Gall bladder & bile duct diseases

Gallstone disease

Overview

Gallstones are made of cholesterol, excess bilirubin and bile salt deposits and are more common in women. Gallstones vary in colour, from yellow-green to red-brown. They can range in size from a grain of sand to a golf ball. Some people develop only one gallstone, while others develop multiple gallstones simultaneously.

Signs and symptoms

Gallstones may not cause any symptoms until they get stuck and cause a blockage to bile drainage from the gall bladder. This leads to inflammation, bloating and pain. It may present as a sudden, intense pain in the upper right abdomen, between the shoulders or the right shoulder. The patient may also experience nausea.

Causes and risk factors

Gallstones could be caused by excess cholesterol and bilirubin in the bile or due to improper emptying of the gallbladder. Being overweight, eating a high cholesterol diet or having certain diseases of red blood cells puts one at a higher risk for Gallstones.

Complications

Gallstones can cause inflammation of the bile ducts, blockage of the common bile duct, blockage of the pancreatic duct or gall bladder cancer.

Diagnosis

The diagnosis begins with a physical exam and a patient history. The doctor may require a series of blood tests to check liver function and imaging tests to visualise the gallstones.

Treatment and Surgical Interventions

Treatment isn’t necessary for gallstones unless they cause symptoms. If there is pain, the doctor may go in for surgical removal of the gall bladder, which can usually be performed laparoscopically.

Prevention

You can reduce your risk of gallstones by maintaining a healthy diet, eating high-fibre foods, losing weight in a phased manner.

Bile duct stones

Overview

Bile duct stones are made of cholesterol, excess bilirubin and bile salt deposits. Bile duct stones usually arise in the gall bladder (gall stones) and slip into the bile duct and cause problems. Rarely, these stones may be formed in the bile duct itself. These stones may be asymptomatic or may cause obstruction of the bile duct, causing jaundice, bile duct infection (cholangitis) or inflammation of the pancreas (pancreatitis).

Signs and symptoms

Bile duct stones may not cause any symptoms until they get lodged in the common bile duct and cause a blockage. This leads to inflammation, bloating and pain. It may present as a sudden, intense pain in the upper right abdomen, between the shoulders or the right shoulder. The patient may also experience nausea, jaundice, lack of appetite and fever.

Causes and risk factors

Bile duct stones could be caused by excess cholesterol and bilirubin in the bile or due to improper emptying of the gallbladder. Presence of many small gall stones increases the risk of bile duct stones as they can easily slip into the bile duct. Some parasitic infections common in Northern and Eastern India can cause bile duct stones and stones in the small bile ducts within the liver (hepatolithiasis)

Complications

Bile duct stones can cause inflammation of the gallbladder, blockage of the pancreatic duct, cholangitis or gallbladder cancer.

Diagnosis

The diagnosis of gallstones begins with a physical exam and a patient history. The doctor may require a series of blood tests to check liver function and bilirubin levels and imaging tests to visualise the bile duct stones.

Treatment and Surgical Interventions

Bile duct stones are first treated with antibiotics to prevent infection and medications to make the bile thin and facilitate their dissolution. Additional procedures may be necessary if the stones are causing jaundice or other complications. This usually includes endoscopic removal of stones or, occasionally, surgery. It is recommended that the gall bladder be removed in these patients to prevent recurrent bile duct stones.

Prevention

A high-fibre, low cholesterol diet helps reduce the risk of developing gall stones and bile duct stones.

Cholangitis

Overview

Cholangitis is inflammation of the bile duct. It is usually caused by a bacterial infection when there is a complete or partial blockage of the bile duct. Occasionally it can be caused by autoimmune conditions where the individual’s immune system damages the bile duct lining.

Signs and symptoms

The symptoms of acute cholangitis can develop over a period of hours to days and include pain in the upper right abdomen, fever with chills, jaundice, nausea and vomiting, blood in the stools, and dark urine. The patient may also experience lethargy and disorientation. Chronic cholangitis, which develops over a period of months and years, can cause swelling of the feet, weight loss, mood swings and problems with memory. Some patients also experience bone and muscle pain.

Causes and risk factors

In most of cases, cholangitis is caused by a blockage in the bile duct due to gallstones or sludge. The blockage could also be caused by a tumour, blood clots, narrowing of the passage due to injury or scar tissue formation, or a swollen pancreas. People having an auto-immune condition like Crohn’s or ulcerative colitis, could be at greater risk of cholangitis. Having HIV infection or recent exposure to parasites also increases the risk of cholangitis.

Complications

Acute cholangitis can be life-threatening due to overwhelming sepsis unless urgently treated. Chronic cholangitis can lead to serious complications like liver cirrhosis, liver swelling and portal hypertension. It can also cause swelling and enlargement of the spleen, enlarged and broken veins in the stomach and liver, gallstones, and sepsis.

Diagnosis

To diagnose cholangitis, doctors will first conduct a patient medical history survey and a physical exam. Blood tests, radiology and endoscopic investigations are usually necessary to make a diagnosis and find the cause of the problem.

Treatment and Surgical Interventions

The key to treating cholangitis is early diagnosis and treatment with effective antibiotics and procedures to treat the blockage of the bile duct. Patients may need monitoring and treatment in an intensive care unit due to the seriousness of the condition. Bile duct blockage can be effectively treated by endoscopic or radiological procedures in well-equipped centers. Surgical intervention may be required if these procedures fail and to perform definitive treatment of the cause of cholangitis after initial stabilisation.

Prevention

Awareness of early symptoms of bile duct blockage such as right upper abdomen pain, fever or jaundice is vital to prevent complications such as cholangitis. Early consultation with a liver specialist is necessary.

Cholangiocarcinoma

Overview

Cholangiocarcinoma is a cancerous tumour that forms in the bile duct. This is a rare form of cancer that mainly occurs in patients above 50 years. Intrahepatic cholangiocarcinoma occurs in the parts of the bile duct within the liver. Hilar cholangiocarcinoma occurs in the bile ducts just outside the liver. Distal cholangiocarcinoma occurs in the parts of the bile duct adjoining the small intestines.

Signs and symptoms

Symptoms of cholangiocarcinoma include jaundice, itchy skin rashes, fatigue, unexplained weight loss, abdominal pain and white stools.

Causes and risk factors

Cholangiocarcinoma occurs when there is a mutation in the cells of the bile duct. The cause of the mutation is unclear, but it causes the cells to multiply uncontrollably, resulting in cancerous growth. Pre-existing liver conditions like primary sclerosing cholangitis, chronic liver failure, bile duct abnormalities can increase the risk of cholangiocarcinoma. Smoking also increases this risk.

Complications

Cholangiocarcinoma causes jaundice by blocking the bile ducts. Patients can develop severe infection within bile ducts. The tumor can block the blood supply into the liver causing liver failure. As the tumor spreads to other organs, it can cause cough, breathlessness, bone pains and fractures.

Diagnosis

Liver function tests, tumour marker test, an endoscopic retrograde cholangiopancreatography (ERCP), CT scans, MRI scans, and rarely a biopsy may be required to make the diagnosis.

Treatment and Surgical Interventions

The course of treatment varies for different patients. It depends on the stage of the tumor, extent of spread, function of liver and condition of the patient. The main options are surgery, radiation therapy and chemotherapy. Most patients with tumor limited to the liver will need surgery in combination with radiotherapy or chemotherapy. In a small group of patients, liver transplantation is the best treatment option with excellent results.

Prevention

There is no proven way to prevent cholangiocarcinoma. However, individuals with risk factors such as cirrhosis, primary sclerosing cholangitis should be regularly screened for these tumors with blood tests and scans. Quitting smoking may reduce your risk.

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