Biliary Disease 

  • Author: Annie T Chemmanur, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jun 24, 2011
 

Background

A diverse spectrum of disease affects the biliary system, often presenting with similar clinical signs and symptoms.

A normal postcholecystectomy cholangiogram. A normal postcholecystectomy cholangiogram. Biliary disease. In this patient with persistent eBiliary disease. In this patient with persistent elevation of liver-associated enzymes, the contrast entering the biliary ductal system preferentially enters the cystic duct. Biliary disease. Even when the catheter is advanceBiliary disease. Even when the catheter is advanced to the proximal common hepatic duct, contrast dye preferentially fills the cystic duct and gallbladder rather than allowing visualization of the intrahepatic ductal system. Biliary disease. In this image, the common bile duBiliary disease. In this image, the common bile duct is occluded with a balloon-tipped catheter. Contrast fills the intrahepatic ductal system to reveal diffuse intrahepatic sclerosing cholangitis.
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Pathophysiology

Bile is produced by the liver and channeled by the biliary ductal system into the intestinal tract for the emulsification and absorption of fats. Biliary disease is caused by abnormalities in bile composition, biliary anatomy, or function. The liver determines the chemical composition of bile, and this may be modified later by the gallbladder and biliary epithelium. Cholesterol, ordinarily insoluble in water, comes into solution by forming vesicles with phospholipids (principally lecithin) or mixed micelles with bile salts and phospholipids.

When the ratio of cholesterol, phospholipids, and bile salts is outside an optimum range, cholesterol monohydrate crystals may come out of solution from multilamellar vesicles. Cholesterol supersaturation of bile appears to be a prerequisite for gallstone formation, which involves a variety of factors that affect the activity of low-density lipoprotein (LDL) uptake, hepatic 3-methylglutaryl coenzyme A reductase (HMG CoA), acyl cholesterol-lecithin acyltransferase, and 7-alpha hydroxylase.

By itself, cholesterol supersaturation is inadequate for explaining gallstone pathogenesis. Nucleation, the initial step in gallstone formation, is the transition of cholesterol from a soluble state into a solid crystalline form. Within gallbladder bile, biologic molecules influence the process in a positive or negative fashion.

For example, mucus may function to promote nucleation, while bile-specific glycoproteins may function to inhibit nucleation. Mucin hypersecretion by the gallbladder mucosa creates a viscoelastic gel that fosters nucleation. Arachidonyl lecithin, which is absorbed from the alimentary tract and secreted into the bile, stimulates prostanoid synthesis by gallbladder mucosa and promotes mucus hypersecretion, while inhibitors of prostaglandin inhibit mucus secretion.

Finally, gallbladder hypomotility and bile stasis appear to promote gallstone formation and growth, which may be important in diabetes, pregnancy, oral contraceptive use in women, and prolonged fasting in critically ill patients on total parenteral nutrition.

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Epidemiology

Frequency

United States

Gallstone disease is one of the most common and costly of all digestive diseases. The third National Health and Nutrition Examination Survey estimated that, in the United States, 6.3 million men and 14.2 million women aged 20-74 years had gallbladder disease.

The incidence of gallstones is 1 million new cases per year. The prevalence is 20 million cases among Americans.

Approximately 2-7 cases per 100,000 population of primary sclerosing cholangitis (PSC) exist. About 5% of patients with chronic ulcerative colitis develop PSC.

The incidence of gallbladder cancer is 2.5 cases per 100,000 population.

International

The incidence of primary biliary cirrhosis (PBC) is 5.8-15 cases per 1 million population. The incidence of PBC appears to be increasing, but the cause of the increase is unclear. However, the increase is possibly due to better detection and increased awareness rather than a true change in disease incidence.

Mortality/Morbidity

  • Gallstones are a rare cause of mortality, accounting for 5000 of the 2.2 million deaths annually in the United States.
  • PBC accounts for 0.6-2% of deaths from cirrhosis worldwide. The median time of patient survival was 9.3 years from diagnosis. Independent predictors of survival included age and alkaline phosphatase, serum albumin, and bilirubin levels. Liver failure developed in 26% of patients by 10 years after diagnosis. Neither the presence of antimitochondrial antibodies nor their titer affects disease progression or survival.
  • PSC is a leading reason for liver transplantation. Median survival without liver transplantation after diagnosis is approximately 12 years. Variables that appear to predict prognosis in PSC include age, histological stage, hepatomegaly, splenomegaly, and serum alkaline phosphatase and serum bilirubin levels.

Race

Mexican Americans and several American Indian tribes, particularly the Pima Indians in the Southwest, have very high prevalence rates of cholesterol gallstones. Decreased bile acid secretion is believed to be the common denominator in these ethnic groups.

  • Gallbladder cancer is the most common GI malignancy in both Southwestern Native Americans and Mexican Americans. A prominent geographic variability exists in the incidence of gallbladder cancer that correlates with the prevalence of cholelithiasis. High rates of gallbladder cancer are also seen in South American countries, particularly Chile and Bolivia. These populations all share a high prevalence of gallstones and/or Salmonella infection, both recognized risk factors for gallbladder cancer.

Sex

The prevalence of cholesterol gallstones is higher among females than males (lifetime risk of 35% vs 20%, respectively). This likely is due to endogenous sex hormones, which enhance cholesterol secretion and increase bile cholesterol saturation. Progesterone also may contribute by relaxing smooth muscle and impairing gallbladder emptying.

  • PSC: Males are affected twice as frequently as females.
  • PBC: Females are affected 9 times as often as males.

Age

Increased age is associated with lithogenic bile and an increased rate of gallstones.

  • PSC: Mean age of onset is 40 years.
  • PBC: Among the autoimmune diseases, PBC is unique in that it never occurs in childhood and is rarely found before age 30 years. The onset is usually between the ages of 30-65 years, but the disease has been reported in women as young as 22 years and as old as 93 years.
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Contributor Information and Disclosures
Author

Annie T Chemmanur, MD  Attending Physician, Metrowest Medical Center and University of Massachusetts Memorial Hospital, Marlborough Campus

Annie T Chemmanur, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jeanette G Smith, MD  Fellow, Department of Gastroenterology-Hepatology, University of Connecticut School of Medicine

Jeanette G Smith, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, and American Public Health Association

Disclosure: Nothing to disclose.

George Y Wu, MD, PhD  Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, and Association of American Physicians

Disclosure: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Gilead Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership

Specialty Editor Board

Ronnie Fass, MD  Chief of Gastroenterology, Southern Arizona VA Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine

Ronnie Fass, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Motility Society, American Society for Gastrointestinal Endoscopy, and Israel Medical Association

Disclosure: Takeda Pharmaceuticals Grant/research funds Conducting research; Takeda Pharmaceuticals Consulting fee Consulting; Takeda Pharmaceuticals Honoraria Speaking and teaching; Vecta Consulting fee Consulting; XenoPort Consulting fee Consulting; Eisai Honoraria Speaking and teaching; Wyeth Pharmaceuticals Conducting research; AstraZeneca Grant/research funds Conducting research; Eisai Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James L Achord, MD  Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine

James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Paul Yakshe, MD, to the development and writing of this article.

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A normal postcholecystectomy cholangiogram.
Biliary disease. In this patient with persistent elevation of liver-associated enzymes, the contrast entering the biliary ductal system preferentially enters the cystic duct.
Biliary disease. Even when the catheter is advanced to the proximal common hepatic duct, contrast dye preferentially fills the cystic duct and gallbladder rather than allowing visualization of the intrahepatic ductal system.
Biliary disease. In this image, the common bile duct is occluded with a balloon-tipped catheter. Contrast fills the intrahepatic ductal system to reveal diffuse intrahepatic sclerosing cholangitis.
Biliary disease. Common bile duct stones are among the most common problems occurring in the biliary system. In this cholangiogram, the stones line up like peas in a pod.
Biliary disease. After a biliary sphincterotomy, a balloon-tipped catheter is used to remove the stones one by one.
Biliary disease. This clearing cholangiogram shows a common bile duct free of filling defects and good flow into the duodenum. The stones are visible as filling defects in the duodenal bulb.
Biliary disease. This patient with pancreatic cancer has developed jaundice during his treatment. The cholangiogram shows a stricture in the distal common bile duct.
Biliary disease. A patient with pancreatic cancer has developed jaundice during his treatment. To palliate the jaundice, the biliary stricture is dilated and stented with a 10F plastic stent. Note the contrast flowing down the stent.
Biliary disease. The CT scan of the abdomen shows a large tumor mass in the head of the pancreas. The brightly colored object within the mass is the biliary stent placed by endoscopic retrograde cholangiopancreatography (ERCP).
Biliary disease. This abdominal CT scan shows mild intrahepatic biliary ductal dilation.
Biliary disease. This patient with jaundice has polycystic liver disease on abdominal CT scan.
Biliary disease. Findings on an endoscopic retrograde cholangiopancreatography (ERCP) exclude extrahepatic biliary obstruction but demonstrate that the intrahepatic biliary ductal system is splayed by multiple hepatic cysts.
Biliary disease. This cholangiogram shows a choledochal cyst. Fusiform dilation of the entire extrahepatic bile duct is present.
This 92-year-old woman had recurrent abdominal pain and jaundice. A right upper quadrant ultrasound showed a dilated biliary duct with no stones. She had a previous Roux-en-Y surgery that made endoscopic retrograde cholangiopancreatography (ERCP) impossible. Critical aortic stenosis that increased the risk of most interventions. This percutaneous cholangiogram, performed under conscious sedation in the operating room, revealed a large stone missed by the ultrasound. It was removed successfully with percutaneous choledochoscopy and electrohydraulic lithotripsy.
Biliary disease. This cholangiogram shows a stone too large to deliver through a standard biliary sphincterotomy.
Biliary disease. Here, a mechanical lithotripter is used to grab a stone too large to deliver through a standard biliary sphincterotomy and crush it into small pieces. The smaller pieces then are removed with a balloon-tipped catheter.
Biliary disease. This patient had malignant strictures of the biliary system that were palliated with metal mesh stents. Unfortunately, the tumor has grown through the metal mesh to reobstruct the biliary system.
Biliary disease. This patient had malignant strictures of the biliary system that were palliated with metal mesh stents. Unfortunately, the tumor has grown through the metal mesh to reobstruct the biliary system. After a wire is passed through the lumen, a balloon-dilating catheter is passed into the metal mesh stents and inflated to enlarge the lumen.
Biliary disease. This patient had malignant strictures of the biliary system that were palliated with metal mesh stents. The tumor has grown through the metal mesh to reobstruct the biliary system. After a wire was passed through the lumen, a balloon-dilating catheter was passed into the metal mesh stents and inflated to enlarge the lumen. In this image, 2 plastic stents were passed into the intrahepatic ductal system to again palliate the obstruction.
 
 
 
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