C Anatomic and physiologic considerations • The entoero-hepatic circulation of bilirubin • The hepatobilary tree • Characteristics of pain of biliary origin Diagnostic evaluation of the gallbladder Plain abdominal X-ray Low cost, readily available. Relatively low yield. Contraindicated in pregnancy. Pathognomic findings: calcified gallstones, limey bile, porcelain gallbladder, emphysematous cholecystitis, gallstone ileus Gallbladder ultrasound (US) Rapid; Accurate identification of gallstones (>95%); Simultaneous scanning of gallbladder, liver, bile ducts, pancreas; „Real-time” scanning allows assessment of gallbladder volume, contractility; May detect very small stones. Diagnostic limitations: Bowel gas, massive obesity, ascites, recent barium study. Not limited by jaundice, pregnancy. Procedure of choice to detect stones. Radioisotope scans (HIDA, DIDA, etc.) Accurate identification of cystic duct obstruction. Simultaneous assessment of bile ducts. Contraindicated in pregnancy and when se Bi >103-205 uM/L. Cholecystogram low resolution. Indicated for confirmation of suspected acute cholecystitis. Less sensitive and less specific in chronic cholecystitis. Useful in diagnosis of acalculous cholecystopathy, esp. if given with CCK to assess gallbladder emptying. Diagnostic evaluation of the bile ducts Hepatobiliary ultrasound Ultrasonography of duct stones is not as reliable as of those in the bile duct. Rapid; simultaneous scanning of gallbladder, liver, bile ducts, pancreas. Diagnostic limitations: bowel gas, massive obesity, ascites, barium, portal bile duct obstruction. Poor visualization of distal common bile duct. Initial procedure of choice in investigating possible biliary tract obstruction. CT of the biliary tract Simultaneous scanning of gallbladder, liver, bile ducts, pancreas. Accurate identification of dilated bile ducts, masses. Not limited by jaundice, gas, obesity, ascites. High-resolution image. Guidance for fine-needle biopsy. Diagnostic limitations: Extreme cachexia, movement artifact, ileus, partial bile tract obstruction, high cost, may not be readily available. Contraindicated in pregnancy. Reaction to iodinated contrast, if used. Indicated for evaluation of hepatic or pancreatic masses. Procedure of choice in investigating possible biliary obstruction if diagnostic limitations prevent US. MR of the biliary tract Useful modality for visualizing pancreatic and biliary ducts. Can identify pancreatic duct dilatation or stricture, pancreatic duct stenosis, and pancreas divisum. Has excellent sensitivity for bile duct dilatation, biliary stricture, and intraductal abnormalities. Cannot offer therapeutic intervention. Endoscopic retrograde cholangiopancreatogram (ERCP) Simultaneously pancreatography can be performed. Visualization/biopsy of ampulla and duodenum. Best visualization of distal biliary tract. Bile or pancreatic cytology can be taken. Biliary manometry, endoscopic sphincterotomy and stone removal can be done. Not limited by ascites, coagulopathy, abscess. Diagnostic limitations: gastroduodenal obstruction. Contraindications: Absolute: pregnancy, Relative: acute pancreatitis, severe cardiopulmonary disease. Complications: pancreatitis, cholangitis, sepsis, infected pancreatic pseudocyst, perforation (rare), hypoxemia, aspiration. Cholangiogram of choice in: absence of dilated ducts, pancreatic, ampullary or gastroduodenal disease, prior biliary surgery, when PTC is contraindicated or failed. Endoscopic sphincterotomy is a treatment possibility. Percutaneous transhepatic cholangiogram (PTC) Extremely successful when dilated ducts are dilated. Best visualization of proximal biliary tract. Possible separate visualization of obstructed left ductal system. Bile cytology/culture and percutaneous transhepatic drainage can be performed. Diagnostic limitations: Nondilated or sclerosed ducts. Contraindications: pregnancy, uncorrectable coagulopathy, massive ascites, hepatic abscess (relative). Complications: bleeding, hemobilia, bile peritonitis, bacteremia, sepsis. Usually initial cholangio-gram of choice when bile ducts are dilated. Cholelithiasis Symptoms • Predisposing factors: 3F: female, fat, forty/fifty • Occur following fatty meal • Typically crampy pain n in the right upper quadrant, radiating to the tip of the scapula Laboratory findings • Signs of inflammation, more expressed when cholecystitis is present: elevated ESR, CRP, leukocytosis with the shift to the left • Signs of obstruction only in choledocholithiasis Treatment • Cholecystectomy (laparoscopic preferred) • In case of cholecystitis: antibiotics (amoxicillin, metronidazole) Complications of cholelithiasis • Acute and chronic cholecystitis (gallbladder cc!) • Choledocholithiasis, biliary tract obstruction • Hydrops • Empyema • Perforation of the cholecyst • Gallstone ileus Acute cholecystitis • Symptoms: as above + fever, chills • Elevated ESR, CRP, leukocytosis with the shift to the left • Treatment: cholecystectomy (emergency or elective), antibiotics (amoxicillin, metronidazole) Choledocholithiasis • Typical pain + jaundice, dark urine, clay-like stool • Direct hyperbilirubinemia, elevated serum alkaline phosphatase, (less elevated serum transaminases) • Differential diagnosis: other causes of biliary tract obstruction: cholanciocarcinoma, Vater papilla sclerosis and carcinoma, primary sclerotizing cholangitis • Courvoisier’s sign: jaundice with painless palpable gallbladder • Therapy: Surgical: choledochotomy, cholecystectomy, ERCP Sources • Harrisons’ Principles of Internal Medicine 17 th edition • Images MD .