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Oxford Textbook of Medicine (5 ed.)

Edited by David A. Warrell, Timothy M. Cox, John D. Firth

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Latest update

The November 2012 update sees updates to over 70 chapters, focusing on Neurology and Gastroenterology. This update also incorporates a selection of 29 Case Histories taken from related titles in the Oxford Case Histories series, linked to from related chapters. Each case includes several questions followed by detailed answers and discussion to enhance diagnostic and clinical understanding.

Neurology updates include substantial updates to key chapters and new material on a wide range of topics including spinal cord injury, autonomic nervous system disorders, and inherited neurodegenerative diseases. 

Gastroenterology updates include extensive revisions of key chapters on liver failure and acute pancreatitis and new material on a wide range of matters, ranging from the common to the rare: including surgical treatments for colonic diverticular disease, antibody tests for immune disorders, and a revised treatment algorithm for small bowel bacterial overgrowth.

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Publisher:
Oxford University Press
Print Publication Date:
May 2010
Print ISBN-13:
9780199204854
Published to Oxford Medicine:
May 2012
DOI:
10.1093/med/9780199204854.001.1

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Disclaimer

Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding.

Contents

Diseases of the gallbladder and biliary tree

Chapter:
Diseases of the gallbladder and biliary tree
Author(s):

J.A. Summerfield

DOI:
10.1093/med/9780199204854.003.1523

November 28, 2012: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

Diseases of the gallbladder and bile ducts are common, with gallstones and their complications being most frequent. Less common are biliary strictures, usually malignant, which are caused by adenocarcinomas of the pancreas, bile ducts, ampulla of Vater, and gallbladder. Rarely encountered are sclerosing cholangitis and a variety of congenital disorders.

Disorders of the biliary system usually give rise to the symptoms and signs of biliary obstruction (cholestasis), including pain (ranging from ‘dyspepsia’ to severe right hypochondrial colic), jaundice, itching, nausea and vomiting (which may be prominent in sudden obstruction of the bile duct, usually by a gallstone), fevers, and rigors (indicating bacterial infection of the biliary tract, which frequently accompanies partial obstruction). Jaundice, dark urine, and pale stools indicate obstruction of the bile duct. Weight loss may be due to fat malabsorption, but can also be caused by malignancy. Prolonged biliary obstruction leads to skin changes of increased pigmentation (due to melanin) and cholesterol deposition (xanthelasma and xanthoma). Biliary cirrhosis can cause portal venous hypertension and liver cell failure.

Disorders of the biliary system generally give rise to the biochemical picture of cholestasis: the serum (conjugated) bilirubin concentration may be normal or raised; serum alkaline phosphatase, γ-glutamyl transferase and bile acids are elevated; serum transaminases show only modest elevation. Bilirubinuria is present, with the disappearance of urobilinogen from the urine indicating complete biliary obstruction.

Imaging is critical in the diagnosis of biliary disease, initially by ultrasonography, with CT scanning and MRI then employed in more complicated cases. However, these investigations sometimes provide insufficient anatomical detail for diagnosis or planning of treatment, in which cases further imaging with the cholangiographic techniques of magnetic resonance cholangiography (MRC), endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) are required. ERCP and PRC can be used to place biliary stents.

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