Biliary disease

Cholelithiasis: often asymptomatic. Biliary colic: episodic RUQ after meals, US first.

Tushar Kamath5 min6 questions1 trials

Stones in the gallbladder vs stones in the duct

Cholelithiasis

6% of men, 9% of women. <20% ever become clinical; larger, multiple, older stones and female sex raise events ().
Biliary colic: dull RUQ / epigastric pain 30 min–6 h, postprandial, ± nausea — the gallbladder squeezing on a stone.
RUQUS Sn 84%, Sp 99% > CT (Sn 55–80%). Labs usually normal.
Cholesterol stones most common; pigment stones with Crohn’s / ileal disease, hemolysis, TPN.
Asymptomatic: observe. CCY if GB-cancer risk (stone >3 cm, porcelain GB, adenoma). Symptomatic: elective CCY.

Choledocholithiasis

RUQ pain, nausea, jaundice — or silent.
↑ ALP, ↑ bilirubin ± ↑ AST/ALT.
RUQUS looks for CBD >7 mm (poor at seeing the stone itself). Repeat US, MRCP, or EUS if equivocal.
High probability (very high bili, dilated CBD, visualized stone): go to ERCP. Intermediate: MRCP / EUS (ASGE).
ERCP stone extraction, then interval CCY. Can form de novo in the CBD after cholecystectomy.
Complications: cholangitis, pancreatitis.

Complications of gallbladder stones: cholecystitis, choledocholithiasis, pancreatitis, GB cancer, gallstone ileus, Mirizzi (stone compressing CBD/CHD) (J ; J Hep Panc Sci 2018;25:41).

Cholecystitis vs cholangitis

Cholecystitis (cystic duct)

Persistent RUQ pain to back/shoulder, Murphy, fever, nausea.
↑ WBC; ALP/bili may be up — marked rise suggests CBD obstruction.
RUQUS: wall thickening, pericholecystic fluid, sonographic Murphy. HIDA if still unsure (morphine 2 mg IV raises sensitivity; ). Tokyo guidelines for diagnosis and severity.
Pip-tazo or ceftriaxone + metronidazole. Early CCY this admission (<7 d) cuts morbidity ().
Too sick or failing 1–3 days of antibiotics: percutaneous cholecystostomy. Stop antibiotics 24 h post-CCY unless septic / perc tube (then 4–7 d; JAMA Surg 2019;154:873).
Acalculous: ICU, TPN, burns, fasting, sepsis — ischemia without a stone; high perforation risk ().

Cholangitis (infected obstructed duct)

Stone, stricture (malignancy, PSC, AIDS), liver fluke.
↑ WBC, ↑ ALP, ↑ bilirubin, ± striking transaminase spikes.
RUQUS for dilation, then MRCP/ERCP. Tokyo guidelines time the drainage.
Broad antibiotics (pip-tazo or ceftriaxone/metronidazole) × 7 days.
Urgent ERCP decompression <24–48 h if organ dysfunction / or if not improving at 24 h. Percutaneous drainage if ERCP is impossible. Interval CCY if gallstones.
Palliative CBD stents in malignancy are a cholangitis trap.

Charcot triad

RUQ pain
Jaundice
Fever

Reynolds pentad

Charcot triad
Altered mental status

Autoimmune biliary disease

PBC (AASLD: Hepatology 2019;69:394)

Women; intrahepatic ducts. Asymptomatic 50–60%; pruritus, fatigue, sicca; cirrhosis late.
Dx ≥2 of: ALP ≥1.5× ULN; AMA >1:40 (95%) or gp210 / sp100 if AMA-negative; compatible biopsy.
Associates: dyslipidemia, hypothyroidism, osteoporosis, Sjögren, AIH overlap.
Ursodiol first-line — slows progression and improves survival (). Obeticholic acid second-line (contraindicated in portal hypertension / decompensation). Fibrates off-label. Cholestyramine for itch; modafinil for fatigue. Transplant: ~22% recurrence at 5 .

PSC (AASLD: Hepatology 2022;77:659)

Men; intra- + extrahepatic ducts. Asymptomatic 50%; pruritus, fatigue, stricture-related cholangitis.
↑ ALP ± bili. Autoantibodies nonspecific. MRCP (beading); biopsy only if imaging negative (small-duct PSC). Check AMA / IgG4 to exclude mimics.
IBD in >70% (UC > Crohn). CCA risk 160–400×; also GB cancer, metabolic bone disease, AIH overlap.
Supportive care. Ursodiol may help symptoms. ERCP for dominant strictures. Transplant is definitive (MELD exceptions for recurrent cholangitis or intractable pruritus); ~20% recurrence at 5 .
Annual MRI/MRCP + CA 19-9 for CCA and GB cancer; add HCC screening once cirrhotic.

Malignancy, sphincter of Oddi, imaging

Gallbladder carcinoma: stones (34× risk), porcelain GB, polyps, PSC, chronic infection. LFTs often normal; ↑ CA 19-9 / CEA. RUQUS first, then CT/MRI/MRCP.
Cholangiocarcinoma: extrahepatic 90%, intrahepatic 10%. PSC, liver flukes, intrahepatic stones. ↑ ALP, bili, CA 19-9 / CEA. US then ERCP / MRCP / EUS.
Sphincter of Oddi dysfunction: women, often post-CCY, opioid-provoked spasm, idiopathic recurrent pancreatitis. Rome IV. ERCP with manometry. Sphincter ablation (Curr Gastro Rep 2015;17:31).

Am J Roentgenol 2011;197:551. Normal US does not exclude a passed or missed CBD stone.

Question	First test	Next
Gallstones / cholecystitis	RUQUS	HIDA if US equivocal
Choledocholithiasis, intermediate probability	RUQUS (dilation)	MRCP or EUS, then ERCP
Choledocholithiasis, high probability	RUQUS	Straight to ERCP
Cholangitis	RUQUS + labs	Urgent ERCP (drainage is therapy)
PSC / CCA anatomy	MRCP	ERCP + sampling, CA 19-9