Cholecyst and Bile Duct Diseases

Vesicular lithiasis is the presence of stones in the gallbladder. The presence of gallstones in the gallbladder is not considered a disease unless it causes symptoms.

Gallstones are composed of a mixture of cholesterol, various calcium salts (organic or inorganic), protein and mucin, and can be of two types, cholesteroleptic (the most common) and pigmentary.

Most patients with biliary lithiasis are asymptomatic, with the diagnosis being discovered incidentally following an abdominal ultrasound.

Patients who present symptoms typically experience biliary colic – intense, dull and constant pain located in the right hypochondrium, epigastrium , usually occurring after eating (postprandial) associated or not with nausea and vomiting.

Other more nonspecific symptoms may include:

• Eructation
• Early satiety
• Abdominal distention/meteorism
• Pirozis
• Precordial pain
• Nausea
• Bitter taste sensation especially in the morning
• Non-specific abdominal pain

Acute cholecystitis

Inflammation of the wall of the gallbladder, the most common complication of vesicular lithiasis, manifested by intense, violent pain in the upper and right abdominal floor (right hypochondrium), local pus, subicterus (yellowing of the tegument and sclera), dynamic occlusion (lack of intestinal transit), peritonitis, which is most often localized, febrile/cold syndrome.

Chronic cholecystitis

Assumes the existence of a recurrent inflammatory process (incomplete and intermittent obstruction of the cystic duct) of the gallbladder with biliary lithiasis. Clinically it is manifested by pain in the right hypochondrium and the presence of a variable degree of dyspeptic syndrome (nausea, vomiting, meteorism, bitter mouth).

– Objective/clinical examination – pain on palpation in the right hypochondrium during forced inspiration (Murphy sign)
– Abdominal ultrasound – a non-invasive and atraumatic imaging method based on ultrasound is the method of choice and the most sensitive in the detection of gallstones; it can also reveal the presence of stones in the main bile duct, intrahepatic bile ducts. In acute cholecystitis, the cholecystis appears thickened, thin-walled, distended, with an enlarged calculus in the infundibulum of the cholecystis, pericocystic fluid
– Blood tests – useful and meaningful after the colicky episode
– Signs of biliary retention – increased bilirubin, increased serum alkaline phosphatase, presence of bile pigments in urine
– Signs suggesting infection – increased white blood cells
– Signs of pancreatic reaction – increased serum pancreatic enzymes – amylases, lipases, presence of amylases in urine – amyluria
– Signs of hepatic cytolysis – increased transaminases
– Upper digestive endoscopy (gastroscopy) – involves inserting a thin tube (diameter of a pen) through the oral cavity into the stomach, with a camera at the end, which allows the examining physician to visualize the inside of the stomach; it is indicated only if the differential diagnosis of a gastric pathology is in question.

Surgical treatment – removal of the cholecyst (cholecystectomy) by laparoscopic approach (minimally invasive surgery) is indicated for acute lithiasic cholecystitis, alithiasis (without stones), chronic lithiasic cholecystitis, symptomatic vesicular lithiasis, in the presence of small stones (under 3mm-microlithiasis) with increased risk of acute pancreatitis. Classic/open cholecystectomy is indicated if the laparoscopic approach fails.

It represents the migration of a portion of the stomach from the abdominal cavity into the thoracic cavity through the diaphragmatic orifice. The exact causes of hiatal hernia are not known. In some cases, following injury or trauma the muscle tissue may weaken, leading to the stomach being pushed through the diaphragmatic muscle.

Tumours of the gallbladder are divided into benign and malignant formations.

Benign tumours are non-cancerous tumours, they remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms.

Pre-cancerous (pre-malignant) tumours are benign tumours containing abnormal cells that have the potential to turn into cancer if left untreated.

In contrast, malignant tumours are cancerous tumours that develop in nearby tissues, contain cells that can rupture and reach the blood or lymphatic system, thus spreading to lymph nodes and other distant regions of the body.

Benign tumours are most commonly represented by polyps (inflammatory, cholesterol, adenomatous – which have malignant potential).
80-90% of malignant tumours of the gallbladder are carcinomas – neoplasms with an epithelial starting point. The most common type is adenocarcinoma.

There are several factors that increase a person’s risk of developing cancer of the main bile duct, such as:

• Vesicular lithiasis – over 75% of cholecystic cancer cases are associated with this condition
• Gallstone greater than 3 cm
• Adenomatous polyps
• Chronic inflammation: cholecysto-enteric fistula, primary sclerosing cholangitis, pancreatico-biliary reflux, chronic infection or Salmonella typhi
• Porcelain” bladder
• Age over 50
• Female
• Overweight

Most cases of gallbladder neoplasm have non-specific initial manifestations, common with the signs of biliary colic or cholecystitis; diagosis of more than 50% of malignant tumours occurs in late stages:

• Abdominal pain syndrome in the right upper abdomen (right hypochondrium)
• Weight loss
• Yellowing of the skin and whites of the eyes (sclerosing jaundice)
• Itchy skin (generalized itching)

– Abdominal ultrasound – non-invasive and atraumatic imaging method based on ultrasound, which can reveal vesicular lithiasis, presence of vesicular polyps, vesicular tumor, mucosal discontinuity, porcelain vesicle, local extension of tumor, loco-regional metastasis
– Computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, contrast substance is used. May show presence of tumor, local extension of tumor, metastases, adenopathy
– Nuclear Magnetic Resonance Imaging (MRI) – an imaging method that uses a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; contrast material may also be used for better visualisation. May show presence of tumor, local extension of tumor, metastases, adenopathy
– Cholangiography-NMR – indicated as a first-line treatment if you have jaundice syndrome
– Endoscopic retrograde cholangiography (ERCP) – a procedure that is performed using an endoscope and the introduction of a radiopaque substance into the bile ducts, followed by X-rays; useful if you have mechanical jaundice (it has both a diagnostic and therapeutic role by fitting a biliary drainage prosthesis when indicated)
– Blood tests – which may show abnormal liver function (liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase – GGT)
– Serological tumour marker assay – CA19-9

Depending on the stage of the disease, the extent of the tumour formation, there are several treatment options:

Surgical treatment

Cholecystectomy, segmental resection of the main bile duct, resection of a portion of the liver (hepatic resection), lymphadenectomy; in the case of unresectable tumours with mechanical jaundice, surgical, endoscopic or imaging-interventional biliary drainage is indicated.

Chemotherapy

Anti-tumour treatment, which uses certain drugs to destroy cancer cells; it may be given before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be removed surgically, or it may be given after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may already be spread in the body, or in some cases it is used as a single treatment for palliative purposes.

Radiotherapy

Anti-tumour treatment, which uses high-intensity X-rays or other types of radiation that are capable of destroying malignant cells.

Radiochemotherapy

It involves combining chemotherapy with radiotherapy to increase their effectiveness.

Main bile duct tumours are tumours that manifest as an obstruction that can block the flow of bile physiologically from the liver to the small intestine, duodenum. They can be of two types, benign (papilloma, adenoma, fibroid, myoblastoma) and malignant (cholangiocarcinoma).

Benign tumours are non-cancerous tumours that remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms. Pre-cancerous (pre-malignant) tumours are benign tumours containing abnormal cells that have the potential to turn into cancer if left untreated.

In contrast, malignant tumours are cancerous tumours that develop in nearby tissues, contain cells that can rupture and reach the blood or lymphatic system, thus spreading to lymph nodes and other distant regions of the body.

The most common type of malignant tumour of the main bile duct is cholangiocarcinoma. It can be located in the main bile duct proximal (near the liver), middle or distal (near the duodenum).
There are several factors that increase a person’s risk of developing cancer of the main bile duct, such as:

– Genetic mutations/abnormal changes in the AND of cells
– Bile duct malformations present at birth
– Alcohol consumption
– Exposure to toxic substances

In the early stages you may not have any symptoms. If you experience symptoms, they may be:
– Weight loss without apparent cause
– Night sweats
– Yellowing of the skin and whites of the eyes (sclerosing jaundice)
– Itchy skin (generalized pruritus)
– Lack of appetite
– Abdominal pain below the ribs on the right side
– Fatigue and weakness
– Light-coloured chair, white (watercolour)

In order to accurately determine the diagnosis of a PBC tumour it is necessary to carry out certain investigations:
– Abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method, which can show, depending on the location of the tumour, for tumour in the proximal PBC, dilatation of the intrahepatic bile ducts and tumour formation in the hepatic hilum, for tumour in the middle PBC, intrahepatic bile duct dilatation, main bile duct dilatation (upstream of tumour), liver pedicle tumour formation, for tumour in distal CBP, intrahepatic bile duct dilatation, main bile duct dilatation (upstream of tumour), retroduodenal formation
– Computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, the contrast substance is used. May highlight the presence of tumour and biliary obstruction, assessment of relationships with neighbouring structures (invasion into blood vessels, neighbouring structures), secondary determinations/metastases in lymph nodes or other organs
– Nuclear Magnetic Resonance Imaging (MRI) – an imaging method that uses a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; contrast material may also be used for better visualisation. May highlight the presence of tumour and biliary obstruction, assessment of relationships with neighbouring structures (invasion into blood vessels, neighbouring structures), secondary determinations/metastases in lymph nodes or other organs
– Cholangiography-NMR – indicated as a first-line treatment if you have jaundice syndrome
– Endoscopic retrograde cholangiography (ERCP) – a procedure that is performed using an endoscope and the introduction of a radiopaque substance into the bile ducts, followed by X-rays; useful if you have mechanical jaundice (has both a diagnostic and therapeutic role by fitting a biliary drainage prosthesis when indicated)
– Biopsy – a manoeuvre that may be performed during echoendoscopy or ERCP, whereby the doctor removes a piece of tissue from a suspicious-looking area, which is then analysed under a microscope
– Blood tests – which may show abnormal liver function (liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase – GGT)
– Serological tumour marker assay – CA19-9

Depending on the stage of the disease, the location of the tumour formation, there are several treatment options:

Surgical treatment

Involves surgical removal of the affected portion of the bile duct and a portion of the liver (liver resection) in the case of hilar tumours located in the proximal or middle main bile duct. If the tumour is located in the distal bile duct near the duodenum, a cephalic duodenopancreatectomy is performed, which involves removing the duodenum, the first portion of the jejunum and the pancreatic head, the last part of the stomach, the cholecyst, the last part of the main bile duct leading from the liver to the duodenum and the neighbouring lymph nodes (lymphadenectomy), followed by subsequent restoration of the digestive continuity.

Liver transplantation

In the case of hilar cholangiocarcinomas.

Chemotherapy

Anti-tumour treatment, which uses certain drugs to destroy cancer cells; it can be given before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be removed by surgery, or it can be given after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may already be spread in the body.

Radiotherapy

Anti-tumour treatment, which uses high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be, as with chemotherapy, of two types: neoadjuvant or adjuvant.

Photodynamic therapy

It involves injecting a photo-sensitive chemical that accumulates in cancer cells and then destroying them with a laser.

Biliary drainage

A procedure whose purpose is to restore bile flow; it can be performed surgically by performing a digestive bypass (biliodigestive bypass) to redirect bile flow, thus bypassing the obstruction, or by fitting a prosthesis/stent that keeps open the bile duct collapsed due to cancer; biliary drainage is a treatment method that reduces symptoms and signs of cholangiocarcinoma.

A main bile duct cyst is a dilatation in the main bile duct. It can be of several types depending on the type of Todani.

– Type I – fusiform solitary extrahepatic cyst
– Type II- extrahepatic supraduodenal diverticulum
– Type III – intraduodenal diverticulum (choledochocele)
– Type IVA – extra and intrahepatic fusiform cysts
– Type IVB – multiple extrahepatic cysts
– Type V – multiple intrahepatic cysts (Caroli disease)

Symptoms may be missing, the diagnosis being made incidentally. If symptoms are present they are intermittent:

– Pain in the upper abdomen (epigastric) or in the upper right region (right hypochondrium)
– Fever
– Yellowing of the skin and whites of the eyes (sclerosing jaundice)

– Abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method that can reveal cystic dilatations, liver fibrosis, intracystic lithiasis, Caroli disease (limited by duodenal gas overlap in end choledochal cysts)
– Cholangio-MRI – imaging method using a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; with the possibility of 3D reconstruction of the biliary tree; for better visualisation, contrast material can also be used
– Endoscopic retrograde cholangiography (ERCP) – a procedure that is performed using an endoscope and the introduction of a radiopaque substance into the bile duct, followed by x-rays
– Blood tests – which may show abnormal liver function (liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase – GGT);

Surgical treatment

depending on the Todani classification, excision of the cyst is indicated +/- a connection between the proximal main bile duct and the small intestine (hepatico-jejunostomy on the Roux-en-Y loop); tactical cholecystectomy may also be indicated. In the case of intrahepatic cysts, liver resection is also indicated.

Liver transplant

in the case of Caroli disease, generalized hepatic, with hepatic fibrosis, cirrhosis of the liver.