitis need emergency
admission for investigations and management.
• Nil by mouth
• IV fluids
• Antibiotics (as per local guidelines)
• Endoscopic retrograde cholangiopancreatography (ERCP)
can be used to remove stones trapped in the common bile
duct.
• Cholecystectomy (removal of the gallbladder) is usually be
performed during the acute admission, within 72 hours of symptoms.
In some cases, it may be delayed for 6-8 weeks after the acute
episode to allow the inflammation to settle.

9. COMPLICATION
• Sepsis
• Gallbladder empyema
• Gangrenous gallbladder
• Perforation

10. CHRONIC
CHOLECYSTITIS:
Pathogenesis:
- Stones in GB →repeated attacks of biliary colic → lead to
chronic inflammation in the GB(thickening and fibrosis of the
wall).
- Symptoms:
- Fatty dyspepsia (ingestion + blenching)
- Right upper abdominal pain especially after fatty food
- May be associated with heart burn
Treatment :
Elective laparoscopic cholecystectomy

11. ACUTE CHOLANGITIS
Acute cholangitis is infection and inflammation in the bile ducts. It
is a surgical emergency and has a high mortality due to sepsis
and septicaemia.
There are two main causes of acute cholangitis:
• Obstruction in the bile ducts stopping bile flow (i.e. gallstones
in the common bile duct)
• Infection introduced during an ERCP procedure
• The most common organisms are:
 Escherichia coli
 Klebsiella species
 Enterococcus species

13. Charcot’s Triad: Acute cholangitis presents with Charcot’s triad:
• Right upper quadrant pain
• Fever
• Jaundice (raised bilirubin)
Management:
• Nil by mouth
• IV fluids
• IV antibiotics
• Blood cultures

14. DIAGNOSES
Imaging to diagnose common bile
duct (CBD) stones and cholangitis (from least to
most sensitive) are:
• Abdominal ultrasound scan
• CT scan
• Magnetic resonance cholangio-pancreatography (MRCP)
• Endoscopic ultrasound
An endoscopic retrograde cholangio-pancreatography (ERCP) is
required to remove stones blocking the bile duct. It involves inserting an
endoscope down the oesophagus, past the stomach, to the duodenum
and the opening of the common bile duct (the sphincter of Oddi).

15. PRIMARY SCLEROSING
CHOLANGITIS
Primary sclerosing cholangitis is a condition where
the intrahepatic and extrahepatic bile ducts become inflamed
and damaged, developing strictures that obstruct the flow of bile
out of the liver and into the intestines. Sclerosis refers to the
stiffening and hardening of the bile ducts, and cholangitis is
inflammation of the bile ducts. Chronic bile obstruction eventually
leads to liver inflammation (hepatitis), fibrosis and cirrhosis.
Cause: is unclear and thought to be combined genetic and
environmental factors
-

17. The key risk factors for primary sclerosing cholangitis are:
• Male
• Aged 30-40
• Ulcerative colitis
Symptoms :
• Abdominal pain in the right upper quadrant
• Pruritus (itching)
• Fatigue
• Jaundice
• Hepatomegaly
• Splenomegaly

18. INVESTIGATIONS
1.Liver function tests show:
• Raise alkaline phosphatase (the most notable liver enzyme as with
most “obstructive” pathology)
• Other liver enzymes and bilirubin are raised later in the disease
2. Magnetic resonance cholangiopancreatography (MRCP) is the
diagnostic imaging investigation. It involves an MRI scan that gives a
detailed view of the bile ducts, showing bile duct strictures in primary
sclerosing cholangitis

19. MANAGEMENT
• Endoscopic retrograde cholangiopancreatography (ERCP)
may be used to treat dominant strictures.
• Antibiotics are given alongside ERCP to reduce the risk of
infection (bacterial cholangitis).
• Liver transplant is used in advanced disease, with around
80% survival at five years post-transplantation

20. COMPLICATONS
• Acute bacterial cholangitis
• Cholangiocarcinoma develops in 10-20% of cases
• Cirrhosis and the related complications
• Colorectal cancer in patients with ulcerative colitis