Medical and Surgical Approach to Biliary and Gallbladder Disease

1. Medical and Surgical Approach to Biliary and Gallbladder Disease Norman H. Gilinsky, M.D., FACP, FACG Associate Professor of Medicine Medical Director, Digestive Diseases Center University of Cincinnati

2. ObjectivesAt completion of this lecture, the student will be able to: • State the main disorders afflicting the gallbladder and biliary system • Describe the interventions employed in differentiating biliary from other disorders • Formulate a management plan for diagnosing biliary diseases • Develop a strategy to treat gallbladder and biliary diseases • Differentiate between benign and malignant biliary diseases

3. Biliary and GallbladderDiseaseClinical Classification of Disorders • Gallstones • Strictures and other obstructions to bile flow • Lumen (stone, blood, foreign body) • Bile duct (post-operative, benign, malignant) • Extrinsic compression (benign, malignant) • Cholangitis • Bacterial • Sclerosing (PSC) • Other (congenital, infections, medications, post-surgical syndromes, etc)

4. Biliary and GallbladderDiseaseClinical Approach Requires Understanding of: • Biliary anatomy • Relevance of liver enzyme abnormalities • Hepatocellular vs cholestatic • Role (and limitations) of imaging techniques • Ultrasound • CT scan • ERCP • HIDA scan • Clinical symptoms associated with biliary disorders

5. Biliary and GallbladderDiseaseImaging Modalities (1) • Ultrasound: Good for gallbladder, calculi, bile duct visualization (esp in liver); not expensive, generally readily available • CT scan: Generally good for visualizing bile ducts and other intraabdominal organs, staging ot tumors. Expensive • ERCP: Excellent for ductal visualization, including pancreas, therapeutic (removal of stones in bile duct, placement of stents for palliation; invasive; very operator dependent One of the above utilized as initial imaging modality in virtually 100% of patients with suspected biliary disease

6. Biliary and GallbladderDiseaseImaging Modalities (2) • HIDA scan: Nuclear medicine study. Helpful if suspect gallbladder dysfunction (esp acute cholecystitis) when other imaging equivocal. Many false negatives (and positives). Cannot be used if significant jaundice. • Oral cholecystogram: Oral contrast taken up by gallbladder. Rarely used these days • PTC (percutaneous transhepatic cholangiogram):Performed by interventional radiologist. Invasive. Occasionally employed when ERCP unable to be performed and non-surgical intervention required • EUS: Ultrasound system attached to endoscope

7. Biliary and GallbladderDiseaseWorkup Helps Determine Ultimate Management Plan • Liver enzyme profile • Is there evidence for cholestasis? • Imaging modality • Is there evidence of biliary pathology (stone, mass, dilated/obstructed ducts)? • What is the level of the obstruction? • Clinical judgement • What is the likely disease process? • How best to confirm (radiology, tissue, serology)? • How best to treat, palliate?

8. Gallstones • Incidence 10% • More common in women • Majority asymptomatic • Is a cause of significant morbidity if complicate

9. Types of Gallstones • Cholesterol • >75% of gallstones • Arise by crystallization of bile • Pigment • Approximately 10-20% of gallstones; calcium bilirubinate • Arise from precipitation of unconjugated bilirubin or associated with biliary infection

10. GallstonesRisk Factors for Cholelithiasis • Age • Gender (multiparity, pregnancy) • Obesity • Hereditary • Drugs (e.g. hormones, TPN) • Other (ileal disease, rapid weight loss, etc) • Chronic hemolytic states

11. GallstonesNatural History • Asymptomatic • Majority (>2/3) asymptomatic • Risk of symptoms about 2% per year • Complication rate 0.1% per year • No treatment necessary • Symptomatic • If symptomatic episode resolves, risk of future problems 35% by 5 years; complication 1% per year • Treat all (few exceptions)

12. Spectrum of Gallstone Disease • Gallbladder (>85%) • Biliary colic • Acute cholecystitis* • Bile duct (choledocholithiasis) • Biliary obstruction • Ascending cholangitis** • Pancreatitis *With risk of septic complications, perforation; **With risk of septicemia, liver abscesses

13. Biliary ColicAcute inflammationof the gallbladderabsent • Clinical features • Episodic, epigastric, RUQ • Pain or discomfort rises steeply in intensity • May last hours • May wake patient from sleep

14. Biliary Colic • Diagnosis • Compatible clinical picture • Bloodwork often normal • Confirm gallstones (ultrasound most cost-effective) • Treatment • Symptomatic (if seen during acute episode) • Elective cholecystectomy • Laparoscopic vs open • Other (rarely employed now) • Shock wave lithotripsy, dissolution agents

15. Acute CholecystitisAcute inflammation of the gallbladderpresent • Clinical features • Epigastric, RUQ pain often persistent • May radiate to right shoulder, infrascapular • Tender RUQ, Murphy’s sign, rigidity, fever, tachycardia, chills may be present • Differential diagnosis • Any intraabdominal infection, hepatitis, pneumonia, perforated viscus, pyelonephritis

16. Acute Cholecystitis • Diagnosis • Compatible clinical picture • White count, liver enzymes may be elevated • Radiology • X-ray abdomen (to exclude other pathologies, may see calcification RUQ) • Ultrasound (or CT, HIDA) • Treatment • Antibiotics (with gram –ve coverage) • Cholecystectomy

17. Complications of Gallstones and Cholecystitis • Compression of bile duct (Mirizzi’s syndrome) • Mucocele, empyema, emphysematous cholecystitis (air in gallbladder wall) • Gangrene, perforation, bile peritonitis • Cholecyst-enteric fistula (air in gallbladder lumen) • Gallstone ileus (small bowel obstruction) • Porcelain gallbladder (calcified gallbladder wall) • Carcinoma (rare) • Choledocholithiasis (about 10%)

18. CholedocholithiasisMost calculi originate from gallbladder; some primary. Symptoms and complications likely, therefore remove even if asymptomatic • Presentation • Biliary colic • Obstructive jaundice • Cholangitis • Pancreatitis • Secondary biliary cirrhosis • Symptoms and Signs • Of obstruction: Pain, jaundice, cholestasis • Of secondary infection (cholangitis): Sepsis, fever

19. Choledocholithiasis • Diagnosis • Demonstration of cholestasis (elevated bilirubin, alkaline phosphatase) • Demonstration of dilated bile ducts; and or demonstration of filling defects in bile duct • Imaging modality (US, CT, ERCP) • Treatment • Endoscopic sphincterotomy and stone extraction • Surgery

20. Other Gallbladder Disorders • Polyps • Asymptomatic, benign. No treatment necessary • Concern if large, irregular shape • Acalculous cholecystitis • Severe inflammatory disorder in absence of calculi • Often painful, but may present with fever or general deterioration in already ill, hospitalized patient • Thought to be ischemic; may result in sepsis, perforation. Thick wall on US; air in wall ominous • Also a complication of salmonellosis

21. Biliary and GallbladderDiseaseBacterial Cholangitis • Infection of bile duct system (invariably obstructed) • Majority have pain, jaundice and fever (Charcot’s triad) • Elevated bilirubin, WBC, alkaline phosphatase invariable • High fatality if untreated Blood cultures often yield gram negative organism (E. coli, Klebsiella, Pseudomonas, enterococci, Proteus, anaerobes) • Diagnosis as for choledocholithiasis • Treat with intravenous antibiotics, obtain biliary drainage, treat specific cause • Sequelae include all complications of Gram –ve septicemia, liver abscess, shock syndrome

22. Biliary and GallbladderDiseaseOther Causes of Cholangiopathy(Inflammatory disorder of the bile ducts) • Primary sclerosing cholangitis • Autoimmune • AIDS cholangiopathy • Cryptosporidiosis • CMV • Cholangiocarcinoma • Chemotherapy (hepatic artery infusion) • Biliary papillomatosis

23. Primary Sclerosing Cholangitis • Inflammatory disorder of intra- and or extra-hepatic bile duct system • May be immunologic mediated (pANCA) • Males, >50% have inflammatory bowel disease • Results in multiple bile duct strictures • Progressive cholestatic disorder • Predisposed to liver failure, cholangiocarcinoma

24. Bile Duct Neoplasms • Intrinsic • Primary bile duct origin (cholangiocarcinoma) • Ampullary • Gallbladder • Extrinsic • Pancreatic carcinoma • Periampullary carcinoma • Contiguous malignant process

25. Biliary TumorsPresentation & Diagnosis • Present with cholestasis, jaundice. May have weight loss, abdominal mass. Pain not always present • Biochemistry invariably abnormal (cholestasis) • Imaging modality often reveals obstructed, dilated bile ducts. Mass may be present • Tissue sampling to confirm diagnosis (radiologically-guided aspiration or by ERCP)

26. Biliary TumorsTreatment Strategy • Relieve mechanical obstruction • ERCP and stent placement • Percutaneous placement (by radiology) • Surgery • Cure may not be possible • Therefore palliation often required • Supportive treatment • Itch, pain, nutrition, bowel obstruction

27. References • Greenberger NJ, Isselbacher KJ. Diseases of the gallbladder and bile ducts. In: (eds. Fauci AS, et al): Harrison’s Principles of Internal Medicine, 14th edition, vol #2, pp 1725-1736; McGraw-Hill, New York, 1998 • Lee YM, Kaplan MM. Primary sclerosing cholangitis. N Engl J Med 1995; 332:924