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Department of Surgery Ruijin Clinical Medical College Shanghai Jiao Tong University

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  • Slide 1
  • Department of Surgery Ruijin Clinical Medical College Shanghai Jiao Tong University
  • Slide 2
  • Anatomy and Pathophysiology Diagnostic techniques Stones of Biliary tract Infection of Biliary tract Biliary Tumors
  • Slide 3
  • Anatomhy of biliary tract
  • Slide 4
  • Intrahepatic bile duct: Biliary tract extrahepatic bile duct: Left hepatic duct Right hepatic duct Common hepatic common bile duct Gallbladder cystic duct
  • Slide 5
  • 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
  • Slide 6
  • Common bile duct Diameter 0.6-0.8cm > 1cm abnormal Length 7-9cm supraduodenal segment retro duodenal segment retro pancreatic segment duodenal wall segment
  • Slide 7
  • The papilla of Vater pancreatic sphincter common sphincter biliary sphincter The sphincter of oddi
  • Slide 8
  • Gallbladder Length:8-12cm width:3-5cm variable size:40-60ml shape: pearshaped fundus body the neck
  • Slide 9
  • The physiological function of Gallbladder Store and concentrate hepatic bile Secretion of water and electrolytes Empty bile into the common bile duct
  • Slide 10
  • Bile secretion Hepatocytes secrete bile 800-1200ml Bile composition: bile acids, bile pigments,cholesterol, phospholipids,inorganic electrolytes,water
  • Slide 11
  • Diagnostic techniques
  • Slide 12
  • Abdominal ultrasonography 1.untraumal 2.low cost 3.flexibicity 4.first choice
  • Slide 13
  • Abdominal ultrasonography Diagnose biliary stone Identify the cause of jaundice PTCD by -ultrasound guided Doppler blood flow
  • Slide 14
  • Percutaneous Transhepatic Cholangiography Show the dilated bile duct above obstruction site Drainage of bile by PTCD Traumatic methods
  • Slide 15
  • Complications Bile leakage Haemorrhage Sepsis
  • Slide 16
  • 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
  • Slide 17
  • Complications acute pancreatitis postprocedure cholangitis Other complications
  • Slide 18
  • Operative and postoperative direct cholangiography Show the entire biliary tract Display the stone and stenosis Tube cholangiography done before biliary drainge with drawn
  • Slide 19
  • CT and MRI High resolution More accurate Expensive Show the stone,tumor, dilated duct MRCP show the entire biliary tree
  • Slide 20
  • Plain radiographs show radio-opaque calcui air in the biliary tree calcification of the gallbladder
  • Slide 21
  • Oral cholecystography Show the function of gallbladder Show the stones polyps and tumor contraindications Sensitivity to iodine Liver and renal disease pregnancy
  • Slide 22
  • Choledochoscope Intraoperative use: Explore the CBD stone Tumor,stenosis Reduce retained stone rate Remove stone biopsy
  • Slide 23
  • Other examination Intravenous cholangiogram Angiography Isotopic studies
  • Slide 24
  • How to choose 1.B ultrasound 2.MRCP and CT 3.ERCP and PTC
  • Slide 25
  • Infections of biliary tract 1.Cholecystitis 2.Cholangitis obstruction stone infection core
  • Slide 26
  • Acute cholecystitis Acute calculous cholecystitis 95% Acute acalculous cholecystitis 5%
  • Slide 27
  • 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
  • Slide 28
  • Pathology Cystic duct obstruction gallbladder Edema suppurate gangrene pericholecystic abscess perforation Cholecyst-enteric fitula Peritonitis intestinal obstruction Acute chronic atrophy
  • Slide 29
  • 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)
  • Slide 30
  • 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.
  • Slide 31
  • Differential Diagnsis Perforated peptic ulcer Acute pancreatitis Retrocaecel appendicitis Right low lobe pneumonia Hepatic abscess Acute viral hepatitis
  • Slide 32
  • Laboratory Test Leukocytosis in the range of l0000-15000 Serum bilirubin or normal Alkaline phosphatase or normal Transaminase or normal Serum amylase or normal
  • Slide 33
  • Treatment Conservative treatment 1.Intravenons fluid and electrolyte replacement 2.Nasogastric suction 3.Systemic antibiotics 4.Parenteral analgesia 5.fast
  • Slide 34
  • 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
  • Slide 35
  • Surgical methods Open cholecystectomy Laparoscopic cholecystectomy
  • Slide 36
  • 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
  • Slide 37
  • Acute cholangitis and acute obstructive suppurative cholangitis
  • Slide 38
  • Etiology Choledocholithiasis 80% Benign strictures Obstructed biliary anastomotic strictures Malignant obstruction Ascarid
  • Slide 39
  • Pathophysiology Biliary obstruction intraductal pressure >20 mH20 biliary stagnation bacteremia,bacteria proliferationreflux into hepatic veins and perihepatic lymphaticssystemic signs of cholangitis
  • Slide 40
  • Clinical presentation Fever and chill Jaundice charcots triad) Right upper-quadrant pain Hypotension Mental obtundation Reynolds
  • Slide 41
  • Physical examination Tenderness Abdominal guarding Swollen gallbladder Hepatomegaly
  • Slide 42
  • Laboratory Test Leukocytosis Hyperbilirubinemia Alkaline phosphatase Aminotransferases Leukopenia Profound gram-negative sepsis and immunosuppression lmmunosuppression Serum amylase
  • Slide 43
  • Radiological Evaluation Ultrasonography CT MRCP PTC ERCP
  • Slide 44
  • General support Cessation of oral intake,fast Antibiotics Keep liquid and electrolyte balance Intravenous fluids Treatment
  • Slide 45
  • Biliary decompression Percutanecus transhepatic biliary drainage Endoscopic drainage papillotomy and placement of a nasobiliary tube Operative decompression CBD exploration and T tube drainage
  • Slide 46
  • Cholelithiasis
  • Slide 47
  • 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
  • Slide 48
  • Slide 49
  • Location Gallbladder stones Common bile duct stone Intrahepatic bile duct stone Extrahepatic bile duct stone
  • Slide 50
  • 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
  • Slide 51
  • Physical examination Usually normal Chronic hydrops of gallbladdermass Some times tenderness
  • Slide 52
  • Radiological Test A plain abdominal roentgenogram Oral cholecystography Ultrasonography the initial diagnostic study CT MRI
  • Slide 53
  • Complications Acute cholecystitis Jaundice Cholangitis Pancreatitis Mtrizzi syndrome cancer
  • Slide 54
  • Surgical Indication Accelerating symptoms Poor visualization or non-visulization on oral cholecystography Diabetas Porcelain gallbladder stone>2-3cm
  • Slide 55
  • Laparoscopic Cholecystectomy Indications: Chronic, uncomplicated cholecystitis Cholelithiasis GB polyps Benefits: Reducing hospitalization and associated costs Decreasing pain Improved cosmetic outcome Reduced post-operative recovery
  • Slide 56
  • Other treatment Dietary therapy a low-fat diet, avoidance of heavy meals Antispasmodic medication Chenodeoxycholic acid and ursodeoxycholic acid Extracorporeal shock wave lithotripsy
  • Slide 57
  • Carcinoma of Gallbladder Incidence The commonest form of biliary tract

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