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Diseases of the gallbladder and biliary tree 

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

July 30, 2015: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

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date: 29 April 2017

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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