What are the symptoms and treatment options for biliary disorders?

Symptoms of Biliary Disorders

Biliary disorders present with a characteristic constellation of symptoms that vary by the specific condition, but the classic presentation includes right upper quadrant abdominal pain, fever, and jaundice—known as Charcot's triad—which occurs in 50-70% of patients with acute cholangitis. 1, 2

Clinical Presentations by Disorder Type

Acute Cholangitis (Biliary Infection)

• Fever is the most common symptom, present in over 90% of cases 1, 2
• Right upper quadrant or epigastric abdominal pain occurs in approximately 70% of patients 1, 2
• Jaundice develops in about 60% of cases 1, 2
• Reynolds' Pentad (all five symptoms together) indicates severe disease: fever, right upper quadrant pain, jaundice, altered mental status, and hypotension 2
• Altered mental status and hypotension signal life-threatening septic cholangitis requiring urgent intervention 2

Biliary Colic (Gallstone-Related Pain)

• Severe, steady pain in the right upper quadrant and/or epigastrium that is unaffected by position changes, antacids, or gas passage 3
• Pain typically lasts 30 minutes to several hours 3
• May radiate to the back or right shoulder 4
• Often triggered 30-40 minutes after consuming fatty meals 5

Acute Cholecystitis (Gallbladder Inflammation)

• Right upper quadrant abdominal pain with Murphy's sign (inspiratory arrest during palpation) 3
• Fever and abdominal tenderness 3
• Nausea and vomiting commonly accompany the pain 4
• Leukocytosis on laboratory testing 4

Bile Duct Injury (Post-Surgical Complication)

• Alarm symptoms include fever, abdominal pain, distention, jaundice, nausea and vomiting depending on the type and severity of injury 6
• Symptoms may develop immediately postoperatively or be delayed by days to weeks 6
• Biliary fistula, biloma formation, or bile peritonitis may occur 6

Laboratory Abnormalities

Cholestatic Pattern (Hallmark Finding)

• Elevated alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (GGT) are the characteristic biochemical pattern 6, 1
• Elevated direct and indirect bilirubin levels 6, 1
• AST and ALT elevations may be present but are not diagnostic 6, 1

Markers of Severe Inflammation/Sepsis

• In critically ill patients, elevated CRP, procalcitonin (PCT), and lactate help evaluate severity and monitor treatment response 6, 1
• Elevated immunoglobulin M is typical in primary biliary cirrhosis 6
• Prothrombin time alterations and low albumin indicate advanced disease 6

Diagnostic Imaging Findings

First-Line Imaging

• Ultrasound is the initial imaging modality of choice with 96% accuracy for gallstone detection 3
• Ultrasound identifies biliary ductal dilation and gallbladder wall thickening 6, 3

Advanced Imaging for Suspected Obstruction

• Abdominal triphasic CT is recommended as first-line diagnostic imaging to detect intra-abdominal fluid collections and ductal dilation 6, 1
• Contrast-enhanced MRCP provides exact visualization, localization and classification of biliary obstruction with 85-100% sensitivity and 90% specificity 6, 1, 3
• MRCP is preferred over diagnostic ERCP due to lower morbidity and mortality 6

Functional Assessment

• Hepatobiliary iminodiacetic acid (HIDA) scan has 97% sensitivity and 90% specificity for acute cholecystitis 3
• HIDA scan can identify functional gallbladder disorders (biliary dyskinesia or hyperkinesia) when other imaging is unremarkable 5

Common Pitfalls to Avoid

• Do not assume absence of Charcot's triad excludes cholangitis—only 50-70% present with all three classic symptoms 1, 2
• Fever alone may be the only presenting symptom in early cholangitis, so maintain high clinical suspicion 1
• In elderly patients, symptoms may be atypical or minimal despite severe disease 7
• Normal ultrasound does not exclude choledocholithiasis—proceed to MRCP or EUS for intermediate or high probability cases 6
• Patients who fail to recover rapidly after laparoscopic cholecystectomy require prompt investigation for bile duct injury 6