department of surgery ruijin clinical medical college shanghai jiao tong university
TRANSCRIPT
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• Anatomy and Pathophysiology
• Diagnostic techniques
• Stones of Biliary tract
• Infection of Biliary tract
• Biliary Tumors
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Anatomhy of biliary tract
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Intrahepatic bile duct:
Biliary tract
extrahepatic bile duct: Left hepatic duct Right hepatic duct Common hepatic → common
bile duct
Gallbladder →cystic duct
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Calot trangle:Liver : upper border Common hepatic duct diameter =0.
4-0.6cmCystic duct lower border length 3
cmThe cystic artery runs in this
triangle
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Common bile duct
• Diameter 0.6-0.8cm > 1cm abnormal
• Length 7-9cm
• supraduodenal segment
• retro duodenal segment
• retro pancreatic segment
• duodenal wall segment
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The papilla of Vater
pancreatic sphincter
common sphincter
biliary sphincter
The sphincter of oddi
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Gallbladder
• Length:8-12cmwidth:3-5cm variablesize:40-60mlshape: pearshaped fundus body the neck
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The physiological function of Gallbladder
• Store and concentrate hepatic bile
• Secretion of water and electrolytes
• Empty bile into the common bile duct
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Bile secretion
• Hepatocytes secrete bile 800-1200ml
• Bile composition: bile acids, bile pigments,cholesterol, phospholipids,inorganic electrolytes ,water
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Diagnostic techniques
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Abdominal ultrasonography
1.untraumal2.low cost3.flexibicity4.first choice
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Abdominal ultrasonography
• Diagnose biliary stone
• Identify the cause of jaundice
• PTCD by β-ultrasound guided
• Doppler blood flow
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Percutaneous Transhepatic Cholangiography
• Show the dilated bile duct above obstruction site
• Drainage of bile by PTCD
• Traumatic methods
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Complications
• Bile leakage
• Haemorrhage
• Sepsis
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Endoscopic Retrograde Cholangiopancreatography ERCP
• Directly observe papilla lesion and biopsy
• Show the entire biliary tract
• Show the biliary tract proximal to obstruction site
• Drain bile
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Complications
• acute pancreatitis
• postprocedure cholangitis
• Other complications
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Operative and postoperative direct cholangiography
• Show the entire biliary tract
• Display the stone and stenosis
• Tube cholangiography done before biliary drainge with drawn
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CT and MRI
• High resolution
• More accurate
• Expensive
• Show the stone ,tumor, dilated duct
• MRCP show the entire biliary tree
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Plain radiographs
• show radio-opaque calcui
• air in the biliary tree
• calcification of the gallbladder
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Oral cholecystography
Show the function of gallbladder
Show the stones polyps and tumor contraindications
• Sensitivity to iodine
• Liver and renal disease
• pregnancy
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Choledochoscope
• Intraoperative use:
• Explore the CBD stone
• Tumor,stenosis
• Reduce retained stone rate
• Remove stone
• biopsy
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Other examination
• Intravenous cholangiogram
• Angiography
• Isotopic studies
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How to choose
1.B ultrasound
2.MRCP and CT
3.ERCP and PTC
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Infections of biliary tract
1.Cholecystitis
2.Cholangitis
obstruction
stone infection
core
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Acute cholecystitis
• Acute calculous cholecystitis 95%
• Acute acalculous cholecystitis 5%
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Etiology
1.Cystic duct obstructed by a gallstone impacting in Hartmann’s pouch
2.Bacteial infection of the stagnant bile Aerobic enteric-derived organisms Escherichia coli, klebsiella pneumoniae, streptococcus faecalis gallstone impaction →mucosal damage Lecithin → lysolecithin ↑ phospholipases
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Pathology
Cystic duct obstruction →gallbladder →Edema →suppurate → gangrene → pericholecystic abscess →perforation
Cholecyst-enteric fitula Peritonitis
intestinal obstruction
Acute → chronic → atrophy
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Clinical features
1.Sudden and severe pain mainly in the right hypochondrium radiate to the right scapular region fatty foods
2.Nausea and vomiting3.Fever4.Tenderness and rigidity in the right upper quadra
nt5.Positive Murphy’s sign6.Jaundice7.A palpable gallbladder mass (1/4)
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Mirrizzi’s Syndrome
The common hepatic is obstructed due to stones impacted in or extruded from Hartman’s pouch of the gallbldder or the cystic duct.Cholecystobiliary or cholecystoenteric fistulae are common complication.
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Differential Diagnsis
• Perforated peptic ulcer
• Acute pancreatitis
• Retrocaecel appendicitis
• Right low lobe pneumonia
• Hepatic abscess
• Acute viral hepatitis
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Laboratory Test
• Leukocytosis in the range of l0000-15000
• Serum bilirubin ↑or normal
• Alkaline phosphatase ↑or normal
• Transaminase ↑or normal
• Serum amylase ↑ or normal
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Treatment
Conservative treatment
1.Intravenons fluid and electrolyte replacement
2.Nasogastric suction
3.Systemic antibiotics
4.Parenteral analgesia
5.fast
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Surgical Treatment
1.Attack within 48-72 h of diagnosis
2.Deterioration in patient’s general condition
3.Complications are present
Perforation
Peritonitis
Acute obstructive suppurative cholangitis
Acute pancreatitis
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Surgical methods
• Open cholecystectomy
• Laparoscopic cholecystectomy
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Acalculous Cholecystitis
• Complications of major trauma, burns and sepsis
• Complications of parenteral feeding• Not easy to make a clear diagnosis• Need prompt surgical intervention• over 70% with atheroscclerotic cardiovas
cular disease• Biliary scintiscanning helpful for diagnosi
s
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Acute cholangitis and acute obstructive suppurative cholangiti
s
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Etiology
• Choledocholithiasis 80%
• Benign strictures
• Obstructed biliary anastomotic strictures
• Malignant obstruction
• Ascarid
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Pathophysiology
Biliary obstruction →intraductal pressure >20mH20→biliary stagnation
→bacteremia,bacteria proliferation→reflux
into hepatic veins and perihepatic lymphatics→systemic signs of cholangitis
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Clinical presentation
• Fever and chill
• Jaundice charcot’s triad)
• Right upper-quadrant pain
• Hypotension
• Mental obtundation
Reynold’s
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Physical examination
• Tenderness
• Abdominal guarding
• Swollen gallbladder
• Hepatomegaly
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Laboratory Test
• Leukocytosis• Hyperbilirubinemia• Alkaline phosphatase ↑• Aminotransferases ↑• Leukopenia• Profound gram-negative sepsis and im
munosuppression lmmunosuppression• Serum amylase ↑
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Radiological Evaluation
• Ultrasonography
• CT
• MRCP
• PTC
• ERCP
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General support
• Cessation of oral intake ,fast
• Antibiotics
• Keep liquid and electrolyte balance
• Intravenous fluids
Treatment
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Biliary decompression
• Percutanecus transhepatic biliary drainage
• Endoscopic drainage papillotomy and placement of a nasobiliary tube
• Operative decompression
• CBD exploration and T tube drainage
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Cholelithiasis
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Classification of gallstone
Cholesterol stones: light brown, smooth or faceted,
single or multiple cross-section
laminated/crystallineappearance
Pigment stone: small, black or brown, irregular cross-
section a morphous/crystalline
Mixed stone
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Location
• Gallbladder stones
• Common bile duct stone
• Intrahepatic bile duct stone
Extrahepatic bile duct stone
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Clinical presentation
• Dyspepsia
• Right upper quadrant abdominal pain in association with or shortly after a heavy or fatty meal
• A feeling of gaseous bloating
• Biliary colic
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Physical examination
• Usually normal
• Chronic hydrops of gallbladder→mass
• Some times tenderness
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Radiological Test
A plain abdominal roentgenogram
Oral cholecystography
Ultrasonography the initial diagnostic study
CT
MRI
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Complications
• Acute cholecystitis
• Jaundice
• Cholangitis
• Pancreatitis
• Mtrizzi syndrome
• cancer
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Surgical Indication
• Accelerating symptoms
• Poor visualization or non-visulization on oral cholecystography
• Diabetas
• Porcelain gallbladder
• stone>2-3cm
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Laparoscopic Cholecystectomy
• Indications:Chronic, uncomplicated cholecystitisCholelithiasisGB polyps • Benefits:Reducing hospitalization and associated costsDecreasing painImproved cosmetic outcomeReduced post-operative recovery
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Other treatment
• Dietary therapy a low-fat diet, avoidance of heavy meals
• Antispasmodic medication
• Chenodeoxycholic acid and ursodeoxycholic acid
• Extracorporeal shock wave lithotripsy
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Carcinoma of Gallbladder
• IncidenceThe commonest form of biliary tract malignancy
the fifth most common gastrointestinal cancer
Encountered in 1-2% of cholecystectomy specimens
Predominantly occurs in elderly females
Over 90% of patients are were 50 years of age
The peak age of incidence is 70-75% years
A male to female ratio of 1:3
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Etiology
• Cholelithiasis
• Benign adenoma
• Polypoid gallbladder lesions (polyp greater than 1cm)
• Anomalous pancreaticbiliary junction
• Chronic inflammatory bowel disease
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Pathology
• Adenocarcinoma 80% carcinoid tumours
• Undifferentiated carcinoma 6% sarcoma
• Squamous carcinoma 3% melanoma
• Mixed tumor or acanthoma 1% lymphoma
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UICC
Ⅰ stage: mucosa and muscular
Ⅱ stage: total layer of the gallbladder
Ⅲ stage: invasion into liver <2cm or
regional lyphatic spread
Ⅳ A stage: invasion into liver >2cm
Ⅳ B stage: spread to distal organ and
lymph node
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Clinical Features
• The diagnosis of gallbladder cancer is usually made when the disease is well advanced. There are no characteristic features at an early and curative stage
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Laboratory invesitigations
• Can’t provide diagnostic information• Provide some helpful clues• Anaemia• Serum alkaline phosphatase ↑• CEA↑• CA19-9↑• CA125 ↑
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Radiological Diagnosis
• Plain abdominal radiography
• Oral cholecystography
• PTC
• ERCP
• CT
• MRI MRCP
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Other methods for diagnosis
• FNAC
• ultrasound
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Treatment
• UICC Ⅰ • UICC Ⅱ
• UICC IVAⅢ
• UICC BⅣ
cholecystectomy
Curative excision procednre
extended curative excision
Palliative procedures
Billiary or duodenal bypass
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Prognosis
• Piehler and crichlow
Report of 6000 patients :
1 year survivial rate 11.8%
5 year survival rate 4.1%
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Palliative procedure
1.Excra bile drainge
T tube
U tube
PTCD
2.Intra-drainge
Biliary-enteric bypass or intubation
Non-operative endoprosthetic insertion
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Thank you