BILIARY TRACT DISEASE IN THE ELDERLY

Diseases affecting the gall bladder and bile ducts occur commonly in the elderly. Northern India has one of the highest reported incidences of gallbladder cancer (GBC) in the World but the frequency of Bile duct cancers are on the rise in Telangana. Over the last 20 years we have seen the growth of thousands of such patients. By the age of 70, cholelithiasis, and its sequela, choledocholithiasis, are the most frequently occurring disorder affecting these organ systems. Dr. Asha Subbalakshmi Musunuri, Clinical Director and Head of Dept Gastroenterology and Liver Diseases, CARE Hospitals, Hitech City Hyderabad discusses the varied types of Biliary tract disease in elderly people.

Gallstones and cholecystitis :

Asymptomatic gallstones are a common feature of ageing. Gall bladder dysfunction and the increasing lithogenicity of bile seem to predispose the gall bladders of the more elderly population. The longer one has gallstones, the more likely one is to develop cholecystitis and biliary colic. The danger is when the stone slips in to the Bile duct which requires urgent treatment and intervention.

Choledocholithiasis:

Common bile duct stones are frequently found in elderly patients who present with concomitant cholecystitis. In the elderly patient, biliary colic is more likely to accompany bile duct stones with or without cholecystitis.

In the general population, 5% of patients presenting with cholecystitis have co-existing bile duct stones. In the elderly, however, this figure rises to 10–20%.In addition, in elderly patients who have undergone an emergency cholecystectomy, the incidence of bile duct stones approaches 50%.Choledocholithiasis is a significant problem in the elderly.

The primary approach for treating stone disease of the bile ducts should be endoscopic—that is, ERCP. The success rate for the endoscopic treatment of common bile duct stones approaches 98% in centers of excellence. Additionally, oral medications can also be given to soften the stones. Stone disease complicated by strictures is treated either in multiple sessions or palliated by providing long term stenting. ERCP is safe in most of the patients and is the treatment which gives immediate relief.

Malignant Biliary Strictures:

Malignant obstructive jaundice results from disorders such as pancreatic carcinoma, bile duct carcinoma, gall bladder carcinoma, and ampullary cancer. As with younger patients, the usual presentation of this syndrome in the elderly consists of the insidious development of pain abdomen, cholestasis and jaundice.

CT scans using intravenous contrast can accurately evaluate the extent of the tumour and its invasion, especially when three-dimensional reconstruction, computer generated models of the portal vessels is achieved. Endoscopic ultrasound (EUS) is probably the most sensitive diagnostic modality currently available for predicting respectability. EUS also helps in evaluating the mesenteric vasculature.

Endoscopic relief of jaundice has been used successfully for over 20 years, and these endoscopic techniques have a high rate of success (up to 90–95%) of attempts. After placing biliary stents, the jaundice dissipates almost immediately, unless there is co-morbid liver disease, and, usually, the patient is without pain or ileus after the procedure.

Plastic stents placed by ERCP have a propensity to clog or occlude within six months of placement, thus requiring stent exchange.

Book Appointment:: Dr. Asha Subbalakshmi Musunuri, Clinical Director and Head of Dept Gastroenterology and Liver Diseases, CARE Hospitals, Hitech City Hyderabad