Benign biliary disease Dr. Gili Halfteck Department of General
Surgury Shaare Zedek Medical Center January 2014
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Anatomy
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Calots triangle
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Physiology Roles of bile secretion: 1.Excretion of toxins and
cellular metabolites (bilirubin) 2.Lipids absorption Components of
bile: 1.Bile salts 2.Lipids (phospholipids and cholesterol)
3.proteins 4.pigments
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Bile flow
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Stimuli of bile secretion 1.Vagal activity 2.Secretin 3.CCK
(bile secretion and gallbladder wall contraction)
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Fasting state: -entero-hepatic circulation -Accumulation of
bile in the gallbladder -Retrograde filling of the gallbladder -
tonic activity of the sphincter of Oddi Fed state: -CCK (acid, fat
and protein in duodenum) -Vagal activity
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Symptoms of biliary tree disease Pain Fever Juandice
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Pain Biliary colic Usually constant pain Location:
RUQ/epigatrium Can be associated with meals (1 hour or more after a
meal) Caused by contraction of the gallbladder against an
obstructed neck Stasis + pressure + bacterial inoculum infection
and inflammation (RUQ tenderness on palpation) Murphys sign
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Fever Accompanies infection and inflammation of the gallbladder
or biliary tree Not present in biliary colic
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Juandice Elevation of serum bilirubin Surgical (obstruction) /
medical (hepatocellular) >2.5 mg/dl scleral icterus >5 mg/dl
cutaneous juandice Pathogenesis: failure to excrete bile from the
liver to the intestine Charcots triade: fever, RUQ pain, juandice
Reynolds pentad: + hypotension and altered mental status
Imaging 1. US study of choice for initial evaluation of
jaundice and gallbladder or biliary disease Surgical/medical
jaundice High sensitivity and specificity for gallstones
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2. HIDA (hepatic iminodiacetic acid) scan Nuclear medicine test
demonstrated physiologic bile flow but does not provide anatomic
delineation Failure to fill the gallbladder 2 hours after injection
cystic duct obstruction (cholecystitis) Obstruction of the biliary
tree, bile leaks
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3. CT scan Superior anatomic information Most gallstones are
isodense to bile Identifies cause and site of biliary obstruction
Preoperative planning in pancreatic/hepatic neoplastic processes 4.
MRI/MRCP Superior anatomic definition of intra- and extrahepatic
biliary tree and pancreas Non-invasive No radiation exposure
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5. ERCP (endoscopic retrograde cholangiopancreatography)
Invasive test using endoscopy and fluoroscopy Contrast injection
through the ampulla and imaging of the biliary tree Able to
diagnose and treat many biliary tree diseases (choledocholithiasis,
tissue sampleing, CBD stenting) Complication rate - 10%
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Bacteriology Without previous biliary intervention bile is
considered sterile The presence of gallstones or obstruction and
stasis increases the likelihood of bacterial contamination Mostly
gram-negative aerobes passage of bacteria upward from the duodenum
into the biliary tree E. Coli, Klebsiella, Enterobacter,
Enterococcus spp.
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Gallstones Types: 1.Mixed stones (70%) cholesterol and calcium
2.Pure cholesterol stones (10%) 3.Pigment stones brown/black (10%)
Gallstones formation: -Supersaturation of bile -Concentration of
bile in the gallbladder -Crystal nucleation -Gallbladder
dysmotility
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Natural history of gallstones Vast majority are asymptomatic
incidentale finding Biliary colic temporary obstruction of the
cystic duct or gallbladder neck 1% of patients with asymptomatic
stones develop complications before onset of symptoms -
prophylactic cholecystectomy is not warranted High risk patients:
-Hemolytic anemias -Porcelain gallbladder -Large (>2.5 cm)
stones -Long common channels of bile and pancreatic duct -Bariatric
surgery (sleeve, bypass) -Immunocompromised patients
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Non-operative treatment of cholelitiasis Generally
unsuccessfull and rarely used!!! -Oral dissolution -Contact
dissolution -Shock-wave lithotripsy Up to 50% recurrence rate
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Acute calculus cholecystitis Pathogenesis: unresolved cystic
duct obstruction Inflammation, edema, subserosal hemmorhage
Infection of stagnant bile pool Can progress to ischemia and
necrosis (gangrenous cholecystitis) Presentation: -Fever -RUQ pain
-Tenderness to palpation Laboratory finding: leukocytosis, mild
elevation of bilirubin, transaminases, alk-phos.
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diagnosis 1. Transabdominal US -sensitive, inexpensive and
reliable -Sensitivity 85%, specificity 95% -Gallstones, gallbladder
wall thickening, pericholic fluid, sonographic murphys sign 2. Hida
scan -Atypical cases -Cystic duct obstruction 3. CT scan - Less
sensitive then US
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Treatment NPO IV fluids IV antibiotics (broad-spectrum) Pain
control Cholecystectomy (open/lap.) Percutaneous
cholecystostomy
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Chronic cholecystitis Inflammation and scarring of the
gallbladder neck and cystic duct Pathogenesis: recurrent biliary
colic which cause temporary cystic obstruction and do not cause
acute cholecystitis Presentation: recurrent biliary colic (usually
after fatty meals), nausea, vomiting RUQ/epigatric pain radiating
to the scapula, usually resolves within few hours Symptomatic
cholelithiasis indication for chlecystectomy
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Diagnosis History Transabdominal US stones, sludge Treatment
Elective cholecystectomy Curative in > 90% of patients
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choledocholithiasis 1.Primary common duct stones -De novo in
the bile duct -Usually brown pigment stones -More common in Asian
population -Associated with bacterial bile duct infection 2.
Secondary common duct stones -Arising from the gallbladder -Most
common bile duct stones in the USA Retained common duct stones
found within 2 years of cholecystectomy
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Presentation 80-90% of common duct stones remain clinically
silent Routine cholangiography 10% choledocholithiasis Selective
cholangiography (pain, abnormal liver function test) 1-2% of
patients will present with retained stones Symptoms: -Biliary colic
-Obstructive juandice -Ascending cholangitis (fever, pain,
juandice)
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Diagnosis Hepatic function panel abnormalities Leukocytosis US
choledocholithiasis, biliary ductal dilatation, gallstones Bile
duct dilatation (>8 mm) in the presence of biliary colic,
juandice or gall stones is suggestve of choledocholithiasis ERCP
-highly sensitive and specific -Usually therapeutic
-Sphincterotomy, balloon stone extraction -Complication rate 5-8%
MRCP - highly sensitive and specific - Does not provide therapeutic
solution
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treatment 1.ERCP -Sphincterotomy and stone extraction -Reasons
for endoscopic failure: large stones, multiple stones, intrahepatic
stones, altered anatomy, duodenal diverticula, impacted stones
-Does not eliminate the risk of recurrent biliary stone disease (up
to 50% recurrence) 2.Common bile duct exploration (lap./open)
-Intraoperative cholangiogram -Trans-cystic/common duct
incision
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Ascending cholangitis Acute ascending bacterial infection of
the biliary tree cause by obstruction Obstruction: stones,
malignancy Presentation: Charcots triad (fever, RUQ pain,
jaundice), Reynolds pentad (+hypotension, altered mental
status)
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Diagnosis Tachycardia, shock symptoms Laboratory test:
leukocytosis, abnormal liver panel US dilatation of the biliary
tree CT site of obstruction ERCP/PTC diagnostic as well as
therapeutic
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Treatment NPO IV fluids IV antibiotics Most patients respond to
medical therapy Emergent decompression of the biliary tree
(ERCP/PTC)
