biliary system

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biliary system
Gall bladder Bile ducts

• Surgical physiology
• Bile, as it leaves the liver, is composed of 97
  water, 12 bile salts and 1 pigments,
  cholesterol and fatty acids.
• The liver excretes bile at a rate estimated to be
  approximately 40 ml h.
• The rate of bile secretion is controlled by
  cholecystokinin (CCK), which is released from the
  duodenal mucosa. With feeding, there is increased
  production of bile.

GALLBLADDER AND BILIARY TREE - IMAGING TECHNIQUES
Ultrasound Plain radiograph Magnetic
resonance cholangiopancreatography
Multidetector row computerised tomography scan
Radioisotope scanning Endoscopic retrograde
cholangiopancreatography Percutaneous
transhepatic cholangiography anatomy and biliary
strictures Endoscopic ultrasound Peroperative
cholangiography
Ultrasound examination. Single large gallstone
casting an acoustic shadow
Ultrasound

• It can demonstrate biliary calculi, the size of
  the gall bladder, the thickness of the gall
  bladder wall, the presence of inflammation around
  the gall bladder, the size of the common bile
  duct and, occasionally, the presence of stones
  within the biliary tree.
• Endoscopic ultrasonography uses a specially
  designed endoscope with an ultrasound transducer
  at its tip, which allows visualisation of the
  liver and biliary tree from within the stomach
  and duodenum.

Ultrasound examination. showing the dilated
common bile duct (B). P, portal vein I, inferior
vena cava
Magnetic resonance cholangiopancreatography

• Contrast is not required and, using appropriate
  techniques, excellent images can be obtained
  ofthe biliary tree that demonstrate ductal
  obstruction, strictures or other intraductal
  abnormalities.

Multidetector row computerised tomography scan
Magnetic resonance cholangiopancreatography demons
trating hilar obstruction
- Anatomy, liver, gall bladder and pancreas
cancer. It can identify the extent of the primary
tumour anddefines its relationship to other
organs and blood vessels . - For benign biliary
diseases, standard computerised tomography (CT)
is not that useful an investigation. However,
improvements in CT technology such as
multidetector helical scanners that allow for
three-dimensional reconstruction of the biliary
tree have led to greater diagnostic accuracy and
may increase the use of this modality in the
future.
Computerised tomography scan demonstrating a
Hilar mass (thick arrow) and biliary dilation
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• Endoscopic retrograde cholangiopancreatography
• ERCP, has a role in the assessment of the
  jaundiced patient. In this group, it is
  especially useful in determining the cause and
  level of obstruction. Bile can be sent for
  cytological and microbiological examination, and
  brushings can be taken from strictures for
  cytological studies. Therapeutic interventions
  such as stone removal, sphincterotomy or stent
  placement to relieve the obstruction can be
  performed.

Endoscopic retrograde cholangiopancreatography dem
onstrating stone obstructing the common bile duct

• Percutaneous transhepatic cholangiography
• Percutaneous transhepatic cholangiography
  anatomy and biliary strictures It is only
  undertaken once a bleeding tendency has been
  excluded and the patients prothrombin time is
  normal. Antibiotics should be given prior to the
  procedure. Bile can be sent for cytology. In
  addition, PTC enables the placement of a catheter
  into the bile ducts to provide external biliary
  drainage or the insertion of indwelling stents.
  The scope of this procedure can be further
  extended by leaving the drainage catheter in situ
  for a number of days and then dilating the track
  sufficiently for a fine flexible choledochoscope
  to be passed into the intrahepatic biliary tree
  in order to diagnose strictures, take biopsies or
  remove stones.

• Radioisotope scanning
• Technetium-99m (99mTc)-labelled derivatives of
  iminodiacetic acid Dimethyl iminodiacetic acid
  (HIDA) scan are, when injected intravenously,
  selectively taken up by the retroendothelial
  cells of the liver and excreted into bile. This
  allows visualisation of the biliary tree and gall
  bladder. Non-visualisation of the gall bladder is
  suggestive of acute cholecystitis. If the patient
  has a contracted gall bladder, as often occurs in
  chronic cholecystitis, gall bladder visualisation
  may be reduced or delayed. Biliary scintigraphy
  may also be helpful in diagnosing bile leaks and
  iatrogenic biliary obstruction. It is very
  important tool in differentiating biliary atrisia
  from neonatal hepatitis .

Transhepatic cholangiogram showing a stricture
of thecommon hepatic duct
Peroperative cholangiography During open or
laparoscopic cholecystectomy, a catheter can be
placed in the cystic duct and contrast injected
directly into the biliary tree. The technique
defines the anatomy and is mainly used to exclude
the presence of stones within the bile ducts
Dimethyl iminodiacetic acid (HIDA) scan
demonstrating at 20 min non-visualisation of the
gall bladder (arrow), suggestive of acute
cholecystitis
Congenital anomalies 1)gall bladder (absent,
Pharyngin cap, double, intrahepatic) 2)bile duct
(biliary Artesia, choledocal cyst ) 3)hepatic
duct anomalies 4)cystic duct anomalies
5)hepatic artery anomalies
Gall stones (cholelithiasis) Risk factors
Overall risk factors include female gender, 40,
obese, fatty diet and fertile .

• Types and etiology
• Gallstones represent a failure to maintain
  certain biliary solutes
• Types cholesterol stones ,black or brown pigment
  stones , or mixed stones
• Disturbed bile salts /cholesterol ratio
• Stasis of bile
• Nidus
• Hemolytic anemia

Peroperative cholangiography. Dilated biliary
system with multiple stones in the common bile
duct and reflux of contrast into the pancreatic
duct. Sphincterotomy was performed
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Clinical feature and investigation

• Asymptomatic
• Recurrent biliary colic The pain usually begins
  abruptly and subsides gradually, lasting for a
  few minutes to several hours. The pain of biliary
  colic is usually steadynot intermittent, like
  that of intestinal colic. Biliary colic is
  usually felt in the right upper quadrant, but
  epigastric and left abdominal pain are common,
  and some patients experience precordial pain. The
  pain may radiate around the costal margin into
  the back or may be referred to the region of the
  scapula, nausea and vomiting often accompany each
  episode. Classically, the pain of biliary colic
  occurs following a greasy meal, develops more
  than an hour after eating.
• Complication
• Investigation
• Differential Diagnosis Biliary colic may
  simulate the pain of duodenal ulcer, hiatal
  hernia, pancreatitis, and myocardial infarction.
• An electrocardiogram and a chest x-ray should be
  obtained to investigate cardiopulmonary disease.
  It has been suggested that biliary colic may
  sometimes aggravate cardiac disease, but angina
  pectoris or an abnormal electrocardiogram should
  rarely be indications for cholecystectomy.

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Treatment

• Laparoscopic cholecystectomy for symptomatic
  cholelithiasis.

• Acute cholecystitis
• Types Acute Acalculous Cholecystitis , Acute
  calculous Cholecystitis
• Pathology
• Clinically Right upper quadrant abdominal pain is
  the most common complaint in patients with acute
  cholecystitis. The pain may be similar to
  previous episodes of biliary colic, but the pain
  of acute cholecystitis persists for longer than
  an uncomplicated episode of biliary colic (days
  vs. several hours). Other common symptoms include
  nausea, vomiting, and fever. On physical
  examination, focal tenderness and guarding are
  usually present inferior to the right costal
  margin, distinguishing the episode from simple
  biliary colic. A mass may be present in the right
  upper quadrant (gallbladder with adherent
  omentum). If instructed to breathe deeply during
  palpation in the right subcostal region, the
  patient experiences accentuated tenderness and
  sudden inspiratory arrest (Murphy sign).
• A mild leukocytosis is usually present (12,000 to
  14,000 cells/mm3 ). In addition, mild elevations
  in serum bilirubin (gt4 mg/dL), alkaline
  phosphatase, the transaminases, and amylase may
  be present.
• ComplicationsEmpyema , Perforation ,
  Pericholecystic Abscess, Free Perforation,
  Cholecystenteric Fistula
• DD An acute peptic ulcer with or without
  perforation ,Acute pancreatitis and Acute
  appendicitis in patients with a high cecum
• Investigation
• TTT in most patients with acute cholecystitis,
  laparoscopic cholecystectomy should be attempted
  soon (24 to 48 hours) after the diagnosis is
  made.
• Early cholecystectomy Vs initial conservative
  treatment followed by cholecystectomy

• Asymptomatic Gallstones
• Each year, about 2 of patients with asymptomatic
  gallstones develop symptoms, usually biliary
  colic rather than one of the complications of
  gallstone disease. The present practice of
  operating only on symptomatic patients, leaving
  the millions without symptoms alone, seems
  appropriate. A question is often raised about
  what to advise the asymptomatic patient found to
  have gallstones during the course of unrelated
  studies. The presence of either of the following
  portends a more serious course and should
  probably serve as a reason for prophylactic
  cholecystectomy (1) large stones (gt 2 cm in
  diameter), because they produce acute
  cholecystitis more often than small stones and
  (2) a calcified gallbladder, because it so often
  is associated with carcinoma. However, most
  asymptomatic patients have no special features.
  If coexistent cardiopulmonary or other problems
  increase the risk of surgery, operation should
  not be considered. For the average asymptomatic
  patient, it is not reasonable to make a strong
  recommendation for cholecystectomy. The tendency,
  however, is to operate on younger patients and
  temporize in the elderly.

• Choledocholithiasis
• Pathology (primary-secondary)
• Fate 1)Passage
• 2)Obstruction jaundice urine
  stool, itching ,decrease HR.
• 3)Complication (coagulopathy ,
  cholangitis , renal frailer .,billiary cirrhosis
  )
• Clinical picture (pain ,jaundice , fever and
  rigors) Charcot triad
• Signs jaundice ,Courvoisiers low
• Investigation CBC,LFT,RFT,CT,BTUS,CT,ERCP,MRCP,PT
  C.

• Choledocholithiasis management
• Aim to remove the (obstruction and then the gall
  bladder ) after preparation
• Preoperative ( monitoring, adequate hydration
  , IV vitamin K, high glucose intake, antibiotic
  )
• ERCP
• possible complications
• If failed exploration of CBD.

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• CBD strictures
• Congenital - Traumatic
• Sclerosing cholangitis
• Neoplastic cholangiocarcinoma

• Benign Stricture/Bile Duct Injury
• Benign biliary strictures occur in association
  with a wide variety of conditions including
  chronic pancreatitis, primary sclerosing
  cholangitis, acute cholangitis, several
  autoimmune diseases, or following either blunt or
  penetrating abdominal trauma.
• However, most benign strictures follow iatrogenic
  bile duct injury, most commonly during
  laparoscopic cholecystectomy. Most injuries are
  recognized intraoperatively or during the early
  postoperative period, and with appropriate
  management the long-term results are acceptable.
• However, with inappropriately managed biliary
  strictures, result in recurrent cholangitis,
  secondary biliary cirrhosis, and portal
  hypertension may eventually develop.

• Management
• The appropriate management of biliary tract
  injuries depends on the time of diagnosis after
  the initial injury and the type, extent, and
  level of the injury.
• Cystic duct bile leaks can usually be managed
  with percutaneous drainage of any intra-abdominal
  fluid collections, followed by placement of a
  biliary endoprosthesis.
• Lateral bile duct (partial transection) injuries
  recognized at the time of cholecystectomy should
  be managed with placement of a T tube.
• If the biliary rent is more extensive, the injury
  is repaired primarily and stented with a T tube
  placed through a proximal or distal
  choledochotomy.
• Isolated hepatic ducts smaller than 3 mm or those
  draining a single hepatic segment can be safely
  ligated. Ducts larger than 3 mm are more likely
  to drain several segments or an entire lobe and
  need to be reimplanted.
• CBD stricture should be manged by ERCP stinting
  or repair

• Acute Cholangitis
• Acute cholangitis is a bacterial infection of the
  biliary ductal system, which varies in severity
  from mild and self-limited to severe and life
  threatening.
• The clinical triad of fever, jaundice, and pain
  associated with cholangitis was first described
  in 1877 by Charcot.
• Etiology
• The most common causes of biliary obstruction are
  choledocholithiasis, benign strictures, biliary
  enteric anastomotic strictures, and
  cholangiocarcinoma or periampullary cancer.
• ERC, PTC, and stent placement via either the
  endoscopic or percutaneous route all are known to
  cause bacteremia. These procedures are frequently
  performed in patients with unresectable malignant
  obstruction

• Clinical Presentation
• Severe illness, including jaundice, fever,
  abdominal pain, mental obtundation, and
  hypotension (Reynolds pentad).
• Fever is the most common presenting symptom and
  is often accompanied by chills. Jaundice is a
  frequent physical finding but may be absent,
  especially in patients with an indwelling
  endoprosthesis or biliary stent.
• Pain is also commonly present but is often mild.
  Severe pain or marked tenderness should prompt
  consideration of an alternate diagnosis such as
  acute cholecystitis. Up to 33 of patients with
  choledocholithiasis present with toxic
  cholangitis characterized by septic shock.

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• Management
• Patients with toxic cholangitis may require
  intensive care unit monitoring and vasopressors
  to support blood pressure. Most patients require
  intravenous fluids and antibiotics. Most patients
  with cholangitis respond to antibiotic therapy
  alone with clinical improvement.
• However, in the 15 of patients who do not
  respond to antibiotics within 12 to 24 hours or
  in patients with toxic cholangitis, emergency
  biliary decompression may be necessary. Biliary
  decompression may be performed endoscopically or
  via the percutaneous transhepatic route.
• In settings where either endoscopic or
  percutaneous biliary drainage is not possible,
  common bile duct exploration and placement of a T
  tube remains a life-saving procedure for
  seriously ill patients with toxic cholangitis.
  However, the mortality for patients treated
  surgically is considerably higher than for
  patients successfully managed endoscopically.

• MALIGNANT BILIARY DISEASE
• Gallbladder Cancer
• Cholangiocarcinoma intrahepatic , hilar tumors
  distal cholangiocarcinoma,

Bismuth classification of hilar Cholangiocarcinoma
Bismuth classification of perihilar
cholangiocarcinoma by anatomical extent. Type I
tumors are confined to the common hepatic duct,
and type II tumors involve the bifurcation
without involvement of secondary intrahepatic
ducts. Type IIIa and IIIb tumors extend into
either the right or left secondary intrahepatic
ducts, respectively. Type IV tumors involve the
secondary intrahepatic ducts on both sides.

• Diagnosis
• At the time of presentation, most patients with
  perihilar and distal cholangiocarcinoma have a
  total serum bilirubin level greater than 10
  mg/dL. Marked elevations are also routinely
  observed in alkaline phosphatase.
• Serum CA 199 may also be elevated in patients
  with cholangiocarcinoma, although levels may fall
  once biliary obstruction is relieved.

• Management
• Preoperative preparation is of paramount
  importance ( monitoring, adequate hydration ,
  IV vitamin K, high glucose intake, antibiotic )
• The operative approach depends on the site and
  extent of the tumor.
• For patients with anatomically resectable
  intrahepatic cholangiocarcinoma and without
  advanced cirrhosis, partial hepatectomy is the
  procedure of choice
• Patients with perihilar tumors involving the
  bifurcation or proximal common hepatic duct
  (Bismuth type I or II) that have no vascular
  invasion are candidates for local tumor excision.
  Biliary enteric continuity is restored with
  bilateral hepaticojejunostomies.
• If preoperative evaluation suggests involvement
  of the right or left hepatic duct (Bismuth type
  IIIa or IIIb), right or left hepatic lobectomy,
  respectively, should be Planned
• For patients with resectable distal
  cholangiocarcinoma, pancreatoduodenectomy
  (Whipple ) is the optimal procedure.
• ERCP and stinting for inoperabable CCA

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Standard and pylorus-preserving Whipple procedure