• Anatomy and Pathophysiology

• Diagnostic techniques

• Stones of Biliary tract

• Infection of Biliary tract

• Biliary Tumors

Anatomhy of biliary tract

Intrahepatic bile duct:

Biliary tract

extrahepatic bile duct: Left hepatic duct Right hepatic duct Common hepatic → common

bile duct

Gallbladder →cystic duct

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

Common bile duct

• Diameter 0.6-0.8cm > 1cm abnormal

• Length 7-9cm

• supraduodenal segment

• retro duodenal segment

• retro pancreatic segment

• duodenal wall segment

The papilla of Vater

pancreatic sphincter

common sphincter

biliary sphincter

The sphincter of oddi

Gallbladder

• Length:8-12cmwidth:3-5cm variablesize:40-60mlshape: pearshaped fundus body the neck

The physiological function of Gallbladder

• Store and concentrate hepatic bile

• Secretion of water and electrolytes

• Empty bile into the common bile duct

Bile secretion

• Hepatocytes secrete bile 800-1200ml

• Bile composition: bile acids, bile pigments,cholesterol, phospholipids,inorganic electrolytes ,water

Diagnostic techniques

Abdominal ultrasonography

1.untraumal2.low cost3.flexibicity4.first choice

Abdominal ultrasonography

• Diagnose biliary stone

• Identify the cause of jaundice

• PTCD by β-ultrasound guided

• Doppler blood flow

Percutaneous Transhepatic Cholangiography

• Show the dilated bile duct above obstruction site

• Drainage of bile by PTCD

• Traumatic methods

Complications

• Bile leakage

• Haemorrhage

• Sepsis

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

Complications

• acute pancreatitis

• postprocedure cholangitis

• Other complications

Operative and postoperative direct cholangiography

• Show the entire biliary tract

• Display the stone and stenosis

• Tube cholangiography done before biliary drainge with drawn

CT and MRI

• High resolution

• More accurate

• Expensive

• Show the stone ,tumor, dilated duct

• MRCP show the entire biliary tree

Plain radiographs

• show radio-opaque calcui

• air in the biliary tree

• calcification of the gallbladder

Oral cholecystography

Show the function of gallbladder

Show the stones polyps and tumor contraindications

• Sensitivity to iodine

• Liver and renal disease

• pregnancy

Choledochoscope

• Intraoperative use:

• Explore the CBD stone

• Tumor,stenosis

• Reduce retained stone rate

• Remove stone

• biopsy

Other examination

• Intravenous cholangiogram

• Angiography

• Isotopic studies

How to choose

1.B ultrasound

2.MRCP and CT

3.ERCP and PTC

Infections of biliary tract

1.Cholecystitis

2.Cholangitis

obstruction

stone infection

core

Acute cholecystitis

• Acute calculous cholecystitis 95%

• Acute acalculous cholecystitis 5%

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

Pathology

Cystic duct obstruction →gallbladder →Edema →suppurate → gangrene → pericholecystic abscess →perforation

Cholecyst-enteric fitula Peritonitis

intestinal obstruction

Acute → chronic → atrophy

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)

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.

Differential Diagnsis

• Perforated peptic ulcer

• Acute pancreatitis

• Retrocaecel appendicitis

• Right low lobe pneumonia

• Hepatic abscess

• Acute viral hepatitis

Laboratory Test

• Leukocytosis in the range of l0000-15000

• Serum bilirubin ↑or normal

• Alkaline phosphatase ↑or normal

• Transaminase ↑or normal

• Serum amylase ↑ or normal

Treatment

Conservative treatment

1.Intravenons fluid and electrolyte replacement

2.Nasogastric suction

3.Systemic antibiotics

4.Parenteral analgesia

5.fast

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

Surgical methods

• Open cholecystectomy

• Laparoscopic cholecystectomy

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

Acute cholangitis and acute obstructive suppurative cholangiti

s

Etiology

• Choledocholithiasis 80%

• Benign strictures

• Obstructed biliary anastomotic strictures

• Malignant obstruction

• Ascarid

Pathophysiology

Biliary obstruction →intraductal pressure >20mH20→biliary stagnation

→bacteremia,bacteria proliferation→reflux

into hepatic veins and perihepatic lymphatics→systemic signs of cholangitis

Clinical presentation

• Fever and chill

• Jaundice charcot’s triad)

• Right upper-quadrant pain

• Hypotension

• Mental obtundation

Reynold’s

Physical examination

• Tenderness

• Abdominal guarding

• Swollen gallbladder

• Hepatomegaly

Laboratory Test

• Leukocytosis• Hyperbilirubinemia• Alkaline phosphatase ↑• Aminotransferases ↑• Leukopenia• Profound gram-negative sepsis and im

munosuppression lmmunosuppression• Serum amylase ↑

Radiological Evaluation

• Ultrasonography

• CT

• MRCP

• PTC

• ERCP

General support

• Cessation of oral intake ,fast

• Antibiotics

• Keep liquid and electrolyte balance

• Intravenous fluids

Treatment

Biliary decompression

• Percutanecus transhepatic biliary drainage

• Endoscopic drainage papillotomy and placement of a nasobiliary tube

• Operative decompression

• CBD exploration and T tube drainage

Cholelithiasis

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

Location

• Gallbladder stones

• Common bile duct stone

• Intrahepatic bile duct stone

Extrahepatic bile duct stone

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

Physical examination

• Usually normal

• Chronic hydrops of gallbladder→mass

• Some times tenderness

Radiological Test

A plain abdominal roentgenogram

Oral cholecystography

Ultrasonography the initial diagnostic study

CT

MRI

Complications

• Acute cholecystitis

• Jaundice

• Cholangitis

• Pancreatitis

• Mtrizzi syndrome

• cancer

Surgical Indication

• Accelerating symptoms

• Poor visualization or non-visulization on oral cholecystography

• Diabetas

• Porcelain gallbladder

• stone>2-3cm

Laparoscopic Cholecystectomy

• Indications:Chronic, uncomplicated cholecystitisCholelithiasisGB polyps • Benefits:Reducing hospitalization and associated costsDecreasing painImproved cosmetic outcomeReduced post-operative recovery

Other treatment

• Dietary therapy a low-fat diet, avoidance of heavy meals

• Antispasmodic medication

• Chenodeoxycholic acid and ursodeoxycholic acid

• Extracorporeal shock wave lithotripsy

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

Etiology

• Cholelithiasis

• Benign adenoma

• Polypoid gallbladder lesions (polyp greater than 1cm)

• Anomalous pancreaticbiliary junction

• Chronic inflammatory bowel disease

Pathology

• Adenocarcinoma 80% carcinoid tumours

• Undifferentiated carcinoma 6% sarcoma

• Squamous carcinoma 3% melanoma

• Mixed tumor or acanthoma 1% lymphoma

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

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

Laboratory invesitigations

• Can’t provide diagnostic information• Provide some helpful clues• Anaemia• Serum alkaline phosphatase ↑• CEA↑• CA19-9↑• CA125 ↑

Radiological Diagnosis

• Plain abdominal radiography

• Oral cholecystography

• PTC

• ERCP

• CT

• MRI MRCP

Other methods for diagnosis

• FNAC

• ultrasound

Treatment

• UICC Ⅰ • UICC Ⅱ

• UICC IVAⅢ

• UICC BⅣ

cholecystectomy

Curative excision procednre

extended curative excision

Palliative procedures

Billiary or duodenal bypass

Prognosis

• Piehler and crichlow

Report of 6000 patients :

1 year survivial rate 11.8%

5 year survival rate 4.1%

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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