Definition and Overview

The biliary tract, also known as the biliary system or biliary tree, is composed of all the body’s ducts and organs (bile ducts, gall bladder, and the liver) that are responsible for the production, storage and secretion of bile. Bile, which is mainly consist of bilirubin, cholesterol, and calcium, is a dark green to yellowish brown fluid that is extracted by the liver from the blood. Bile secreted by the liver into the small ducts is stored in the gallbladder and is released into the duodenum during a meal to help the body absorb oils and dietary fats as well as remove the waste stored in the body.

When calcium, cholesterol, and bilirubin inside the biliary tract become out of balance and harden, they can form either several small lumps or one large stone that can be initially lodged in the gallbladder (gallstone) where they disrupt the flow of digestive fluids going to the small intestine. This can lead to the pancreatitis or the inflammation of the pancreas.

Gallstones can move out of place and become lodged in the bile ducts (choledocholithiasis), resulting in less common but more serious condition called cholangitis. The condition, which causes pain and jaundice, blocks the flow from the gallbladder and liver. In some cases, the condition responds to antibiotic therapy but unless it was caught and treated early, it can lead to a life-threatening condition that may require emergency biliary drainage.

Causes of Condition

Biliary tract calculus are caused by a number of factors involving the organs that make up the biliary system, namely the bile ducts, gallbladder, small intestine, pancreas, and liver.

It is believed that calculus in biliary tract form due to certain imbalances that results in the bile containing too much bilirubin or cholesterol, when the gallbladder does not empty completely, or when there is not enough bile salts.

These include:

  • Enlarged lymph nodes

  • Gallstones

  • Pancreatitis

  • Scarring of the liver (cirrhosis)

  • Severe liver damage

  • Tumors of the pancreas, bile ducts, liver, or gallbladder

  • Hereditary blood disorders such as sickle cell anemia

Various risk factors can also increase a person’s chances of developing the condition. These risk factors include the following:

  • A history of gallstones

  • A history of tumor or injury to right part of the abdomen

  • Age – Older people are more likely to develop gallstones as their body tends to secrete more cholesterol into bile

  • Bile ducts and liver worms (flukes)

  • Cholesterol-lowering drugs

  • Diabetes

  • Diet low in fibre and high in fat and cholesterol

  • Enlarged lymph nodes in the porta hepatis

  • Excess strogen – Based on studies, excess from pregnancy can decrease gallbladder movement and increase cholesterol levels in bile. The same is true for hormone replacement therapy and prolonged use of birth control pills. This explains why women have a higher risk of developing gallstones than men.

  • History of bile duct cancer and recent biliary surgery

  • Injury from a gallbladder surgery

  • Obesity

  • Rapid weight loss

Key Symptoms

Patients suffering from biliary obstruction due to the presence of calculus in the biliary tract typically notice various physical changes as the body struggles to properly produce, store, and secrete bile. These gallbladder symptoms include yellowish skin or eyes (jaundice), itching, and pain in the upper right side of the abdomen. Other symptoms of gallstones include:

  • Dark urine

  • Fever

  • Light-colored stools

  • Nausea

  • Vomiting

  • Weight loss

  • Pain in between shoulder blades

  • Gallbladder pain

Who to See and Types of Treatments Available

Patients who experience gallstone symptoms, such as prolonged pain, fever, clay-colored stools, and yellowish color of the skin or whites of the eyes are advised to consult their primary physician for initial assessment. If choledocholithiasis is suspected, the patient will be referred to as specialist called gastroenterologist. Gastroenterologists are doctors with additional dedicated education and training on the proper treatment and management of diseases affecting the gastrointestinal tract and liver.

Initial blood tests are then performed to confirm the presence of gallbladder stones in the biliary tract. Such diagnostic will determine if there’s an increase in the patient’s bilirubin, alkaline phosphate, and liver enzymes levels. Depending on the result of the initial assessment, physical examination, and initial set of diagnostic tests, the following may also be performed:

  • Abdominal ultrasound and computed tomography (CT) scan

  • Cholescintigraphy (HIDA scan)

  • Endoscopic ultrasound

  • Endoscopic retrograde cholangiopancreatography (ERCP)

  • Magnetic resonance cholangiopancreatography (MRCP)

  • Percutaneous transhepatic cholangiogram (PTCA)

Doctors typically perform several tests to confirm that the symptoms are caused by a gallbladder stone and not by other medical conditions that share the same symptoms. These include irritable bowel syndrome, appendicitis, hiatal hernia, pancreatitis, and hepatitis. This is important in determining the best course of action in treating the condition.

Patients with small gallstones who do not experience symptoms are typically do not undergo any type of treatment. The “wait and see” approach, in which patients are placed under active surveillance protocols and regular follow-up checks, is typically considered if doctors feel that the risks of treatment outweigh the possible benefits.

However, treatment is considered if the patient experiences the symptoms of “gallbladder attack”. Gallbladder attacks causes pain under the right shoulder, between the shoulder blades, and in the right upper abdomen. Such pain can last between 30 minutes and several hours.

Patients suffering from frequent gallbladder attacks may be advised to undergo cholecystectomy to remove the gallbladder. The procedure, which is one of the most performed surgeries in the United States, is typically performed using minimally invasive approach. Using a laparoscope, it involves making several tiny incisions (instead of a 5-8 inches incision) in the abdomen where a miniature camera and surgical instruments are inserted. During the procedure, the gallbladder is carefully separated from the structures that surround it. Because the procedure is minimally invasive, the recovery time is faster with the patients able to resume to their normal activities after just a few days.

Although laparoscopy is widely preferred, there are about 5% of cases that warrant an open surgery. These include those that involve severe inflammation and infection.

Patients who undergo surgery for the removal of their gallbladder face the risk of various complications with injury to the bile duct being the most common. This complication can cause serious infection.

In special situations, such as when surgery is not an option due to the patient’s overall health conditions, alternative treatment can be prescribed. These include oral dissolution therapy (patients take drugs designed to dissolve gallstones) and contact dissolution therapy (an experimental procedure where in a special drug is injected directly into the gallbladder).

References:

  • Biliary obstruction. (n.d.). Retrieved from http://medicine.georgetown.edu/divisions/gastroenterology/knowledge/biliary-obstruction

  • Intestinal obstruction. (2012, December 18). Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/basics/definition/con-20027567

  • Management of bile duct problems (n.d.). Retrieved from http://www.cpmc.org/advanced/liver/patients/topics/bileduct-profile.html

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