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Department of Surgery Ruijin Clinical Medical College Shanghai Jiao Tong University

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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- 0.6cm Cystic duct lower border length 3cm The 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:8-12cm width:3-5cm variable size:40-60ml shape: 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.untraumal 2.low cost 3.flexibicity 4.first choice

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Abdominal ultrasonography Diagnose biliary stone Identify the cause of jaundice PTCD by -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 Hartmanns 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 vomiting 3.Fever 4.Tenderness and rigidity in the right upper quadrant 5.Positive Murphys sign 6.Jaundice 7.A palpable gallbladder mass (1/4)

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Mirrizzis Syndrome The common hepatic is obstructed due to stones impacted in or extruded from Hartmans 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 patients 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 cardiovascular disease Biliary scintiscanning helpful for diagnosis

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Acute cholangitis and acute obstructive suppurative cholangitis

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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 >20 mH20 biliary stagnation bacteremia,bacteria proliferationreflux into hepatic veins and perihepatic lymphaticssystemic signs of cholangitis

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Clinical presentation Fever and chill Jaundice charcots triad) Right upper-quadrant pain Hypotension Mental obtundation Reynolds

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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 immunosuppression 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 gallbladdermass 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 cholecystitis Cholelithiasis GB polyps Benefits: Reducing hospitalization and associated costs Decreasing pain Improved cosmetic outcome Reduced 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 Incidence The commonest form of biliary tract