Biliary system
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Transcript Biliary system
Biliary system
Anatomy
Plain x ray
GB stone in 10 %
Gas in biliary tree
Gall stone ileus
Gas in GB wall
Porcilin GB
Radiological investigations
Oral Cholecystography
We comment on
Site
Size
Shape
Filling
Defect
Function
Concentration
contractility
of dye
Investigations
Imaging techniques
Ultrasound this is most useful
Most important to show intrahepatic bile ducts
dilatation
Measure the diameter of CBD (normal up to 7 mm)
Comment on the status of the GB and its stones
Visualize CBD diameter, stones or areas of narrowing
Tumors in the region of the pancreas is seen
CT (conventional or helical) competes with the U/S
especially as regards the pancreatic tumors.
Radiological investigations
Ultrasound
cholangiogram
Preoperative cholangiogram
IV
cholangiogram
PTC
ERCP
Intra operative
T tube ( post operative )
Investigations for a case of
obstructive jaundice
ERCP
ERCP is an outpatient procedure that combines
endoscopic and radiologic modalities to visualize
both the biliary and pancreatic duct systems.
Endoscopically,
the ampulla of Vater is identified and
cannulated.
A contrast agent is injected into these ducts, and
x-ray images are taken to evaluate their caliber,
length, and course.
ERCP
is used to
get a final diagnosis and
do biopsy of ampullary tumors,
or brush cytology.
Investigations for a case of
obstructive jaundice
ERCP
It can be also therapeutic for
stone extraction by Dormia basket or
insertion of a stent, both are preceded by
sphincterotomy.
It
has its risks
ascending infections,
perforations,
pancreatitis, an
bleeding due to sphincterotomy done routinely
before CBD cannulation
ERCP
Congenital
caroli’s syndrome
Chledochal cyst (type I)
Investigations for a case of
obstructive jaundice
MRCP
a sensitive noninvasive method of
detecting biliary and pancreatic duct
stones, strictures, or dilatations within
the biliary system.
It is also sensitive for helping detect
cancer.
Investigations for a case of
obstructive jaundice
MRCP (contraindications)
Absolute include
the presence of a cardiac pacemaker,
cerebral aneurysm clips,
ocular or cochlear implants
ocular foreign bodies.
Relative contraindications include
the presence of cardiac prosthetic valves,
neurostimulators,
metal prostheses,
penile implants
Investigations for a case of
obstructive jaundice
PTC
performed by a radiologist using fluoroscopic
guidance.
The liver is punctured to enter the peripheral
intrahepatic bile duct system.
An iodine-based contrast medium is injected into
the biliary system and flows through the ducts.
Obstruction can be identified on the fluoroscopic
monitor.
Investigations for a case of
obstructive jaundice
PTC
It
is especially useful for lesions proximal to the
common hepatic duct.
Still,
PTC
ERCP is generally preferred.
is reserved for use if ERCP fails or when
altered anatomy precludes accessing the ampulla.
Investigations for a case of
obstructive jaundice
PTC
Complications of this procedure include
the possibility of allergic reaction to the
contrast medium.
peritonitis.
intraperitoneal hemorrhage, sepsis
cholangitis.
subphrenic abscess.
lung collapse.
Severe complications occur in 3% of cases
PTC
Investigations for a case of
obstructive jaundice
Endoscopic ultrasound (EUS) combines
endoscopy and US to provide remarkably
detailed images of the pancreas and biliary
tree.
It uses higher-frequency ultrasonic waves
compared to traditional US (3.5 MHz vs 20
MHz)
allows diagnostic tissue sampling via EUSguided fine-needle aspiration (EUS-FNA).
Acute Cholecystitis
Acute
obstructive
(Calcular)
Acute Acalcaus
Acute emphysematous
Acute obstructive (Calcular)
(Pathology)
Calcular obstruction
GB become hyperemic, oedematous & distended
Chemical inflammation
Release of Phosphlipases
Act on lecithin which is a mucosal protector
transforming it into
Lysolecithin (mucosal toxin
Arachidonic acid (PG precursor) (inflammation)
Sepsis
Ecoli, klebsilla & strept which occur later on
Acute obstructive (Calcular)
(Pathology)
Following acute inflammation the
condition end by one of the following
Resolution
Mucocele
Empyema
Gangrene
And perforation
Bilo-enteric fistula
Acute Acalcular Cholecystitis
It form 8 %
Risk factors are
Sepsis
Starvation
Prolonged
TPN
Ileus
Morphine
use > 6 days
Acute Acalcular Cholecystitis
Pathology is not knowen
Prolonged
distention of GB , Bile stasis &
inspissations lead to mucosal injury and vessel
thrombosis
Hypersensitivity to concomitant antibiotics
Gangrene occur in 25 % of cases
Acute emphysematous
GB
Caused by mixed poly-microbial infection
including gas forming bacteria
70% male , diabetics
Thrombosis of cystic artery is the cause
It lead tom
Gangrene
in 75 %
Perforation in 15 %
Patient 5 F
General
Clinical picture
High
fever with shivering
Nausea, vomiting & biliary dyspepsia
Local
Biliary
colic
Tenderness
Murphy’s
sign
Boa’s sign
Complication
Clinical picture
The attack of biliary colic is the start with visceral type of
pain (diffuse, colicky, radiating, and associated with
vomiting)
Later on after 6 to 8 hours, the pain localizes to the right
hypochondrium, and become associated with
tenderness, rebound T, and rigidity and mild fever
(somatic pain)
The presence of distended gall bladder is the hallmark of
the disease, either discovered clinically or by U/S
In 25% of cases the bilirubin rises, due to compression
of the CBD (Mirrizi syndrome) or less commonly due to
an associated stone CBD
Serum amylase should be a routine as well as plain X ray
abdomen (pancreatitis, and perforation or gas in biliary
system
Acute calculous cholecystitis
Obstruction of GB outlet leads to chemical
inflammation, which persists for 72 h then a fate
of the following, will occur
Resolution (most common), with relief of obstruction
~>scarring and non-function of GB
Resolution of the inflammatory process with
persistence of the obstruction (mucocele of the GB)
Persistence of infection (empyema of the gall bladder)
with obstruction persistence
Gangrene and acute perforation leading to localized
pericholecystic abscess or generalized frank biliary
peritonitis
Chronic perforation with development of biliary
eneteric fistula
Investigation
Laboratory
Leucocytosis
Liver
function
S. amylase
Radiological
Plain
xray
US
Doppler
US
HIDDA scan
CT scan & MRI
Investigations: the best is
ultrasound
An
ultrasound is the most common
screening test.
It is 90-95% sensitive for cholecystitis
It is 78-80% specific.
For simple cholelithiasis, it is 98%
sensitive and specific.
Investigations: the best is
ultrasound
Findings include gallstones or sludge and one or more of
the following conditions:
Gallbladder wall thickening (>2-4 mm)
Gallbladder distention (diameter >4 cm, length >10
cm)
Pericholecystic fluid from perforation or exudate
Air in the gallbladder wall (indicating gangrenous
cholecystitis)
Sonographic Murphy sign (86-92% sensitive, 35%
specific), pain when the probe is pushed directly on
the gallbladder (not related to breathing)
Treatment (conservative)
NPO, nasogastric & IV fluids
Analgesic, antipyretic & spasmolytic
Antibilotic
Broad spectrum ( cephalosporins )
Metronidazole & aminoglycoside
Follow up and surgery
In the same admission
Interval cholecystectomy
Urgent if
Treatment (surgical)
Doubt
in diagnosis
Failure to improve
Complication
We perform
Chole-cyst-ectomy
retrograde
Chole-cyst-ectomy
Chole-cyst-ostomy
Subtotal Chole-cyst-ectomy
Mini Chole-cyst-ectomy
Laparscopic Chole-cyst-ectomy
Treatment (surgical)
Established
Non-progressive
disease
Interval Chole-cyst-ectomy
Early chole-cyst-ectomy
Gall stones
Increase bile pigments
Decrease phosphlipid
&bile salts
Increase
cholesterol
Metabolic
Gall
stones
Infection
Stasis
75%
Cholesterol stone
of stones formed in sterile GB
(10% infection)
Protein matrix
cholesterol (70%)
bile pigment
Ca carbonate
Ca palmitate (Ca salts deposited at
periphery, their amount determine
the radiolucency)
Cholesterol stone
Two types
Pure cholesterol
Oval or rounded
mamillated or mullbery-surfaced
pale yellow in color
solitary big size (100% cholesterol
rounded)
60% cholesterol (mixed)
Multiple mediums sized (60%
cholesterol, faceted)
brownish polished surface
Gall stones
Formation involves 7 processes
1.
2.
3.
4.
5.
6.
7.
Super saturation with cholesterol
Incomplete transfer of cholesterol from vesicles
to micelles
Formation of vesicles with high cholesterol
Aggregation and fusion of unstable vesicles
Cholesterol crystallization (mucin is a nucleating
agent)
Biliary sludge formation (mucin+ cholesterol+
Ca+pigment ~precursor of stones)
Stone growth
Black Pigment Stone
25% of stones.
It is common in cirrhotics, after terminal ileum
resection and in hemolytic diseases. Formed in a
sterile GB (20% infection rate)
Composed of bilirubin polymer without Ca
palmitate and +cholesterol (25%)+matrix of
organic material
Usually multiple, small, irregular, dark green or
black in color
Hard in consistency and cut surface is layered
Formation
Elevated concentration of mono-conjugated bilirubin
lower bile salt concentration is the usual constitution
in forming patients
yet the exact pathogenesis is not known
Brown Pigment Stone
Rare ductal stones caused by infection by
gram -ve bacteria releasing B
glucuronidase releasing free bilirubin
Composed mainly of
Ca
bilirubinate,
Ca palmitate + small amounts of cholesterol
matrix of organic material
Amorphous soft stones
Gall stone disease
Symptom less
no interference
interference in
Diabetics
Acromegalic
Calcified
Patient under go surgical intervention
Symptomatic
Chronic cholecystitis
Acute biliary colic, acute cholecystitis
Jaundice
Clinical presentations
Acute cholecystitis
Empyema of the gallbladder
Mucocele of the gallbladder
Biliary colic
'Flatulent dyspepsia'
Mirrizi's syndrome
Obstructive jaundice
Pancreatitis
Acute cholangitis
Chronic calcular cholecystitis
Clinical picture
Recurrent attacks of epigastric or right
hypochondrial pain (persistent pain)
May be attacks of severe biliary colic
Nausea &vomiting
Flatulent dyspepsia with intolerance to fatty
meals
Tenderness in right hypochondrium (Murphy’s
Treatment :
Cholecystectomy
either conventional
or laparoscopic is the ideal treatment
for symptomatic patients.
Patients with asymptomatic gall
stones can be left without surgery
specially if cirrhotics.
However patients with a calcified or
porcelain gallbladder should consider
elective cholecystectomy due to the
increased risk of carcinoma (25%).
Laparoscopic cholecystectomy
(LC)
Shown to be equally as effective as open
cholecystectomy in controlled trials
Pre-operative ERCP is indicated if:
Recent
jaundice
Abnormal liver function tests
Significantly dilated common bile duct
Ultrasonic suspicion of bile duct stones
cholecystectomy
Indication
Trauma
Inflammation
Acute
& chronic
Mucocele
empyema
Tumor
Torsion
As
a part of other operations
cholecystectomy
Incisions
Subcostal
(Kocher’s)
Upper right paramedian
Right upper transverse
Upper midline
cholecystectomy
Technique
Preliminary exploration
Signs of cholecystitis
Associated pathology
Saint’s triade
Welkie’s triade
Pancrease
Stone in CBD
Saint’s triade
Welkie’s triade
Technique
Packing
of the field & retractors
GB is grasped
Separation of GB
Artery
Duct
Identification of Calot’s
Operative complications
Injury to important structure
Common bile duct injury:
observed more frequently in the laparoscopic approach.
Iatrogenic common bile duct injury often results from a
combination of inexperience of the surgeon, the presence of
anomalous biliary anatomy, and acute inflammation.
Duodenum injury
Pancreatic and liver injury
Ligation of Rt hepatic artery
Primary hge
Injury of cystic artery
Injury of Rt hepatic
Injury portal vein
GB bed
Post operative complications
General
Chest
& abdomen
DVT
Infection:
Spillage
of stones into the peritoneal cavity during
cholecystectomy increases the risk of infection and
abscess formation.
Wound infections also are possible but are less
common in the laparoscopic approach..
Post operative complications
Local
Bleeding:
Ligation of
Reactionary slipped ligature
2 ry hge if infection which may lead to collection above IVC
( Waltman- Walter syndrome)
CBD or CHD
Hepatic artery
Biliary peritonitis
Biliary fistula
Subphrenic collection
Postcholecystectomy syndrome
Post cholecystectomy syndrome
Organic causes
Long
stump of cystic duct
Missed stone
Stricture
Stenos is of sphincter of Oddi
Non organic causes
Psycho-somatic
Biliary
dyskinesia
Long stump of cystic duct
If stone is formed
Stump
must be excised with
Stone extraction
If no stones
symptomatic treatment
Missed stone after cholecystectomy
Confirm diagnosis by US & ERCP
Minimal invasive
ERCP
sphincterectomy & stone extraction by
Dormia Basket
PTC then choledochoscpic extrction
Surgical
Supradoudenal
choledochotomy
Transdoudenal sphincteroplasty
Stricture
Minimal
invasive by stent insertion
Surgical
Roux
en Y choledocho
jujunostomy
Roux en Y hepatico jujunostomy
Post cholecystectomy syndrome
Organic causes
Long
stump of cystic duct
Missed stone
Stricture
Stenos is of sphincter of Oddi
Non organic causes
Psycho-somatic
Biliary
dyskinesia
Post cholecystectomy syndrome
Stenos is of sphincter of Oddi
Endoscopic
papillotomy and sphincterotomy
Sphincteroplasty
Choledocho doudenotomy
Biliary dyskinesia
Endoscopic
papillotomy and sphincterotomy
Stone in CBD
Aetiology
GB stone (commonest)
Primary stones of CBD usually (Brown)
Parasites
Stasis
FB
cholangitis
Clinical picture
Symptom less 20 %
Symptoms
Charcot’s
triade
Jaundice
Pain
Fever
Raynaud’s
Charcot’s
pentale
triade
Hypotension
Altered mental status
Investigations
Laboratory
CBC
Liver
function
urine
Radiological
US
ERCP
MRCP
PTC
Management of stone CBD
Support liver by correction of the general
condition by I.V. fluids for hydration
Support kidney by Mannitol
(hypotension and hyperbilirubinemia
together causes renal shut down)
Prevent infection by antibiotics,
Prevent bleeding by correction of the
avitaminosis K by parentral vitamin
administration
Concurrent common bile duct and
gallbladder stones
Preoperative
ERCP, with clearance of the
common bile duct, followed by LC
Open cholecystectomy and common bile duct
exploration
Combined laparoscopic-endoscopic
management:
Endoscopic sphincterotomy and stone extraction
are performed on the operation table
after the surgeon has passed a guidewire through
the cystic duct into the duodenum
to help the endoscopist because the procedure is
performed with the patient in the supine position.
Management of a case of stone
CBD
Minimal invasive
Endoscopic extraction of calculi
followed by cholecystectomy whether
surgical or most commonly
laparoscopic
PTC which provide drainage and
subsequent choledochoscopy & stone
extraction
Management of a case of stone
CBD
Conventional
choledochtomy
Chole cystectomy and supra
doudenal choledochtomy
choledocholithotomy (exploration of
the common bile duct)
Trans doudenal sphincterotomy
Choledocho douden ostomy
Indications of common bile duct
exploration (supra doudenal
Preoperative
confirmation of the presence of CBD stones (U/S, ERCP, or
operative cholangiography)
Jaundice or history of jaundice
History of pancreatitis (although it is usually due to a passing
stone)
Operative
choledochtomy)
Stone palpable in CBD
Dilated CBD with thick lusterless fibrous wall, with mud inside
Dilated cystic duct specially if there is multiple small stones in
the gall bladde
Postoperative
Surgical Jaundice
Management of a case of stone
CBD
T tube insertion which should be
Widest possible diameter
Latex or red rubber (never plastic)
Exist from one side of the choledochotomy
wound
Horizontal limb is cut to lie below the carina and
above the common channel
Vertical limb comes out straight from the
abdomen
T tube cholangiography is done on the 4 th days
and tube is extracted at the 10-12 days after 24hour occlusion without problems (fever, leakage,
or pain)
Management of stone CBD
Sphincterotomy or sphincteroplasty done In
the presence of
stenosed termination of CBD or
an impacted stone in its lower end that
cannot be extracted from the
choledochotomy wound
the ampulla is attacked through a duodenal
incision and the ampulla should undergo
either sphincterotomy or sphincteroplasty
at 10 or 11-oclock positions to avoid
pancreatic duct injury
Management of a stone CBD
Chole docho duodenostomy is done (in the
following situations)
In dilated CBD (more than one cm)
In case there is multiple stones (> 4
stones in CBD) because of the high
possibility of missing a stone inside
Presence of intrahepatic biliary stones
Stricture of the lower end of CBD
Missed stone after CBD exploration
Confirm diagnosis bt US & ERCP
Wait for 6 weeks
Hydrostatic pressure
Minimal invasive
ERCP sphincterectomy & stone extraction by Dormia
Basket
PTC then choledochoscpic extrction
Surgical
Supradoudenal choledochotomy
Transdoudenal sphincteroplasty
Jaundice
Jaundice
Pre-hepatic
(Hemolytic)
Hepatic
Post
hepatic (Obstructive)
Pre-hepatic (Hemolytic)
Congenital abnormal
Shape
spherocytosis,
eleptocytosis
Hb
thalssemia,
sickle
cell
Enzymes
G6
PD,
pyruvate kinase
Pre-hepatic (Hemolytic)
Acquired
Immune hemolytic
Collagenic SLE, Rheumatoid
Tumor lekemia, lymphoma
Infections malaria, syphilis
Drugs penicillin tetracycline, quinidine, aSPIRIN
Non immune
Septicemia
Burn
Metal poisoning
Mismatch blood transfusion
Haematoma
Snake venum
Hepatic
Acute
Viral
Amoebic
or bacterial
Alcoholic
Liver
cell necrosiis
Drugs
Direct
hepatotoxic
A antibiotics (Tetracycline),
Analgesic (salycilate, paracetamol)
Antihelminthic carbon tetra chloride
Anaesthestics fluthane
Arsenic
Hepatic
Drugs
Direct hepatotoxic
B benzidine dervative TNT
C cytotoxic 5FU
Intra hepatic cholestasis
Non sensitivity methyl testosterone
Sensitivity
neomercazole, thiuracil, chloropromazine
Hypersensitivity
PASA
Chronic
Chronic
active
Cirrhosis
Primary hepatic cirrhosis
Space occuping lesions
Obstructive jaundice (Etiology)
Common
Common
bile duct stones
Carcinoma of the head of pancreas
Malignant porta hepatis lymph nodes
Infrequent
Ampullary
carcinoma
Pancreatitis
Liver secondaries
Obstructive jaundice (Etiology)
Rare
Benign
strictures - iatrogenic, trauma
Recurrent cholangitis
Mirrizi's syndrome
Sclerosing cholangitis
Cholangiocarcinoma
Biliary atresia
Choledochal cysts
Calcular obstruction
Intermittent
(can be progressive if
stone is impacted)
Usually no reaching high levels
Pain is colicky in nature, and typical
for biliary colic
G.B not palpable except very rarely if
its neck is obstructed too (double
stone)
Malignant obstruction
Progressive except very rarely in
ampullary tumors where sloughing can
give temporary decrease
Usually reaching high levels
Pain is constant and referred to the back
in pancreatic tumor, while it is absent in
CBD tumors
G.B is palpable except in Klatskin tumors
Obstructive jaundice
Calcular
Complications of obstructive
jaundice
Ascending cholangitis
Charcot's
triad is classical clinical picture
which is formed of intermittent pain, jaundice
and fever
Cholangitis can lead to hepatic abscesses
Need parenteral antibiotics and biliary
decompression
Operative mortality in elderly of up to 20%
Complications of obstructive
jaundice
Clotting disorders
Vitamin
K required for gamma-carboxylation
of Factors II, VII, IX, XI
Vitamin K is fat-soluble. No absorbed. So it
needs to be given parenterally
Urgent correction will need Fresh Frozen
Plasma
Also endotoxin activation of complement
system
Complications of obstructive
jaundice
Hepato-renal syndrome
Poorly understood
Renal failure post intervention
Most probably due to gram negative
endotoxinaemia from gut
Preoperative lactulose may improve outcome
by improving altered systemic and renal
haemodynamics
Drug Metabolism
Half-life of some drugs prolonged. (E.g.
morphine)
Impaired wound healing.
Investigations for a case of
obstructive jaundice
Laboratory
Raised
Direct bilirubin (in most of the cases the
indirect bilirubin also rises due to
hepatic cellular malfunction).
Alkaline phosphatase
Gamma glutamyl transferase
5 nucleotidase
Investigations for a case of
obstructive jaundice
Laboratory
Mild elevation or normal
SGOT & SGPT (these are shooting in
viral hepatitis)
Slightly depressed or normal
Prothrombin time (due to avitaminosis
K)
Urine urobilinogen
Investigations for a case of
obstructive jaundice
Imaging techniques
Ultrasound this is most useful
CT (conventional or helical) competes with
the U/S especially as regards the pancreatic
tumors.
ERCP
MRCP
PTC
EUS
malignant
Treatment for
cholangiocarcinoma of CBD
Palliative
Plastic stent insertion through ERCP
Stent insertion through percutanous
transhepatic route
Self-expanding stainless steel wire biliary
endoprosthesis is new modality with high
patency rate, and less infection rate
Treatment for
cholangiocarcinoma of CBD
Palliative
Bypass surgery
Round
ligament approach for Klatiskin tumors
(on condition that the carina is permitting
right to left communication)
Hepatico jujenostomy for middle and low
tumors
Cholecystojujenostomy for low tumors.
usually we add gastrojujenostomy and
enteroanastomosis (triple anastomosis) for
pancreatic head tumors
Treatment for
cholangiocarcinoma of CBD
For operable cancers
For Klastiskin tumor,
segment IV excision provides good access to the
confluence
allows good proximal clearance and facilitates
hepaticojujenostomy
For middle tumors excision of the tumor from
just below the carina to the duodenum is done
with hepaticojujenostomy
For distal tumors. Whipple operation is done
Biliary stricture
Etiology
Congenital (biliary atresia)
Traumatic (most important, and usually follow
cholecystectomy)
Complete ligation of CBD
Narrowing of the duct by partial inclusion in a ligature
Ischemia of the duct, or diathermy injury
Inflammatory Sclerosing cholangitis (multiple
strictures separated by normal or dilated
segments).
Cholangiocarcinoma
Sclerosing cholangitis
PSC (primary sclerosing choangitis ) is a
chronic cholestatic biliary disease
characterized by non suppurative
inflammation and fibrosis of the biliary
ductal system.
The cause is unknown but is associated
with autoimmune inflammatory diseases
such as chronic ulcerative colitis.
Sclerosing cholangitis
Most
patients present with fatigue
and pruritus and, occasionally,
jaundice.
The natural history is variable but
involves progressive destruction
of the bile ducts, leading to
cirrhosis and liver failure.
Biliary stricture
Investigations used are similar to those
used in any case of obstructive jaundice
(U/S then CT, ERCP, MRCP or PTC
Treatment is centered on creating a biliary
enteric anastomosis with mucosa-tomucosa sutures without compromising the
blood supply of any of the ends.