1. Biliary Tract Disease
August 26, 2014
V. Raman Muthusamy, MD, FACG, FASGE
Director of Interventional Endoscopy
Clinical Professor of Medicine
David Geffen School of Medicine at UCLA
2. Gallstones
• Common: about 20-30 million in US
• Gender and Ethnic Predisposition
- Over 65% are female
- Hispanic and Native American
• Lower socioeconomic status
• 700,000 annual cholecystectomies in
U.S.
• $6.5 billion annual cost
9. Pigmented Gallstones
• Bilirubin deconjugation and precipitation
- Bacterial β glucuronidase
• Chronic hemolytic disorders
- Sickle cell, thalassemias
• Chronic liver disease: ie. Cirrhosis
• Gallbladder stasis
• Older age and women
• Disrupted enterohepatic circulation
- TI resection, Crohn’s disease
10. Brown stones
• Seen with chronic infections of biliary tree
- Bacterial and parasitic
• Asian-pacific ethnicity
• Prior surgery of biliary tree
- Stasis and dilation of duct system
- Often after cholecystectomy
• Recurrent pyogenic cholangiopathy
11. Gallbladder Sludge
• Mixture of crystals and mucus
• Can cause the same symptoms as stones
• Can be transient
• Diagnosed on ultrasound
• Nonshadowing
15. Biliary Colic
• RUQ, mid-epigastric
• Lasts hours not weeks
- Crescendo, plateau, and then relief
• Often post-prandial
- Nocturnal awakening
- Many hours after meal
• Nausea and vomiting
• Radiation to shoulder and back
21. 76 yo male
• In ICU for recent STEMI, moderate failure
• On ventilator, stormy course; NPO,
distended abdomen
• No prior abdominal surgeries
• Low grade fever, leukocytosis
• Tenderness in RUQ, no rebound
• Increasing AST, ALT and alk phos
- Bilirubin normal
22. What is the most likely
diagnosis??
A. Mirizzi’s syndrome
B. Choledocholithiasis
C. Ascending cholangitis
D. Acalculus cholecystitis
23. What is the best therapy in
the critically ill patient??
A. Lap cholecystectomy
B. ERCP with sphincterotomy
C. Percutaneous cholecystotomy
D. Observation
24. Acalculous Cholecystitis
• Older; male > female
• Triad
- Hemodynamic instability
- Prolonged fasting
- Immobility
• Fever, RUQ pain, leukocytosis, tenderness
may be absent
• More fulminant course
25. Acalculous Cholecystitis
• RUQ sonogram
- GB wall > 4 mm*
- Sonographic
Murphy’s sign
- Pericholecystic fluid
collection
- Sensitivity: 67-92%
- Specificity: > 90%
• CT scan
- GB wall > 4 mm
- Subserosal edema
- Intramural gas
- Sloughed mucosa
- Sens / Spec >95%
• Scintigraphy
- False (+) and (-)
NB. Ascites without other cause
27. Cholecystectomy
• Open or laparoscopic: 0.1% mortality
• Laparoscopic: reduction in postoperative
LOS and pain
• Complicated presentation, coagulopathy or
adhesions->open
• IOC: allows for ID and potential treatment
of choledocholithiasis
28. Complications of
Cholecystectomy
• Overall incidence: ~1% in recent series
• Types:
- Bile leak without significant duct injury
- Major duct injury +/- leak
• Transection, stricture etc
• Typically treat leaks with ERCP with stent
placement for 4-6 weeks without sphincterotomy
(90% success rate)
• Endoscopic therapy similar to surgery for major
biliary injury except for disconnection
29. ERCP with Stent placement
for CBD Leak
Before After (Healed)
30. Other Treatment Modalities
• Ursodeoxycholic acid
- Patent cystic duct and non-calcified
stones
- Small floating stones best response
- High recurrence rate (>50%)
- Risk of pancreatitis and cholangitis
• ESWL not approved in U.S.
• Cholecystostomy tube
31. Gallbladder Dyskinesia
• Decreased GB ejection (via CCK-HIDA)
fraction may predispose to gallstone
formation
• Controversial whether cholecystectomy
leads to symptomatic improvement
• More common in subjects with functional
bowel disorders
32. Gallbladder Polyps
• Common: 1-5% of population
• > 95% non-neoplastic (mostly cholesterol)
• Follow with ultrasound for 6 month-1 yr
intervals
• If growth > 10 mm, cholecystectomy
• If no growth after 2 yrs, can dispense
surveillance
• GB polyp (any size) + PSC = surgery
33. Gallbladder Polyps
• Cholesterolosis: Most common (60%)
• Adenomyomatosis (25%)
• Inflammatory (10%)
• Adenoma: rare
- May be precursor to GB cancer
34. Gallbladder Polyps
• Cholesterolosis
- Cholesterol / TG within epithelial
macrophages
- Local or diffuse
- Can be combined with cholesterol polyps
- 10-15% autopsy series
- Ultrasound remains best way to detect
- Rarely thought to be symptomatic
36. Gallbladder Polyps
• Adenomyomatosis
- Hypertrophy of the muscle layer
- Usually focal (fundus) although can be
diffuse
- Incidental and asymptomatic
- Classic comet tail appearance on US
- Surgery when wall > 10 mm, associated
mass or in rare instances with diffuse
disease
46. Choledocholithiasis
• Recurrent biliary colic in the post-
cholecystectomy patient
• ERCP for patients with high probability
- 95% success rate
- 5% complication rate
• For low or intermediate probability
- MRCP – usually for low probability
- EUS – often for intermediate probability
47. Choledocholithiasis
• Biliary sphincterotomy
• Balloon / basket extraction
• Balloon sphincteroplasty
- For larger stones; usu after small sphincterotomy
• Lithotripsy
- Mechanical (basket)
- Cholangioscopy
• Laser
• Electrohydraulic (EHL)
- Extracorporeal shockwave lithotripsy
48. Sphincter of Oddi Dysfunction
• Stenosis or spasm of the Sphincter of Oddi
• Persistent / recurrent biliary pain following
cholecystectomy without structural
abnormalities
• Idiopathic recurrent pancreatitis
- Recent study shows no advantage to dual
sphincterotomy over biliary sphx alone
• Biliary type pain with intact gallbladder and
no stones
49. Sphincter of Oddi Dysfunction
• Type I:
- biliary type pain, elevated liver enzymes
(> 2x nl on two occasions)
- bile duct diameter > 12 mm on ERCP
- delayed contrast drainage > 45 minute
• Type II: biliary type pain and 1 or 2 of the
aforementioned criteria
• Type III: biliary type pain only
Rome III criteria: Doesn’t include contrast drainage as a criteria.
50. Sphincter of Oddi
Dysfunction
• Type I: empiric biliary sphincterotomy
• Type II: sphincter of Oddi manometry
(SOM)
- Abnormal in up to 50-63% pts
- Pain relief up to 85% in this subset with
biliary sphincterotomy
- Normal SOM and sphincterotomy:
controversial
51. Sphincter of Oddi
Dysfunction
• Type III:
- Less than 10% response to
sphincterotomy
- NIH sponsored trial recently published in
JAMA shows NO benefit for manometric
testing and sphincterotomy
- ERCP +/- SOM no longer recommended
- Consider other treatments for functional
bowel disorders
Cotton et al, JAMA 2014, 311:(20)
52. Sphincter of Oddi Manometry
Basal pressure > 40 mm Hg
Correlates best with presence
of symptoms and relief
following sphincterotomy
53. Choledochal Cysts
• Congenital anomalies of the biliary tree
• Incidence: 1/100-150,000
• 15-100 x more common in Japan
• Females more commonly affected (3-4:1)
• 2/3 cases manifest by age 10
• More seen in adults recently
• Classic triad: Abd. Pain, jaundice, palpable
mass
54. Choledochal Cysts
• Type I: (most common) 80-90% of cases.
Fusiform dilation of CBD (segmental or
diffuse)
• Type II: Choledochal diverticulum: 2%
• Type III: Choledochocele (intraduodenal
dilation): 1-5%
• Type IV: Multiple extra +/- intrahepatic
cysts
- 10%, divided into and A and B type
• Type V: Multiple intrahepatic dilation
(Caroli’s disease): rare, but up to 20% in
some series
55. Choledochal Cysts
• Association with anomalous union of pancreatic
and biliary ducts (seen in 50-80%)
- Recommend cholecystectomy for GB CA risk
• Jaundice, abdominal pain, intraductal stones
• At risk for cholangiocarcinoma (esp. I and IV)
- Risk of 10-30%; 20-30 x gen. population
• Surgical excision for most cysts
- Type III: Large biliary sphincterotomy
• Caroli's disease associated with congenital hepatic
fibrosis, renal tubular ectasia and polycystic kidney
disease
57. Board Questions
• 39 yo male presents with
pruritis, jaundice and
pain
• No prior PMH or PSH
• FH is non-contributory
• PE: scleral icterus, mid-
epigastric tenderness
• LABS: Alk phos: 487,
• Bili: 5.2, AST: 164, ALT:
628
• CT on right panel
revealed no stones:
Coyle in GASTRO 2010;138:e3–e4
59. Board Question 1: What is the
most likely diagnosis?
• A. Choledocholithiasis
• B. Peri-ampullary diverticulum
• C. Choledochal Cyst
• D. Ampullary adenoma
• E. None of the above
60. Board Question 2: What is the
best treatment?
• A. Observation
• B. Ampullectomy
• C. Whipple resection
• D. Sphincterotomy
• E. None of the above
61. Board Question Answer
• This is a choledochal
cyst, Type III
• Aka Choledochocele
• Can usually be
treated by large,
biliary
sphincterotomy that
unroofs the cyst
Coyle in GASTRO 2010;138:e3–e4
62. Summary
• Stone disease: Common
- Know the types and pathogenesis
- Know the complications and treatment
• Gallbladder polyps
- Know the types and natural history
• Acalculous cholecystitis
- Recognize and treat
• Choledocholithiasis:
- Know how to diagnose and treat
63. Summary
• Ascending Cholangitis: Recognize,
urgent treatment
- Know organisms and causes
• Sphincter of Oddi dysfunction
- Know sub-types and treatment
• Choledochal cysts
- Know types, natural history and
treatment
