chapter 4
Biliary disorders
Questions
1.A 42-year-old woman presented to clinic with an incidental finding of gallstones on ultrasound performed for another indication. She had no fever, rigors, or pain. She had a moderate alcohol intake but denied any other medical problems.
Investigations:
| Serum albumin | 39 g/L |
| Serum bilirubin | 17 µmol/L |
| Serum alanine transferase (ALT) | 42 U/L |
| Serum alkaline phosphatase (ALP) | 104 U/L |
| Serum C-reactive protein (CRP) | 6 mg/L |
| Abdominal ultrasound | Three small gallstones in thin walled gallbladder with normal intra- and extrahepatic bile ducts. |
Which of the following most accurately reflects the patient’s prognosis over the next 10 years?
A. Cholecystectomy is indicated to prevent symptomatic gallstones from developing
B. Fifty per cent chance of developing Mirizzi syndrome
C. Less than 1% chance of developing pancreatitis, cholecystitis, or biliary obstruction
2.A 64-year-old man underwent a cholecystectomy for right upper-quadrant pain.
Investigations:
| Cholecystectomy specimen | The muscle wall is thickened with multiple prolapsed glands in the subserosal tissue (Rokitansky–Ashoff sinuses). The glands are variably dilated. |
What is the most likely diagnosis?
3.A 55-year-old woman was found incidentally to have gallbladder calcification on a computed tomography pulmonary angiogram (CTPA) performed to investigate a shortness of breath on the acute medical take. She did not have a pulmonary embolism and was discharged with an outpatient computed tomography (CT) abdomen. She was asymptomatic with no other comorbidities.
Investigations:
| Serum bilirubin | 12 µmol/L |
| Serum alkaline phosphatase (ALP) | 120 U/L |
| Serum alanine transferase (ALT) | 18 U/L |
| Serum albumin | 35 g/L |
| CT abdomen | Gallbladder contains several calculi with intramural spotty calcification of the gallbladder wall. |
What is the most appropriate next step for this patient?
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Endoscopic ultrasound (EUS)
D. Magnetic resonance cholangiopancreatography (MRCP)
What would be the next best management approach?
A. Conservative management with prophylactic antibiotics
B. ERCP and plastic biliary stent insertion
5.A 75-year-old man presented with right upper-quadrant pain, jaundice, and fever. He had a myocardial infarction six months ago and received a drug-eluting coronary artery stent. He takes daily aspirin 75 mg, clopidogrel 75 mg, bisoprolol 5 mg and atorvastatin 80 mg. He still drives and enjoys playing golf. He remains septic despite 48 hours of intravenous co-amoxiclav and gentamicin.
Investigations:
| Serum bilirubin | 71 µmol/L |
| Serum alkaline phosphatase (ALP) | 317 U/L |
| Serum alanine transferase (ALT) | 43 U/L |
| Serum albumin | 35 g/L |
| International normalized ratio (INR) | 1.4 |
| Haemoglobin | 120 g/L |
| White cell count | 12 × 109/L |
| Platelet count | 150 × 109/L |
| Serum C-reactive protein (CRP) | 70 mg/L |
| Blood cultures | Escherichia coli |
| Ultrasound abdomen | Common bile duct (CBD) dilatation with probable calculi. Sludge and gallstones in non-inflamed gallbladder. |
| MRCP | (Fig. 4.1) |
Fig. 4.1 MRCP
What is the best treatment option for sepsis source control?
A. Broaden antimicrobial cover
B. ERCP with sphincterotomy and stone extraction
D. Extracorporeal shock wave lithotripsy
E. Percutaneous transhepatic cholangiogram and internal–external biliary drain
Investigations:
| Abdominal ultrasound dilated CBD (15 mm) with no obvious filling defect and dilated intrahepatic ducts. Multiple small stones within a thin walled gallbladder. | |
| Haemoglobin | 110 g/L |
| White cell count | 18.3 × 109/L |
| Platelet count | 162 × 109/L |
| Prothrombin time | 12.5 seconds |
| Serum bilirubin | 73 µmol/L |
| Serum alkaline phosphatase (ALP) | 556 U/L |
| Serum alanine transferase (ALT) | 67 U/L |
| Serum C-reactive protein (CRP) | 187 mg/L |
What is the most appropriate next step in the management of this patient?
7.A 40-year-old woman presented with recurrent episodes of nocturnal right upper-quadrant pain radiating to the back, and vomiting over the past one month.
Investigations:
| Serum bilirubin | 45 µmol/L |
| Serum alkaline phosphatase (ALP) | 258 U/L |
| Serum alanine transferase (ALT) | 65 U/L |
| Serum amylase | 39 U/L |
| Abdominal ultrasound | Several gallbladder calculi. Normal bile duct calibre. |
| MRCP (Fig. 4.2) | |
| EUS (Fig. 4.3) | |
Fig. 4.2 MRCP
Fig. 4.3 Endoscopic ultrasound image
Investigations:
Which of the following is the most likely cause?
9.A 28-year-old-man was seen in clinic with a five-year history of recurrent episodic right upper-quadrant pain and two previous episodes of cholangitis requiring ERCP and clearance of CBD calculi. His pain had persisted despite cholecystectomy two years before.
Investigations:
| Serum bilirubin | 25 µmol/L |
| Serum alanine transferase (ALT) | 75 U/L |
| Serum alkaline phosphatase (ALP) | 230 U/L |
| Haemoglobin | 125 g/L |
| Platelet count | 245 × 109/L |
| Liver stiffness | 4.5 kPa |
| Abdominal ultrasound | Multiple foci of intrahepatic microlithiasis in both lobes of the liver. No CBD calculi or duct dilatation. |
| Genetic analysis | Homozygous mutation (c.139C>T) in ABCB4 gene |
What is the best next management strategy?
10.Question focused on knowledge of the procedure rather than diagnostics/patient management.
Which of the following statements about cholangioscopy is most correct?
A. Air embolism is a recognized complication of dual-operator cholangioscopy (DOC)
B. Biliary sphincterotomy is usually not required
D. It is associated with higher rates of cholangitis compared with conventional ERCP
11.A 35-year-old man with large-duct primary sclerosing cholangitis (PSC) developed jaundice, worsening liver biochemistry, and fevers.
Investigations:
Fig. 4.4 MRCP
Which of the following statements is true with regard to the MRCP finding?
A. It is associated with specific genetic polymorphisms affecting bile acid transport
B. It occurs in 50% of patients with PSC over the course of their disease
D. Prophylactic antibiotics are not required prior to investigation with ERCP
Which of the following is an established risk factor for CCA?
13.A 55-year-old man with a history of recurrent pancreatitis presented with a one-week history of painless jaundice. Ultrasound and MRCP revealed dilated common hepatic and intrahepatic ducts with suspicion of a distal CBD stricture. Staging CT revealed no mass lesion, vessel, or nodal involvement. Cholangiogram at ERCP confirmed a short distal CBD stricture. Brush cytology was obtained and the stricture was stented (Fig. 4.5).
Fig. 4.5 Brush cytology specimen from biliary stricture. See also Plate 10
What is the next step in management?
Investigations:
| Serum bilirubin | 222 µmol/L |
| Serum alanine transferase (ALT) | 262 U/L |
| Serum alkaline phosphatase (ALP) | 290 U/L |
| Serum gamma-GT | 386 U/L |
| Serum albumin | 34 g/L |
| INR | 1.0 |
| Haemoglobin | 140 g/L |
| White cell count | 7.7 × 109/L |
| Platelet count | 319 × 109/L |
| Serum CA 19-9 | 1,033 U/ml |
| Serum CEA | 2.8 µg/ml |
| Serum CA 125 | 15 U/ml |
| CT abdomen and pelvis with contrast (Fig. 4.6) | |
Fig. 4.6 CT abdomen and pelvis
Investigations:
| Serum bilirubin | 91 µmol/L |
| Serum alkaline phosphatase (ALP) | 425 U/L |
| Serum alanine transferase (ALT) | 77 U/L |
| MRCP | (Fig. 4.7) |
Fig. 4.7 MRCP
Which of the following is most likely to support a benign diagnosis?
A. Absence of arterial or portal venous invasion
B. Bulky pancreas and hypodense wedge-shaped renal lesions
C. Elevated serum immunoglobulin G subclass 4 (IgG4)
D. Enhancing thickened bile duct wall
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