Diseases of the Biliary System

General

Disease of the gallbladder and bile ducts (collectively called the extra-hepatic biliary system) is common in the United States and encompasses a diverse spectrum of disease processes.  Oftentimes, these different disease entities present with similar clinical signs and symptoms, and therefore an accurate clinical assessment involves a good history and physical exam, in addition to multiple diagnostic modalities in order to distinguish between causes.  Although the medical management of biliary disease may differ slightly depending on the process and severity, the surgical treatment for most cases is the same (i.e. cholecystectomy or removal of the gallbladder).  As the gallbladder is not necessary to sustain viable gut function, it has become a convenient cure for most biliary diseases.

A review of the extra-hepatic biliary anatomy follows, which is a primer to understanding the progression of biliary disease as well as important considerations when performing dissection and surgery on the gallbladder.

Biliary Disease

Diseases of the gallbladder fall on a continuum ranging from asymptomatic cholelithiasis (gallstones) to gallbladder colic, cholecystitis, choledocholithiasis, and cholangitis. For the most part, the position on this spectrum of disease depends upon where along the biliary path an abnormality exists.  For example, gallbladder colic is produced by a gallstone temporarily obstructing the cystic duct.  Cholecystitis is inflammation of the gallbladder, resulting from obstruction of the cystic duct or common bile duct.  Cholangitis is the result of infection of the biliary tree.  Each of these disease entities are discussed in more detail below.

Diagnostic Evaluation

A number of diagnostic modalities are available for studying biliary disease.  The most commonly used modalities include lab work (blood tests), ultrasonography, and cholangiography.  Other imaging techniques are available (i.e. plain film x-rays and computed tomography), but are less often used.  For example, approximately only 15% of gallstones are radiopaque and can be visualized on a plain film x-ray, making its yield in diagnosing cholelithiasis low.  Computed tomography (CT) is often used in the workup of abdominal pain without specific localizing signs and symptoms, but is not a preferred first-line study for evaluation of gallstones because of its greater cost and invasiveness.

Treatment

A cholecystectomy is the surgical removal of the gallbladder.  When gallstones are present or the gallbladder becomes infected or inflamed due to gallbladder disease, a cholecystectomy is the only curative treatment.  During this procedure, the bile ducts, which transport bile from the gallbladder to the small intestine, are not removed.  Once the gallbladder is removed, the liver takes over the transportation of bile using these bile ducts.  In most cases, there are no symptoms following this procedure.  Sometimes, however, there are residual symptoms, but these occasions are rare.