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Biliary system
Prof. Weilin Wang [email protected]
Department of Hepatobiliary Pancreatic Surgery
The First Affiliated Hospital
Anatomy of Biliary System1
Methods of Investigation2
Disorders of Gallbladder3
Disorders of Bile Duct4
Case discussion5
Anatomy of Biliary System1
Extrahepatic Biliary Tract
Bifurcation Common hepatic duct
Common bile ductCystic ductGallbladder
The liver secrete bile, bile flow from liver to right and left hepatic ducts.
These ducts drain into the common hepatic duct.
The common hepatic duct then joins with the cystic duct to form the common bile duct.
Transportation of Bile
About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder.
When food is taken, the gallbladder contracts and release stored bile into the duodeum to help digest the fats.
Transportation of Bile
Calot triangle
The triangle is bounded by the cystic duct, the common hepatic duct, and the inferior border of the liver.
Important structures including: the cystic artery, the right hepatic artery, and the cystic duct lymph node.
Papilla of Vater
Tthe opening of the bile duct and panceatic duct in the descending part of the duodenum.
Through the papilla, bile and pancreatic juice pass to to bowel.
obstructive jaundice or pancreatitis will happen when papilla of Vater was blocked by stones and tumors,
Normal gallbladder
Agenesis of the gallbladder is extremely rare, with a prevalence of 0.03-0.07 percent.
Double gallbladder occurs in about 0.03 per cent, usually with a shared cyctic duct, and the accessory gallbladder is often diseased.
Gallbladder Anatomical Variants
Variations of biliary branching
A Typical anatomy of the confluence.
B Trifurcation of left, right anterior, and right posterior hepatic ducts.
C Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct.
Methods of Investigation2
Ultrasonography (B-US) CT, Computed Tomographic Magnetic Resonance Cholangiopancreatography Endoscopic Retrograde Cholangopancreatography Percutaneous Transhepatic Cholangiography T-tube cholangiography Radiographs Intraoperative cholangiography Endoscopic ultrasound ……
Methods of investigation
Fast, real-time, non-invasive, and no ionizing radiation, cheap and could be available even in countryside.
95% sensitivity for detection of cholelithiasis.
--Found a mobile, hyperechoic with acoustic shadowing
>90% sensitivity for detection of acute cholecystitis.
--Gallbladder wall thickening, pericholecystic fluid
B-US
Normal GallbladderGallbladder, with sludge
and stone present
Gallstones can be seen on CT, but it is not used primarily for this purpose.
CT can be used in situations where ultrasound is difficult --such as in obese patients. It can also be used if the ultrasound is
not definitive.
CT scan
Plain CT shows multiple gallstones.
Multiple stones were found in the left intrahepatic bile duct.
Becoming a more viable imaging technique
New tool for non-invasive evaluation of the pancreatic and biliary ductal systems.
Gradually replacing PTC and ERCP for diagnostic purposes.
MRCP
MRCP showed slight dilation of CBD
Pancreatic duct
Common bile duct
Stones was detected in the bile duct by MRCP.
Stones in CBD
ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct.
ERCP
Left: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct.
Right: Radiographic result after the contrast medium was injected into the CBD.
ERCP: Instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments.
ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct.
Stones in CBD Endoscope
Pancreatic duct
Large stone was drawing out from CBD during ERCP was performing.
Show the procedure of removal the stones using endoscope .
ERCP.wmv
PTC
The catheter was placed into the intrahepatic bile duct through patient’s skin guiding by B-US and fixed on the skin.
The radiographic image was taken.
Obstructive lesion can be seen in this picture.
Obstructive lesion
Left : After injection of dye, showing a large gallstone trapped in the duct.
Right: After removal of the stone through the drainage catheter.
Before After
Postoperatively
Injection of contrast medium through a T-tube catheter
placed in the CBD
Easy way to show whether there are remaining stones or any stricture
T-tube cholangiography
T-tube graphyT-tube graphy
Old technique used in the past, widely replaced by the ultrasound and MRCP.
Can be used to visualize calcified stones by abdominal x-ray film.
Radiographs
Abdominal x-ray demonstrating stones in the gallbladder
Stones
Stones
Disorders of Gallbladder3
Acute cholecystitis Gallbladder stones and sludge Adenomyomatous hyperplasia Gallbladder polyps Gallbladder carcinoma ……
Disorders of Gallbladder
Calculous cholecystitis: over 90%
Clinical manifestation: --Pain in right upper quadrant --Radiates to right shoulder & back --Nausea & vomiting --Chill and/or fever --Abdominal tenderness --Murphy's sign (+)
Acute Cholecystitis
Acute Cholecystitis: B-US
The gallbladder contains small stones in the neck and its wall shows oedematous thickening (>5 mm thickness).
Other B-US signs are:
--Gallbladder over distension
--Pericholecystic fluid
--GB wall thickening
-- ……
Less accurate than B-US
The CT findings : --Gallbladder wall thickening
--Subserosal oedema --Gallbladder distension --Pericholecystic fluid --Gallstones
Acute Cholecystitis: CT
•Fine, nonshadowing dependent echoes.
•Composed of calcium bilirubinate granules, cholesterol crystals.
•Gallstones will develop in 5-15 percent.
Sludge
Gallbladder, with sludge and stone present
Stone
Sludge
Gallbladder polyps
The majority of polyps are cholesterol
Cholesterol polyps are usually 2-10mm in size
They appear as small echogenic nonshadowing foci adherent to the gallbladder wall
Lack of mobility indicates polyp
The affected segment often contains bright echoes
Often associated with ‘comet-tail’
Gallbladder-Adenomyomatosis
Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct.
May result in biliary obstruction and jaundice
If not recognized preoperatively, it can result in significant morbidity and
mortality
Mirrizzi syndrome
Symptomatic cholelithiasis
Non-functioning gallbladders (Full of stones)
Malignant considered: GB polyps (>1.2cm) or others
Indication for Cholecystectomy
The first case was performed in 1882
One safe and effective method
Direct visualization and palpation
Open Cholecystectomy
A less invasive way to remove the gallbladder
Smaller incisions and less pain
Shorter hospital stay and a shorter recovery time
Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy
Gallbladder Carcinoma
Gallbladder carcinoma is associated with stones in over 90% of patients
There is a female to male ratio of 3:1
Few patient was diagnosed prior to surgery
Gallbladder Carcinoma
Gallbladder CarcinomaGallbladder Carcinoma
TNM classification
TNM classification
Direct invasion of the liver by gallbladder cancer in a 66-year-old woman
Should differentiate gallbladder cancer from acute cholecystitis
T?N?M?
Quiz
Treatment
Radical surgery including segment liver resection, bile duct resection and extensive lymphadenectomy
Poor prognosis in patients with unresectable tumor
External radiation therapy may provide palliative benefit.
5-Fu and Gemcitabine can be used as chemotherapy.
Gall-Bladder.mp4
LC.mp4
Disorders of Bile Duct4
Disorders of Bile DuctDisorders of Bile Duct
AOSC
Choledocholithiasis/Hepatolithiasis
Choledochal cyst
Cholangiocarcinoma
Pancreatic and ampullary tumor
Acute obstructive suppurative Cholangitis (AOSC)
Emergency disease carries high mortality
Common obstructing factors: stones, tumor
Complete obstruction and suppurative infection
May result in septicemia & septic shock; MSOF
AOSC
Abrupt onset of pain in upper quadrant
Chill, high fever, may nausea and vomiting
Jaundice
May shock, and/or Acute renal failure and ARDS
Clinical manifestation
Charcot triad
Correct the fluid and acid-base balance
Systemic administration of antibiotics
Anti-shock treatment
Drain the biliary tract: ERCP or PTCD
Emergency operation
Treatment
Choledocholithiasis/Hepatolithiasis
Small shadowing stone (Arrow) in dilated bile duct.
CT show multiple stones in hepatic bile duct
Choledocholithiasis/Hepatolithiasis
ERCP: demonstrating stone in the duct (arrow)
Stones
Choledocholithiasis/Hepatolithiasis
Cystic dilatation of the extrahepatic bile ducts
Female to male is about ration 4:1
The majority are now diagnosed in childhood
Classified into five types
Associated with various biliary tumors
Choledochal cysts
Type I
Type II
Type III
Type IV
Type V
Choledochal cysts
CT MRCP
Cholangiocarcinoma
Pancreatic and ampullary tumours
……
Bile Duct CancerBile Duct Cancer
Most commonly at the hepatic duct bifurcation (Klatskin tumor)
Present with jaundice Clinical Presentation: --Jaundice (around 90% ) --Pruritus --fever --mild abdominal pain --fatigue --…… Surgical resection offer a chance for long-term disease-free
survival
Cholangiocarcinoma
B-US: nodules or focal bile duct wall thickening
CT: nodules are usually isodense or slightly hypodense
MRCP: show the proximal extent of the stricturing
Cholangiocarcinoma
Small hilar cholangiocarcinoma (Arrowhead) producing obstruction of the right posteral sectoral duct (Short arrow). Right anterior sectoral duct (long arrow) and left hepatic duct. (A) Thick oblique coronal MRCP. (B) Axial portal phase CT (C) Longitudinal US. (D) Transverse color Doppler US (Open arrow, normal left portal vein).
Type I: confined to the common hepatic duct
type II: involve the bifurcation Type IIIa and IIIb: extend into
either the right or left secondary intrahepatic ducts, respectively
Type IV: involve the secondary intrahepatic ducts on both sides
Bismuth Classification
I II
III IV
II
IV
I II
IVIII
I II
IVIII
I II
IV
I
IVIII
I
IV
II
III
I
IV
Type?
Quiz
Distal lesions are usually treated with Whipple
Intrahepatic lesions are treated by hepatic resection
Perihilar (Klatskin) tumor:
--Type I and II: Resection of the extrahepatic bile ducts and gallbladder
--Type III and IV: Curative resection is difficult
Radiation therapy improves survival for patients
Treatment
Resection of the extrahepatic bile ducts and gallbladder with 5-10 mm bile duct margins, and regional lymphadenectomy with Roux-en-Y hepaticojejunostomy.
Typical operation I
Typical operation II: Whipple
Before After
The head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct are excised, usually to relieve obstruction caused by tumors. Continuity is reestablished between the biliary, pancreatic, and GI systems.
Case discussion5
42-year-old woman patient was admitted to our emergency department because of repeated upper abdominal pain for 2 years and aggravated for three days.
With nausea, vomiting, chill and fever. The highest temperature reached to 39.5 . She also found dark urine and skin turned ℃yellow.
PE: BP 85/52 mmHg. Yellow stained was found in the skin and sclera.
Case: Clinical manifestationCase: Clinical manifestation
Which examination should be performed for diagnosis?
Laboratory test: --Blood routine test
--Liver function and serum electrolyte --Serum Amylase
Imaging test: --B-US (First choice. Why?) --MRCP --CT
Examination neededExamination needed
Laboratory test: --BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l
--Liver function: ALT 154 U/l TB/DB 194/153 mmol/l --Serum Amylase : Normal
Imaging test: --MRCP
Examination findingExamination finding
DiagnosisDiagnosis
Acute Cholecystitis?
Gallstone pancreatitis?
Cholangitis?
No
No
Yes
AOSC, Septic shock
Anti-shock treatment Antibiotic drug Drainage: Emergency ERCP
was performed and ENBD was placed
…….
TreatmentTreatment
Most important!!
CT scan show multiple stone in CBD and hepatic duct. The catheter can be seen.
When the general condition is stable and the TB level declined to 50mmol/l, choledocholithotomy was carried out and stones were removed.
The patient recovery very well without any episode.
TreatmentTreatment
Questions?Questions?