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Gallstones typical features
- - Hx: biliary colic or episodes of chlolecystitis.
- - Obstructive type
- - small calibre gallstones -> pass through the cystic duct.
- - In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice
- - Usu obstructive
- - Charcots triad: pain, jaundice, fever
- - Ascending infection of the bile ducts usually by E. coli
- - by definition occurring in a pool of stagnant bile.
Pancreatic cancer features
painless jaundice with palpable gallbladder (Courvoisier's Law)
Pancreatic cancer pathogenesis
- Direct occlusion: distal bile duct or pancreatic duct by tumour.
- Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.
Bile duct injury pathogenesis
- - bile duct is excised
- + jaundice offers rapidly post operatively
- + often due to diff cholecystectomy
- more insidious: bile duct stenosis <- clips or diathermy injury.
- - Primary sclerosing cholangitis is a RF
- - gradual onset obstructive pattern
Diagnosis 1st line
what and what it shows
US of liver and biliary trree
- - bile duct calibre
- - presence of gallstones
- - may visualise pancreatic masses and other lesions.
The most important clinical question is essentially the extent of biliary dilatation
and its distribution.
Diagnosis 1st and next
- * 1st line: US liver and biliary tree
- * Next if suspect
- - pancreatic neoplasia: prancreatic protocol CT scan
- - liver tumours and cholangiocarcinoma: MRI/MRCP. If failed, ERCP.
- - PET scans: to stage