Understanding Biliary Diseases

Overview

• Four diseases: Cholelithiasis, Cholecystitis, Choledocholithiasis, Cholangitis.
• Severity order: Cholelithiasis (least severe) -> Cholangitis (most severe).

Biliary Tree Anatomy

• Liver: Drained by right and left hepatic duct.
• Gallbladder: Drained by the cystic duct.
• Common Bile Duct: Formed by the hepatic and cystic ducts; joined by the pancreatic duct; empties into the duodenum.

Disease Details

1. Cholelithiasis

• Definition: Stone formation inside the gallbladder.
• Symptoms:
  • Colicky pain in right upper quadrant.
  • Worsens with fatty foods.
  • No fever or systemic signs.
• Diagnosis: Right upper quadrant ultrasound showing acoustic shadowing.
• Treatment: Elective cholecystectomy.
• Stone Types: Cholesterol stones (cholesterol supersaturation) and pigmented stones (hemolysis).

2. Cholecystitis

• Definition: Inflammation of the cystic duct and gallbladder due to obstruction.
• Symptoms:
  • Constant right upper quadrant pain.
  • Fever and leukocytosis.
  • Positive Murphy's sign (pain on deep breath when liver/gallbladder drops onto hands).
• Diagnosis: Right upper quadrant ultrasound or HIDA scan.
• Treatment: Cholecystectomy (not elective).

3. Choledocholithiasis

• Definition: Stone in the common bile duct.
• Symptoms:
  • No inflammation, fever, or leukocytosis.
  • Causes obstructive jaundice and dilates hepatic bile ducts.
• Diagnosis & Treatment:
  • ERCP: Diagnostic and therapeutic.
  • Alternative: MRCP (only diagnostic).

4. Cholangitis

• Definition: Infection in the biliary tree, often due to choledocholithiasis.
• Symptoms:
  • Charcot's triad: Fever, jaundice, right upper quadrant pain.
  • Reynolds' pentad (advanced): Charcot's triad + hypotension + altered mental status.
• Diagnosis: Right upper quadrant ultrasound.
• Treatment: Emergent ERCP to remove obstruction.

Key Points

• Cholelithiasis: Stones in gallbladder; elective removal.
• Cholecystitis: Cystic duct inflammation; requires immediate treatment.
• Choledocholithiasis: Stone in common bile duct; diagnostic and therapeutic ERCP.
• Cholangitis: Infection of biliary tree; requires emergent treatment.
• High-yield for Exams: Differentiate based on symptoms, lab findings, and imaging.

Summary

• Understanding the anatomy and symptom presentation is crucial.
• Use clinical signs and diagnostic tools to differentiate diseases.
• Prepare for exams by knowing these differentiations and treatments.