SU28.12 | Diseases of the Biliary System — Summary & Reflection

KEY TAKEAWAYS

Biliary surgery rests on the anatomy of the biliary tree and the dissection landmark Calot's triangle (cystic duct, common hepatic duct, liver edge — containing the cystic artery), with the critical view of safety preventing bile-duct injury. Gallstones — cholesterol (5 F's), black pigment (haemolysis/cirrhosis), brown pigment (infection/stasis) and mixed — cause a spectrum of disease: biliary colic, acute cholecystitis (Murphy's sign), choledocholithiasis with obstructive jaundice (raised conjugated bilirubin, ALP, GGT; pale stools, dark urine), ascending cholangitis (Charcot's triad; Reynolds pentad when severe) and gallstone pancreatitis. Courvoisier's law — a palpable, non-tender gallbladder with jaundice — warns of malignancy. Ultrasound is first-line, MRCP images the ducts, ERCP is therapeutic. Management: laparoscopic cholecystectomy for stone disease, ERCP with sphincterotomy for CBD stones, and antibiotics plus urgent biliary drainage for cholangitis; malignant obstruction is resected when possible (e.g. Whipple) or palliated by stenting.

REFLECT

Return to the two patients in the hook. For the woman with fever, right upper quadrant pain and jaundice, write down which eponymous signs you would seek, the liver-function pattern you would expect, and the three things you would do at once if she had ascending cholangitis. For the older man with painless jaundice and a palpable non-tender gallbladder, explain why Courvoisier's law makes you worry about cancer rather than stones, and what your next investigation would be. How does a single bedside sign change the urgency and direction of your whole plan?