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Gallbladder and biliary system

i. Gallstones

Many individuals have gallstones present in their gallbladders. The majority never cause problems. However, in certain individuals these gallstones cause symptoms.

Biliary colic is the most common symptom caused by gallstones. This occurs when a stone moves to sit in the neck of the gallbladder. When the gallbladder contracts, e.g. after eating, this can cause upper abdominal pain that may be burning or cramping in nature. In this situation it is usually advised that the gallbladder be surgically removed.

Inflammation of the gallbladder can occur as a result of various diseases. The most common cause is gallstones blocking the neck of the gallbladder. Inflammation can be acute, with individuals becoming feverish and experiencing severe abdominal pain. It can also be chronic, with longstanding pain in the right upper part of the abdomen.

Gallstones may also move into the common bile duct, which drains into the small bowel. Here they can cause a blockage which results in jaundice and possibly infection of the bile ducts – called cholangitis. This condition can be life-threatening and it is very important to relieve the blockage quickly. The best way to achieve this is usually by a procedure called an ERCP (See Endoscopic Retrograde Cholangiopancreaticography). Gallstones moving down the common bile duct can also cause pancreatitis (inflammation of the pancreas).

If any of these complications develop from gallstones, then it is recommended to remove the gallbladder surgically (cholecystectomy). This is usually performed laparoscopically (“key-hole surgery”), but if it is a difficult operation then a traditional surgical procedure may be done. Sometimes gallstones are found in the common bile duct after cholecystectomy, and need to be removed by ERCP.

ii. Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a progressive disease causing scarring (fibrosis) and destruction of the biliary ducts. It can involve only the larger ducts, only the small ducts in the liver, or both. There is a strong association of PSC with inflammatory bowel disease, especially ulcerative colitis. The cause of PSC is not known, but classically it affects young adult males with ulcerative colitis.

Diagnosis

The best test to diagnose PSC affecting the larger ducts is ERCP (See Endoscopic Retrograde Cholangopancreaticogram). However, because this test is invasive and has a risk of complications, another test called a Magnetic Resonance Cholangiopancreaticogram (MRCP) is usually used instead. This is a form of MRI scan, and is done at a radiology practice. If small duct PSC is suspected, a liver biopsy can be performed to diagnose this.

Treatment

PSC should be managed by a gastroenterologist or hepatologist. It does not respond well to treatment, but its progression can be slowed by the use of a drug called urso-deoxycholic acid. Management involves prevention of and watching for complications of the disease, including:

  • Liver cirrhosis
  • Osteoporosis
  • Cholangitis (infection of the biliary ducts)
  • Blockage of the biliary ducts
  • The development of certain forms of cancers e.g. colorectal cancer and cholangiosarcoma

iii. Pancreatic exocrine insufficiency

One of the roles of the pancreas is to aid in the digestion of food. When this function is disturbed, there can be maldigestion and malabsoprtion of food, particularly fats. Manifestations include malnutrition and greasy, loose stools. The main causes of pancreatic insufficiency are:

  • Inadequate production of pancreatic juice and enzymes.
  • Structural abnormailities of the pancreatic duct system preventing delivery of pancreatic juice to the gut.
  • Surgical procedures which disrupt the normal mixing of pancreatic juice and food.

 

Diagnosis
Diagnosis involves demonstration of malnutrition with low enzyme levels in the stools, with or without abnormalities on imaging of the pancreas structure. A cause for the pancreatic insufficiency should be sought.

Treatment
The condition is treated primarily with pancreatic enzyme replacement therapy. Adequate doses of enzyme replacement should be administered to achieve the desired response. In addition, measures should be taken to ensure adequate nutritional intake. Consultation with a dietician is recommended.