Chapter 29 g b & Extrabiliary System

8/13/2019 Chapter 29 g b & Extrabiliary System

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CHAPTER 29 - Gallbladder and Extrahepatic Biliary System

Seymor !" Sch#art$

A%AT&'(

)ct System

The extrahepatic biliary system be*ins #ith the hepatic dcts and ends at the stoma o+the common bile dct in the dodenm" The ri*ht hepatic dct is +ormed by the

intrahepatic con+lence o+ dorsocadal and ,entrocranial branches" The +ormer enters

#ith a sharp cr,e #hich acconts +or the +act that calcli are less common in this

se*ment" The le+t hepatic dct is lon*er than the ri*ht and has a *reater propensity +or

dilatation as a conse.ence o+ distal obstrction" The t#o dcts /oin to +orm a

common hepatic dct that is 0 to 1 cm in len*th" !t is then /oined at an acte an*le by

the cystic dct to +orm the common bile dct 3i*" 29-45"

The common bile dct is approximately 6 to 44"7 cm in len*th and 8 to 4 mm in

diameter" The pper portion is sitated in the +ree ed*e o+ the lesser omentm to the

ri*ht o+ the hepatic artery and anterior to the portal ,ein" The middle third o+ thecommon dct cr,es to the ri*ht behind the +irst portion o+ the dodenm #here it

di,er*es +rom the portal ,ein and hepatic arteries" The lo#er third o+ the common bile

dct cr,es more to the ri*ht behind the head o+ the pancreas #hich it *roo,es and

enters the dodenm at the hepatopancreatic amplla o+ :ater5 #here it is +re.ently

/oined by the pancreatic dct" The portions o+ the dct are re+erred to accordin* to

their relationship to intestinal ,iscera;sprapancreatic intrapancreatic and

intradodenal"

The nion o+ the bile dct and the main pancreatic dct +ollo#s one o+ three patterns"

The strctres may< 45 nite otside the dodenm and tra,erse the dodenal #all

and papilla as a sin*le dct= 25 /oin #ithin the dodenal #all and ha,e a short

common terminal portion= or 05 exit independently into the dodenm" Separate

ori+ices ha,e been demonstrated in 29 percent o+ atopsy specimens and in/ection

into cada,ers re,eals re+lx +rom the common bile dct into the pancreatic dct in 71

percent" Radio*raphically re+lx +rom the common bile dct into the pancreatic dct

is present in abot 48 percent o+ cases" The sphincter o+ &ddi srronds the common

bile dct at the amplla o+ :ater" This pro,ides control o+ the +lo# o+ bile and in

some cases pancreatic /ice" An ampllary sphincter that is present in one-third o+

adlts may prodce a common channel +or the terminal common and pancreatic dcts"

GallbladderThe *allbladder is located in the bed o+ the li,er in line #ith that or*an>s anatomic

di,ision into ri*ht and le+t lobes" !t is a pear-shaped or*an #ith an a,era*e capacity o+

7 m? and is di,ided into +or anatomic portions< the +nds the corps or body the

in+ndiblm and the nec@" The +nds is the ronded blind end that normally

extends beyond the li,er>s mar*in" !t may be nsally @in@ed and present the

appearance o+ a phry*ian cap" !t contains most o+ the smooth mscle o+ the or*an

in contrast to the corps or body #hich is the ma/or stora*e area and contains most o+

the elastic tisse" The body tapers into the nec@ #hich is +nnel-shaped and connects

#ith the cystic dct" The nec@ sally +ollo#s a *entle cr,e the con,exity o+ #hich

may be distended into a dilatation @no#n as the in+ndiblm or Hartmann>s poch"


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The #all o+ the *allbladder is made p o+ smooth mscle and +ibros tisse and the

lmen is lined #ith a hi*h colmnar epithelim that contains cholesterol and +at

*lobles" The mcs secreted into the *allbladder ori*inates in the tblar al,eolar

*lands in the *loblar cells o+ the mcosa linin* the in+ndiblm and nec@"

The *allbladder is spplied by the cystic artery #hich normally ori*inates +rom theri*ht hepatic artery behind the cystic dct" !t is approximately 2 mm in diameter and

corses abo,e the cystic dct +or a ,ariable distance ntil it passes do#n the

peritoneal sr+ace o+ the *allbladder and branches" :enos retrn is carried thro*h

small ,eins #hich enter directly into the li,er +rom the *allbladder and a lar*e cystic

,ein #hich carries blood bac@ to the ri*ht portal ,ein" ?ymph +lo#s directly +rom the

*allbladder to the li,er and drains into se,eral nodes alon* the sr+ace o+ the portal

,ein" The ner,es o+ the *allbladder arise +rom the celiac plexs and lie alon* the

hepatic artery" 'otor ner,es are made p o+ ,a*s +ibers mixed #ith post*an*lionic

+ibers +rom the celiac *an*lion" The pre*an*lionic sympathetic le,el is at T6 and T9"

Sensory spply is pro,ided by +ibers in the sympathetic ner,es corsin* to the celiac

plexs thro*h the posterior root *an*lion at T6 and T9 on the ri*ht side"

The *allbladder is connected #ith the common dct system ,ia the cystic dct #hich

/oins the common hepatic dct at an acte an*le" The se*ment o+ the cystic dct

ad/acent to the *allbladder bears a ,ariable nmber o+ mcosal +olds that ha,e been

re+erred to as the ,al,es o+ Heister bt do not ha,e any ,al,lar +nction"

!mmediately behind the cystic dct resides the ri*ht branch o+ the hepatic artery" The

len*th o+ the cystic dct is hi*hly ,ariable tho*h the a,era*e is arond 1 cm"

:ariations o+ the cystic dct and its point o+ nion #ith the common hepatic dct are

sr*ically important 3i*" 29-25" The cystic dct may rn parallel to the common

hepatic dct and actally be adherent to it" !t may be extremely lon* and nite #ith

the hepatic dct at the dodenm" !t may be absent or ,ery short and ha,e a hi*h

cephalad5 nion #ith the hepatic dct in some cases /oinin* the ri*ht hepatic dct

instead" The cystic dct may spiral anteriorly or posteriorly in relation to the common

hepatic dct and /oin it on the le+t side" Con*enital biliary atresia is discssed in Chap"

0"

Anomalies

The classic description o+ the extrahepatic biliary passa*es and their arteries applies in

only abot one-third o+ patients" There are sr*ically important anomalies in the

*allbladder>s position and +orm and e,en its nmber 3i*" 29-05" !solated con*enital

absence o+ the *allbladder is extremely rare= atopsy incidences o+ "0 percent ha,ebeen reported" Be+ore the dia*nosis is made the presence o+ an intrahepatic ,esicle or

le+t-sided or*an mst be rled ot" )plication o+ the *allbladder #ith t#o separate

ca,ities and t#o separate cystic dcts has an incidence o+ approximately 4 in 1"

The accessory *allbladder may be sitated on the le+t side and its cystic dct may

empty into the le+t hepatic dct rather than the common dct" Patholo*ic processes

sch as cholelithiasis and cholecystitis may in,ol,e one or*an #hile the other is

spared"

The *allbladder may be +ond in a ,ariety o+ anomalos positions" The so- called

+loatin* *allbladder occrs #hen there is an increase in the peritoneal in,estment"

The or*an may be completely in,ested by peritonem #ith no mesentery" !n otherinstances the *allbladder may be sspended +rom the li,er by a complete mesentery


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or the nec@ may ha,e a mesentery in #hich the cystic artery lies #hile the +nds and

body are +ree" This condition occrs in abot 7 percent o+ patients and predisposes to

torsion and resltin* *an*rene or per+oration o+ the ,iscs" A le+t-sided *allbladder

#ith the cystic dct enterin* directly into the le+t hepatic dct or common dct is

extremely rare as is the sitation @no#n as retrodisplacement in #hich the +nds

extends bac@#ard in the +ree mar*in o+ the *astrohepatic omentm" The *allbladdermay also be totally intrahepatic a sitation that occrs in many animals" !n hman

bein*s the partial or complete intrahepatic *allbladder is associated #ith an increased

incidence o+ cholelithiasis"

Anomalies o+ the cystic dct #ere described earlier see 3i*" 29-25" Accessory hepatic

dcts are present in approximately 47 percent o+ cases" ?ar*e dcts are sally sin*le

and drain a portion o+ the ri*ht lobe o+ the li,er /oinin* the ri*ht hepatic dct

common hepatic dct or in+ndiblm o+ the *allbladder" Small dcts o+ ?sch@a5

may drain directly +rom the li,er into the body o+ the *allbladder" Dhen these dcts

*o nreco*ni$ed and are not li*ated or clipped at cholecystectomy an accmlation

o+ bile biloma5 may occr in the sbhepatic area"

Anomalies o+ the hepatic artery and the cystic artery are present in abot 7 percent o+

cases 3i*" 29-15" A lar*e accessory le+t hepatic artery ori*inatin* +rom the le+t

*astric artery occrs in abot 7 percent o+ cases" !n abot 2 percent o+ cases the

ri*ht hepatic artery ori*inates +rom the sperior mesenteric artery and in abot 7

percent o+ cases there are t#o hepatic arteries< one ori*inatin* +rom the common

hepatic and other +rom the sperior mesenteric artery" The ri*ht hepatic artery is

,lnerable drin* sr*ical procedres particlarly #hen it parallels the cystic dct

and is adherent to it or #hen it resides in the mesentery o+ the *allbladder" A

caterpillar hmp ri*ht hepatic artery may be mista@en +or the cystic artery" The ri*ht

hepatic artery may corse anteriorly to the common dct" !n 4 percent o+ cases the

cystic artery ori*inates +rom the le+t hepatic artery or +rom the /nction o+ the le+t or

ri*ht hepatic arteries #ith the common hepatic artery" !n abot 47 percent o+ cases the

cystic artery passes in +ront o+ the common hepatic dct rather than to the ri*ht o+ or

posterior to this dct" )oble cystic arteries occr in abot 27 percent o+ cases and

they may both arise +rom the ri*ht hepatic artery or one may ha,e another ori*in"

Cystic )isease o+ the Extrahepatic Biliary Tract Choledochal Cyst5

Con*enital cystic abnormalities may occr thro*hot the entire biliary system i"e"

+rom intrahepatic biliary radicles to the terminal common dct" !ntrahepatic cystic

dilatation is discssed in Chap" 26" Choledochal cysts are discssed in Chap" 0"There are three ma/or ,arieties 3i*" 29-75< cystic dilatation in,ol,in* the entire

common bile dct and common hepatic dct #ith the cystic dct enterin* the

choledochal cyst= a small cyst sally locali$ed to the distal common bile dct= and

di++se +si+orm dilatation o+ the common bile dct"

Con*enital biliary atresia is discssed in Chap" 0"

PH(S!&?&G(

Bile 3ormation

The normal adlt #ith an intact hepatic circlation and consmin* an a,era*e diet

prodces #ithin the li,er 27 to 4 m? bile per day" This is in lar*e part an acti,eprocess that ta@es place #ithin the hepatocytes and is dependent on a spply o+


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oxy*en" The secretion o+ bile is responsi,e to nero*enic hmoral and chemical

control" :a*al stimlation increases secretion #hereas splanchnic ner,e stimlation

reslts in decreased bile +lo# probably related to ,asoconstriction" The release o+

secretin +rom the dodenm a+ter the stimls o+ hydrochloric acid brea@do#n

prodcts o+ proteins and +atty acids increases bile +lo# and the prodction o+ an

al@aline soltion by the canalicli" Bile salts are also choleretic and a*ment bilesecretion by the li,er"

The acti,e transport o+ bile acids +rom the hepatocytes into the canalicli creates an

osmotic *radient that cases #ater to di++se into those canalicli" !n addition there is

a bile acid-independent acti,e transport o+ electrolytes and other soltes into the

canalicli #ith conse.ent passi,e di++sion o+ #ater and soltes"

Composition o+ Bile

The main constitents o+ bile are #ater electrolytes bile salts proteins lipids and

bile pi*ments" Sodim potassim calcim and chloride ha,e the same concentration

in bile as in extracelllar +lid or plasma" As secretion increases there is an increasein the concentration o+ bicarbonate and in pH and a sli*ht increase in chloride" The

pH o+ hepatic bile is sally netral or sli*htly al@aline and ,aries #ith diet= an

increase in protein shi+ts the pH to the acidic side"

Cholesterol and phospholipids are synthesi$ed in the li,er" The rate o+ cholesterol

synthesis sb/ect to a ne*ati,e +eedbac@ mechanism is inhibited by hi*h cholesterol

inta@e" Bile acids prodced endo*enosly or ta@en orally redce cholesterol

synthesis and increase cholesterol absorption +rom the intestine" The synthesis o+

phospholipids is also re*lated by bile acids" The concentrations o+ cholesterol and

phospholipids are both lo#er in hepatic bile than in plasma"

The principal bile acids cholic and deoxycholic acids are synthesi$ed +rom

cholesterol #ithin the li,er= they are con/*ated there #ith tarine and *lycine and act

#ithin the bile as anions that are balanced by sodim" The concentration o+ these salts

#ithin li,er bile is 4 to 2 mE.?" Proteins are present in bile in lesser

concentrations than in plasma #ith the exception o+ mcoproteins and lipoproteins

that are not present in plasma" ?i,er bile also contains nesteri+ied cholesterol

lecithin and netral +ats"

The color o+ the bile secreted by the li,er is related to the presence o+ the pi*ment

bilirbin di*lcronide #hich is the metabolic prodct o+ the brea@do#n o+hemo*lobin and is present in bile in concentrations 4 times *reater than in plasma"

A+ter this pi*ment has been acted pon by bacteria #ithin the intestine and con,erted

into robilino*en a small +raction o+ the robilino*en is absorbed and secreted into

the bile"

Gallbladder 3nction

The *allbladder pro,ides stora*e and concentration o+ bile" The selecti,e absorption

o+ sodim chloride and #ater reslts in a concentration o+ bile salts bile pi*ments

and cholesterol ten times hi*her than in li,er bile" The *allbladder mcosa has the

*reatest absorpti,e po#er per nit area o+ any strctre in the body" This rapid

absorption pre,ents a rise in pressre #ithin the biliary system nder normal


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circmstances" The absorption o+ +lid by the *allbladder is dri,en by an ener*y-

dependent acti,e transport o+ sodim and a conse.ent passi,e transport o+ #ater"

Secretion o+ mcs approximately at the rate o+ 2 m?h protects the mcosa +rom

the lytic action o+ bile and +acilitates the passa*e o+ bile thro*h the cystic dct" This

mcs ma@es p the colorless #hite bile present in hydrops o+ the *allbladderresltin* +rom obstrction o+ the cystic dct" The *allbladder also secretes calcim in

the presence o+ in+lammation or obstrction o+ the cystic dct"

'otor Acti,ity

The passa*e o+ bile into the dodenm in,ol,es the coordinated contraction o+ the

*allbladder and relaxation o+ the sphincter o+ &ddi" Some bile +lo#s +rom the

*allbladder continosly and there are rhythmic contractions occrrin* t#o to six

times per minte and mediatin* pressres less than 0 mmH2&" The *allbladder>s

emptyin* ho#e,er is mainly a response to the in*estion o+ +ood and the release o+

cholecysto@inin CCF5 by the dodenm" CCF also relaxes the terminal bile dct the

sphincter o+ &ddi and the dodenm" A+ter the intra,enos in/ection o+ CCF the*allbladder is t#o-thirds e,acated #ithin 0 min" CCF exerts its contractile e++ects

mainly thro*h action directly on the *allbladder smooth mscle cells bt also ,ia

interaction #ith choliner*ic ner,es" There is a +eedbac@ inhibition o+ CCF secretion

by bile acids and proteases" Somatostatin has a direct inhibitory action a*ainst CCF-

indced *allbladder contraction"

The ,a*s ner,e stimlates contraction o+ the *allbladder and splanchnic sympathetic

stimlation is inhibitory to its motor acti,ity" Altho*h ,a*otomy +or dodenal lcer

increases the si$e and ,olme o+ the *allbladder the rate o+ emptyin* is nchan*ed"

Parasympathomimetic dr*s contract the *allbladder #hereas atropine leads to

relaxation" 'a*nesim sl+ate is a potent e,acator o+ the *allbladder" Emptyin* o+

the *allbladder ta@es place 0 min a+ter in*estion o+ a +atty meal" There is an

increased ris@ o+ *allbladder disease in patients on prolon*ed total parenteral ntrition

TP%5 becase o+ the lac@ o+ intestinal stimls and conse.ent stasis o+ bile #ithin

the or*an"

Gallbladder +illin* occrs #hen the pressre in the bile dct is *reater than that #ithin

the *allbladder" This is correlated #ith redced CCF le,els bt is also a++ected by

,asoacti,e intestinal polypeptide :!P5 pancreatic polypeptide PP5 and peptide ((

P((5"

The common bile dct can be sho#n to ha,e #a,es o+ peristalsis" )rin* star,ation

the sphincter o+ &ddi maintains an intradctal pressre that approximates the maximal

explsi,e pressre o+ the *allbladder i"e" 0 cmH2& thereby pre,entin* emptyin*"

)rin* the interdi*esti,e periods the hormone motilin re*lates sphincteric pressre

to allo# continos +lo# o+ small amonts o+ bile into the dodenm" A+ter the

in*estion o+ +ood the sphincteric pressre is redced to 4 cmH2&" Dhen pressre

#ithin the extrahepatic bile dcts is *reater than 08 cmH2& secretion o+ bile is

sppressed"

Biliary dys@inesia lac@s ob/ecti,e +indin*s" The term has been sed to describe

distrbances o+ biliary tract motility that occr in the absence o+ anatomic chan*es" !thas been applied as a primary condition and as a complication o+ biliary tract sr*ery"


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Pain has been noted to occr a+ter the in*estion o+ +atty +oods and the in/ection o+

CCF at the time that contraction o+ the *allbladder is indced" Biliary tract pain has

also been ascribed to spasm o+ the sphincter o+ &ddi" The concept o+ hyperplastic

cholecystosis characteri$ed by hyperconcentration and excessi,e emptyin* o+ the

*allbladder mani+est on a cholecysto*ram is .estionable bt cholecystectomy has

been reported to be crati,e in symptomatic patients"

Enterohepatic Circlation

A+ter the bile enters the dodenm o,er 6 percent o+ the con/*ated bile acids are

absorbed in the terminal ilem and the remainder is decon/*ated by bacterial

acti,ity and absorbed in the colon" E,entally almost 97 percent o+ the bile acid pool

is absorbed and retrns ,ia the portal ,enos system to the li,er" &nly 7 percent is

excreted in the stool thereby permittin* a relati,ely small pool o+ bile acids to ha,e

maximal e++ecti,eness" A ne*ati,e +eedbac@ mechanism re*lates the hepatic

synthesis o+ bile acids" Dhen the distal ilem has been resected there is sally

adaptation bt occasionally the lac@ o+ a +eedbac@ mechanism persists and cases

si*ni+icant diarrhea"

)!AG%&S!S &3 B!?!AR( TRACT )!SEASE

See also andice in Chap" 22"5

Radiolo*ic Stdies

Abdominal ltrasono*raphy

ltrasond ima*in* is the most #idely applied dia*nostic techni.e +or biliary tract

disease in electi,e and emer*ent sitations" !t pro,ides anatomic and patholo*ic

in+ormation #ith *reat +lexibility and portability and at lo# cost" The techni.e may

be limited by obesity and lar*e amonts o+ intestinal *as" ltrasono*raphy employs a

hi*h-+re.ency ,ibration in #hich alternate compression and rare+action #a,es tra,el

thro*h the tisse and are re+lected o++ o+ tisses or items that di++er in acostic

impedance" The re+lected portion o+ the sond beam retrns to a transdcer to create

an ima*e" There is ,ariability in the .ality o+ ima*es and the techni.e is operator

dependent" The *allbladder is readily ima*ed becase echo-+ree bile contrasts #ith the

or*an>s #all and the li,er parenchyma" The intrahepatic and extrahepatic ma/or bile

dcts are also de+ined" Calcli can be demonstrated in more than 97 percent o+ cases

in #hich they are present" The discrimination o+ dctal dilatation has an accracy o+

9 percent"

ltrasono*raphy is the most cost e++ecti,e and reliable method +or demonstratin**allstones" They appear as re+lecti,e +oci #ithin the *allbladder or dcts and cast

acostic shado#s 3i*" 29-85" A stone impacted in the *allbladder nec@ or cystic dct

may be di++iclt to detect becase the #alls themsel,es retrn stron* echoes"

ltrasono*raphy has been sed to *ide lithotripsy"

ltrasond ima*in* also pro,ides dia*nostic in+ormation +or acte and chronic

cholecystitis" The characteristic si*ns inclde edema and thic@enin* o+ the *allbladder

#all occasionally *as in the #all and absence o+ ,isali$ation o+ the or*an"

Thic@enin* and edema o+ the #all is particlarly se+l in establishin* the dia*nosis

o+ acalclos cholecystitis #hen they are copled #ith tenderness o,er the or*an

e,o@ed by pressre o+ the ltrasond probe" ltrasono*raphy also can establish thedia*noses o+ hydrops porcelain *allbladder adenomas and carcinomas"


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ltrasond is the +irst radiolo*ic step in the e,alation o+ /andice becase it pro,ides

a sensiti,e method +or detectin* intrahepatic and extrahepatic dctal dilatation" The

le,el o+ obstrction can be de+ined by tracin* the dilatation do#n to a point or

termination" !t can distin*ish bet#een intradctal calcli and tmors as the casati,e

a*ent" Postoperati,ely it readily de+ines bilomas and sbhepatic abscesses"

Abdominal Radio*raphy

Plain x-ray +ilms o+ the abdomen are o+ limited ,ale in assessin* patients #ith

*allstones or #ith /andice" Spine and pri*ht +ilms o+ the abdomen may be se+l in

excldin* other cases o+ abdominal pain sch as a per+orated ,iscs or a bo#el

obstrction" The presence o+ si*ni+icant amonts o+ calcim #ithin *allstones #hich

occrs in 47 to 2 percent o+ patients cases stones to appear as opaci+ied ob/ects

located in the ri*ht pper .adrant on plain x-ray +ilms 3i*" 29-5" There are a

nmber o+ nsal circmstances in #hich complications +rom *allstones may be

s**ested by speci+ic radio*raphic +indin*s" The presence o+ *as #ithin the biliary

tree otlinin* its anatomy occrs in patients #ith a cholecystenteric +istla abnormalcommnication bet#een the *allbladder and dodenm #hich typically occrs as a

conse.ence o+ chronic cholecystitis5" &paci+ication o+ the *allbladder or o+ parts o+

it occrs in patients #ith a porcelain *allbladder" Gas bbbles may be present in the

#all o+ the *allbladder in patients #ith emphysematos cholecystitis in+ection

secondary to anaerobic *as-prodcin* or*anisms5"

&ral Cholecysto*raphy

&ral cholecysto*raphy a relati,ely simple and e++ecti,e test +or dia*nosin* *allstones

#as introdced by Graham and Cole in 4921" Dhile this test may permit ,isali$ation

o+ *allstones #ithin the *allbladder the critical +nction that is assessed is the

absorpti,e ability o+ the *allbladder" A radiopa.e iodine containin* halo*enated dye

is orally in*ested by the patient" The dye is +irst absorbed by the *astrointestinal tract

and extracted in the li,er" The li,er excretes the dye into the biliary dctlar system

and the dye then passes thro*h the cystic dct into the *allbladder" ltimately i+ the

*allbladder has normal mcosal +nction the dye becomes concentrated thro*h the

physiolo*ic absorption o+ #ater and soltes" A positi,e stdyIone s**esti,e o+

*allstones or *allbladder patholo*yIoccrs #hen stones are noted as +illin* de+ects

in a ,isali$ed opaci+ied *allbladder 3i*" 29-65 or #hen the dye is not ade.ately

concentrated and the *allbladder cannot be ,isali$ed" Dhen non,isali$ation occrs

a second doble dose o+ contrast medim is +re.ently administered" Altho*h the

accracy o+ this modality has been reported to be as hi*h as 97 percent a nmber o+important limitations ha,e redced its se" 3alse positi,es may occr #hen patients

ha,e been noncompliant or ha,e been nable to in*est the tablets becase o+ nasea

and emesis or *eneral medical conditions= #hen the tablets ha,e not been absorbed

thro*h the *astrointestinal tract or ha,e not been excreted into the biliary tract as a

reslt o+ hepatic dys+nction= or #hen there is some technical problem #ith the

e.ipment" &ral cholecysto*raphy has been lar*ely replaced by the de,elopment and

re+inement o+ abdominal ltrasono*raphy"

Compted Tomo*raphy and 'a*netic Resonance !ma*in*

Compted tomo*raphy CT5 is sed to assess biliary dilatation and calcli 3i*" 29-95

bt becase both can be stdied more readily by ltrasond ima*in* CT is notrotinely per+ormed" CT is in+erior to ltrasono*raphy +or the detection o+ stones" The


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ma/or application o+ CT is to de+ine the corse and stats o+ the extrahepatic biliary

tree and ad/acent strctres" !ntra,enos contrast enhancement o+ the biliary tract is

mandatory in this stdy" se o+ CT is an inte*ral part o+ the di++erential dia*nosis o+

obstrcti,e /andice" 'a*netic resonance ima*in* crrently has little application in

biliary disease" Dith the introdction o+ ne# contrast a*ents its applicability may be

expanded"

Biliary Scinti*raphy

A+ter technetim 99m-labeled deri,ati,es o+ iminodiacetic acid H!)A5 are in/ected

intra,enosly they are cleared by the Fp++er>s cells in the li,er and excreted in the

bile" %ormally a+ter in/ection pea@ acti,ity is detected in the li,er in 4 min and the

biliary dcts can be identi+ied shortly therea+ter" The *allbladder is ,isali$ed #ithin

8 min in +astin* sb/ects 3i*" 29-45" The test is particlarly applicable #hen the

dia*nosis o+ acte cholecystitis is bein* considered" E,idence o+ cystic dct

obstrction as indicated by non,isali$ation o+ the *allbladder is hi*hly dia*nostic"

The isotopic ,isali$ation o+ the *allbladder essentially precldes the dia*nosis" The

accracy o+ the test in dia*nosin* acte cholecystitis is abot 9 percent"

Perctaneos Transhepatic Cholan*io*raphy PTC5

Dith +loroscopic *idance a small needle is introdced nder local anesthesia

thro*h the abdominal #all and into the sbstance o+ the li,er" A+ter position in a bile

dct has been con+irmed a *ide #ire is introdced and a catheter can be placed" PTC

+acilitates dia*nosis by pro,idin* a cholan*io*ram and permits therapetic

inter,ention as necessary based on the clinical sitation" The techni.e has little role

in the mana*ement o+ patients #ith ncomplicated *allstone disease bt it has been

particlarly se+l +or patients #ith more complex biliary problems incldin*

strictres and tmors 3i*" 29-445" PTC is the pre+erred approach +or patients in #hom

ltrasono*raphy demonstrates intrahepatic dctal dilatation and no extra hepatic

dctal dilatation e"*" Flats@in>s tmor at the con+lence o+ the ri*ht and le+t hepatic

dcts" As #ith any in,asi,e procedre there are potential ris@s< bleedin* cholan*itis

bile lea@ and other catheter-related problems" Hematobilia occrs o+ten bt is sally

sel+-limitin* and o+ little conse.ence"

Endoscopic Retro*rade Cholan*iopancreato*raphy ERCP5

sin* a side-,ie#in* endoscope the biliary tract and pancreatic dct can be intbated

and ,isali$ed" This procedre is *enerally per+ormed #ith the patient nder li*ht

intra,enos sedation" Ad,anta*es o+ ERCP inclde direct ,isali$ation o+ the

ampllary re*ion and direct access to the distal bile dct #hich +acilitates dia*nosisand therapetic inter,ention" This test is *enerally not re.ired #hen dealin* #ith

patients #ho ha,e beni*n *allbladder disease tho*h it has been o+ enormos bene+it

+or patients #ith common bile dct disease beni*n and mali*nant5" This is

particlarly tre +or the e,alation and treatment o+ patients #ith obstrcti,e /andice

#hen there is dilatation o+ the common dct or *allbladder 3i*" 29-425"

Choledochoscopy

Ri*id and +lexible choledochoscopes inserted into the spradodenal common dct to

,isali$e the lmen o+ the extrahepatic dcts ha,e been sed to determine the

presence or absence o+ calcli= an accracy o+ o,er 9 percent has been reported" The

techni.e is sed as an ad/nct to operati,e cholan*io*raphy #hen the common dct


9/32

is explored" Choledochoscopy can also aid in the remo,al o+ stones and bile dct

tmors and in inspectin* and obtainin* biopsy samples +rom stenoses"

TRA'A

Penetratin* and %onpenetratin* !n/ries o+ the Gallbladder

!n/ries o+ the *allbladder are ncommon occrrin* in 2 to 6 percent o+ patients #ithma/or abdominal trama" Penetratin* in/ries are sally cased by *nshot #onds

or stab #onds= they also occr rarely drin* a needle biopsy procedre o+ the li,er"

%onpenetratin* in/ries are extremely rare" 3e#er than 4 cases ha,e been reported

and in only 2 percent #as the trama isolated to the *allbladder"

The types o+ tramatic in/ries to the *allbladder inclde contsion a,lsion

laceration rptre and tramatic cholecystitis" Contsion is di++iclt to ,eri+y bt

may be associated #ith ,a*e or temporary symptoms that re.ire no speci+ic

therapy" The contsed area may nder*o necrosis and per+orate" A,lsion o+ the

*allbladder +rom its li,er bed occrs as a reslt o+ nonpenetratin* in/ry" Dhen the

*allbladder>s attachments are torn the or*an sally han*s by its nec@ bt may beattached only by the cystic dct and artery" :ol,ls o+ the *allbladder may reslt"

Tramatic cholecystectomy in #hich the cystic dct cystic artery and *allbladder

attachments are transected has been reported" ?aceration is the most common type o+

in/ry +ollo#in* penetratin* #onds bt also may reslt +rom blnt trama" )elayed

rptre o+ the *allbladder can occr days to #ee@s +ollo#in* in/ry" Tramatic

cholecystitis is an nsal condition that occrs as a reslt o+ blnt trama" Bleedin*

into the *allbladder +rom in/ry o+ the *allbladder or o+ the li,er precipitates

cholecystitis and sometimes *an*rene o+ the *allbladder" The retained blood may clot

and bloc@ the cystic dct in #hich case the patient presents #ith the mani+estations o+

hematobilia incldin* intermittent /andice colic@y pain hematemesis and melena"

E++ects o+ !ntraperitoneal Bile

The e++ects o+ extra,asation o+ bile into the peritoneal ca,ity depend on #hether or

not the bile is in+ected" Dhen in+ected bile escapes into the peritoneal ca,ity a

+lminatin* and o+ten +atal peritonitis reslts" Dhen bile is sterile ho#e,er it is #ell

tolerated and reslts in a chemical peritonitis that may be relati,ely mild" !n the

ma/ority o+ *allbladder in/ries the or*an is normal and the bile is sterile" The +act

that sterile bile is relati,ely innocos is borne ot by the ,ery lo# mortality rate

associated #ith nonpenetratin* #onds o+ the *allbladder" Continos lea@a*e o+

nonin+ected bile ho#e,er is not innocos" The extra,asated bile may prodce

ascites or become encysted and extensi,e chemical peritonitis cases an otporin*o+ +lid into the peritoneal ca,ity +rom the *eneral circlation that may reslt in

shoc@" There is also some e,idence that lar*e amonts o+ bile salts may be toxic"

Clinical 'ani+estations

Bile lea@a*e thro*h the penetratin* #ond s**ests the possibility o+ dama*e to the

biliary system bt dodenal laceration may ha,e a similar mani+estation" Dith blnt

trama mani+estations may be delayed +or 08 h or more in part becase typically

there are other serios in/ries that mas@ in/ry o+ the biliary tract and sterile bile

itsel+ cases only minimal symptoms" The presence o+ se,ere shoc@ and pain in the

ri*ht pper .adrant or lo#er part o+ the ri*ht side o+ the chest shold raise clinical

sspicion o+ *allbladder in/ry" The mani+estations o+ bacterial peritonitis may enseor i+ the bile lea@a*e is minimal the patient may appear to reco,er bt sbse.ently


10/32

de,elop ascites or an intraperitoneal cyst" The +indin* o+ bile-stained +lid drin*

dia*nostic paracentesis is s**esti,e bt a ne*ati,e tap does not exclde *allbladder

in/ry" !n most instances the dia*nosis is made at celiotomy emphasi$in* the need +or

care+l examination o+ the biliary system a+ter abdominal trama"

TreatmentThe in/red *allbladder has been sccess+lly treated by simple stre o+ the

laceration cholecystostomy and cholecystectomy" !n *eneral it is pre+erable to

remo,e the tramati$ed *allbladder" Cholecystectomy is sally .ite easy to

per+orm since the *allbladder is rarely diseased and it mst be per+ormed i+ the

*allbladder has been a,lsed or the cystic artery torn" !n the se,erely ill patient

cholecystostomy may be sed +or treatment o+ the extensi,e laceration or tramatic

cholecystitis in order to redce the time o+ operati,e procedre and a,oid in/ry to the

common dct" Pro*nosis is directly related to the incidence o+ associated in/ries"

!n/ry o+ the Extrahepatic Bile )cts

Rare cases o+ solitary penetratin* #onds in,ol,in* the bile dct ha,e been reportedbt there is sally associated trama to other ,iscera" Approximately 42 cases o+

tramatic rptre o+ the extrahepatic bile dct ha,e been reported and in 2 cases

complete transection occrred" The clinical mani+estations are similar to those

described +or *allbladder in/ry"

Treatment consists initially o+ meticlos exploration particlarly i+ in/ry to the

*allbladder has been exclded and bile has been demonstrated retroperitoneally or

#ithin the peritoneal ca,ity" A Focher mane,er shold be per+ormed to rle ot

per+oration o+ the common dct behind the dodenm" The presence o+ hematoma in

this re*ion shold raise the sr*eon>s sspicions" Tan*ential in/ries may be treated by

primary repair" Complete transection o+ the common hepatic dct or the common bile

dct e"*" by a penetratin* @ni+e #ond5 may be treated by debridement and an end-

to-end anastomosis o,er a T tbe #hich shold be le+t in place +or se,eral #ee@s" !n

most cases o+ complete transection and in/ries cased by blnt trama ho#e,er the

proximal end o+ the dct shold be anastomosed to a Rox-en-( limb o+ /e/nm" The

patient shold be placed on an appropriate re*imen o+ antibiotics"

&perati,e !n/ry o+ the Bile )cts

The *reat ma/ority o+ in/ries o+ the extrahepatic biliary dct system are iatro*enic

occrrin* in the corse o+ laparoscopic or open cholecystectomy" !n o,er percent

o+ cases the cholecystectomy had apparently been carried ot #ithot incident"

)ia*nosis

!n approximately 47 percent o+ the cases dctal in/ries are reco*ni$ed and treated at

the time o+ operation" The remainin* 67 percent become mani+est by either increasin*

obstrcti,e /andice or pro+se and persistent draina*e o+ bile thro*h a +istla"

andice sally becomes mani+est in 2 to 0 days bt in some instances it does not

de,elop +or #ee@s" !t may be continos or intermittent= i+ intermittent it is

+re.ently accompanied by attac@s o+ chills and +e,er s**estin* ascendin*

cholan*itis" Hepatome*aly almost al#ays accompanies /andice i+ it has been

persistent +or se,eral #ee@s and splenome*aly also may occr i+ secondary biliary

cirrhosis has e,ol,ed" Some patients do not display the si*ns or symptoms o+ partialor complete bloc@a*e ntil months or years a+ter sr*ical treatment" Bloc@a*e in sch


11/32

cases is the reslt o+ increasin* +ibrosis and narro#in* o+ the channel or o+ repeated

episodes o+ cholan*itis #hich in trn leads to +ibrosis" ERCP or PTC most clearly

de+ines the site o+ obstrction or lea@"

Treatment

Patients #ith /andice or persistent +istla re.ire a ,i*oros preoperati,e re*imenthat incldes a hi*h-protein lo#-+at diet and intra,enos administration o+ +at-solble

,itamins particlarly ,itamin F" Concomitant portal hypertension #ith bleedin*

,arices may preclde repair o+ the common dct= the portal hypertension is sally

best treated by a splenorenal shnt becase o+ extensi,e scarrin* in the ri*ht pper

.adrant"

&perati,e Approach

!n/ry o+ the bile dct reco*ni$ed drin* sr*ical operation shold be corrected #ith

an immediate reconstrcti,e procedre" Restoration o+ the continity o+ the dct #ith

an end-to-end anastomosis o,er a T tbe may be +easible a+ter a sharp transection bt

strictre de,elops in abot hal+ the cases" )irect anastomosis is sally impractical +oracte in/ries and chronic strictres #here the proximal end o+ the dct shold be

anastomosed to a Rox-en-( o+ /e/nm" A mcosa-to-mcosa approximation

pro,ides the best lon*-term reslts" !+ this is not +easible a lateral-lateral anastomosis

bet#een the le+t hepatic dct and a Rox-en-( limb o+ /e/nm Hepp- Sopalt5 is

pre+erable to the Smith transhepatic mcosal pll-thro*h techni.e" The ?on*mire

operation #ith transection o+ the le+t lobe o+ the li,er and anastomosis o+ the /e/nm

to a lar*e intrahepatic bile dct has been associated #ith discora*in* reslts"

The operati,e mortality o+ patients #ith chronic strictre is reported to be 0 to 7

percent" A satis+actory reslt is obtained in abot percent o+ patients a+ter one or

more operati,e procedres" !+ the patient is symptom-+ree 1 years a+ter reconstrction

the cre is almost al#ays permanent"

GA??ST&%ES

Composition

The ma/or elements in,ol,ed in the +ormation o+ *allstones are cholesterol bile

pi*ment and calcim" &ther constitents inclde iron phosphors carbonates

proteins carbohydrates mcs and celllar debris" !n Destern cltres most stones

are made p o+ the three ma/or elements and ha,e a particlarly hi*h content o+

cholesterol a,era*in* 4 percent" Pre cholesterol stones are ncommon sally

lar*e #ith smooth sr+aces and solitary" Bilirbin pi*ment stones are alsoncommon #ith a characteristic smooth *listenin* *reen or blac@ sr+ace" The

pi*ment stones may be pre or consist o+ calcim bilirbinate" The pre pi*ment

stones are sally associated #ith hemolytic /andice or sitations in #hich the bile is

abnormally concentrated" !ncreased red blood cell destrction a+ter cardiac ,al,e

replacement has reslted in prodction o+ *allstones" Calcim bilirbinate stones are

pre,alent in Asia #here they constitte 0 to 1 percent o+ all *allstones"

3ormation

Gallstones +orm as a reslt o+ solids settlin* ot o+ soltion" The solbility o+

cholesterol depends on the concentrations o+ con/*ated bile salts phospholipids and

cholesterol in bile" ?ecithin is the predominant phospholipid in bile and altho*hinsolble in a.eos soltions it is dissol,ed by bile salts in micelles" Cholesterol is


12/32

also insolble in a.eos soltion bt becomes solble #hen incorporated into the

lecithin-bile salt micelle" By plottin* the percenta*es o+ cholesterol lecithin and bile

salts on trian*lar coordinates 3i*" 29-405 the limits o+ micellar li.id in #hich bile

is less than satrated #ith cholesterol may be de+ined" Abo,e these limits the bile is

either a spersatrated li.id or a t#o-phase system o+ li.id bile and solid crystalline

cholesterol"

Perhaps no more than 0 percent o+ biliary cholesterol is transported in micelles and

o+ that the ma/ority is carried in a ,esiclar +orm" These ,esicles are made p o+ lipid

bilayers similar to those +ond in cell membranes" The ,esicles are able to solbili$e

more cholesterol than are micelles and the stability o+ these strctres is belie,ed to

be the @ey determinant o+ cholesterol satration and precipitation" Crrent theory

s**ests that there is an e.ilibrim bet#een the physicochemical phases o+ these

,esicles sch that the +ormation o+ li.id crystals may or may not reslt in actal

*allstones" Dhen crystals achie,e macroscopic si$e drin* a period o+ entrapment in

the *allbladder *allstones +orm" The basic secretory de+ect in nonobese patients is

decreased bile salt and phospholipid secretion" Con,ersely in obese sb/ectscholesterol secretion is *reatly increased #ithot any redction in bile salt or

phospholipid secretion"

%cleation is the process by #hich cholesterol monohydrate crystals +orm and

a**re*ate" The time re.ired +or ncleation is shorter in patients #ith *allstones than

in those #ithot stones" Speci+ic heat-labile *lycoproteins #ithin cholesterol-satrated

bile indce ,esiclar a**re*ation and conse.ent stone *ro#th" 3actors that ha,e been

implicated in the +ormation and precipitation o+ cholesterol inclde constittional

elements bacteria +n*i re+lx o+ intestinal and pancreatic +lid hormones and bile

stasis" Constittional elements are best exempli+ied in the Pima !ndians o+ #hom

percent o+ +emales by a*e thirty and percent o+ males by a*e sixty ha,e *allstones"

The 'asai o+ Fenya in contrast do not ha,e *allstones" E,idence in +a,or o+

in+ection as a case incldes the isolation o+ sch or*anisms as Escherichia coli

Salmonella typhi and Streptococcs species +rom *allbladder #alls and +rom the

center o+ stones in a hi*h percenta*e o+ cases and the demonstration o+ slo#-*ro#in*

actinomycetes reco,ered +rom o,er hal+ the stones examined in one series" Gi,en that

*allstones de,elop in the absence o+ in+ection or in+lammation in+ection appears not

to be a ni,ersal +actor" !n Asians concretions are @no#n to +orm abot li,er +l@es

and other parasites #ithin the bile dcts"

The re+lx +actor recei,es spport +rom the +indin*s o+ pancreatic en$ymes in the*allbladders o+ patients #ith cholelithiasis" Trypsin distrbs colloidal balance and

pancreatic phospholipase A can con,ert lecithin into toxic lysolecithin" Hormones

ha,e been implicated in a npro,ed correlation bet#een calcli and parity diabetes

hyperthyroidism and the predominance in +emales"

Stasis #hich incldes temporary cessation o+ bile +lo# into the intestine and

sta*nation in the *allbladder has also been assi*ned a ma/or role in stone +ormation"

Temporary bile stasis may be de to +nctional disorders or to a mechanical bloc@a*e

in the re*ion o+ the choledochododenal /nction or the *allbladder" The interrption

o+ bile +lo# to the intestine is associated #ith an interrption in enterohepatic

circlation #hich in trn is accompanied by a decrease in the otpt o+ bile salts andphospholipids redcin* the solbility o+ cholesterol" Dhen more than 2 percent o+


13/32

bile is di,erted the bile salt pool cannot be maintained" Bile salt secretion is also

diminished by redction o+ the distal third o+ the intestine explainin* the

de,elopment o+ stones in patients #ith ileal resection or disease" Cholecystectomy

cases a *reater +raction o+ the bile salt pool to cycle arond the enterohepatic

circlation thereby increasin* bile salt and phospholipid secretion"

Solbility has been in,esti*ated as a possible re*imen to pre,ent the de,elopment o+

stones in patients at ris@ as #ell as to dissol,e stones already +ormed"

Chenodeoxycholic acid and rsodeoxycholic acid #hich replenish the bile acid pool

and redce cholesterol synthesis and secretion administered to potential stone

+ormers may retrn spersatrated bile to its normal composition pre,entin* stone

+ormation" !n one series the dr* #as administered +or 2 years= complete dissoltion

o+ radiolcent stones occrred in 40"7 percent o+ patients" Partial dissoltion occrred

in 14 percent" The e++ects #ere more +re.ent in #omen in thin patients and in

patients #ith serm cholesterol le,els *reater than 22 m*d?" Clinically si*ni+icant

hepatotoxicity #as rare"

The direct instillation into the *allbladder o+ a*ents that are capable o+ dissol,in*

cholesterol *allstones has become a reality lar*ely as a reslt o+ ad,ances in

inter,entional radiolo*ic technolo*y" Altho*h experience is limited in+sion o+ a

potent cholesterol sol,ent methyl-tert-btyl ether 'TBE5 into the *allbladder ,ia a

perctaneosly placed catheter has been sho#n to be e++ecti,e in selected patients in

achie,in* *allstone dissoltion" This procedre is in,asi,e and is there+ore associated

#ith some speci+ic ris@s incldin* hemorrha*e and catheter-related and dr*-

re*lated problems" The ma/or disad,anta*e o+ this technolo*y is the hi*h recrrence

rate #hich approaches 7 percent at 7 years" ?ithotripsy has sccess+lly +ra*mented

biliary calcli bt *enerally is not re*arded as appropriate therapy becase a diseased

or*an remains to +orm ne# stones and the +lshin* e++ected by normal bile +lo# is not

e.i,alent to that o+ rinary +lo#"

Pi*ment stones can be +rther classi+ied as either bro#n or blac@ stones" Bro#n

stones ha,e a characteristic appearance and consistency and are typically +ond in

Asia" These stones presmably occr as a reslt o+ in+ection and are .ite similar to

primary bile dct stones" Blac@ stones by contrast typically are not associated #ith

in+ected bile" These stones are +ond in patients #ith hemolytic disorders or cirrhosis"

Altered solbili$ation o+ ncon/*ated bilirbin #ith precipitation o+ calcim

bilirbinate and insolble salts is presmed to be the common +inal path#ay +or the

+ormation o+ all pi*ment stones re*ardless o+ the clinical settin*"

Asymptomatic Gallstones

The liberal se o+ cholecysto*raphy and ltrasono*raphy has reslted in the dia*nosis

o+ calcli in patients #ithot symptoms re+erable to the biliary tract" !n se,eral lar*e

series o+ asymptomatic patients #ith *allstones #ho #ere +ollo#ed #ithot sr*ical

treatment symptoms de,eloped in 7 percent and serios complications occrred in

2 percent" By contrast 'cSherry and associates reported that only 4 percent o+

patients de,eloped symptoms drin* a mean 7-year +ollo#-p" Similarly Gracie and

Ransoho++ reported a 47-year cmlati,e probability o+ de,elopin* symptoms o+ 46

percent +or 420 patients #ith asymptomatic *allstones and no deaths +rom *allbladder

disease"


14/32

The relationship o+ cholelithiasis and carcinoma o+ the *allbladder is also o+ some

si*ni+icance" A re,ie# o+ se,eral series sho#ed that the incidence o+ calcli in cancer

o+ the *allbladder ran*ed +rom 87 to 4 percent #ith a mean o+ 9 percent"

Con,ersely the incidence o+ cancer o+ the *allbladder in patients #ith symptomatic

*allstones ran*ed +rom 4 to 47 percent #ith a mean o+ 1"7 percent" Com+ort and

associates reported no carcinoma amon* 442 patients #ith asymptomaticcholelithiasis"

!n *eneral patients #ith asymptomatic *allstones shold not be treated" )yspepsia

erctations and +latlence are not re*arded as speci+ic symptoms" Dith the ad,ent o+

laparoscopic cholecystectomy the nmber o+ cholecystectomies per+ormed has

increased" Cholecystectomy +or asymptomatic stones may be appropriate +or elderly

patients #ith diabetes and +or indi,idals #ho #ill be isolated +rom medical care +or

an extended period"

Cystic )ct &bstrction

Temporary obstrction to the ot+lo# o+ bile +rom the *allbladder is responsible +orthe most common mani+estation o+ calclos disease #hich is biliary colic" This

consists o+ the intermittent spasmodic pain in the ri*ht pper .adrant o+ten radiatin*

to the sholder or scapla and precipitated by a +atty or +ried meal" The attac@s are

sel+-limitin* bt ha,e a tendency to recr in an npredictable manner" Si*ni+icant

temperatre ele,ation or le@ocytosis are ncommon" The bilirbin and al@aline

phosphatase le,els are normal or sli*htly ele,ated becase o+ an in+lammatory

process and hyperamylasemia may be present" The treatment is cholecystectomy

pre+erably by the laparoscopic approach and is best per+ormed drin* that

hospitali$ation bt not as an emer*ent procedre"

Calcli sally o+ the cholesterol type may become impacted in the cystic dct or the

nec@ o+ the *allbladder resltin* in #hat is called hydrops o+ the *allbladder" The bile

is absorbed and the *allbladder becomes +illed and distended #ith mcinos material"

The *allbladder is *enerally palpable and tender and the impacted stone #ith the

resltin* edema may encroach on the common dct and case mild /andice"

Altho*h hydrops may persist #ith +e# conse.ences early cholecystectomy is

*enerally indicated to a,oid the complications o+ biliary tract in+ection empyema or

per+oration o+ the *allbladder" !n .estionable cases isotopic scannin* o+ the

*allbladder +ollo#in* intra,enos CCF can de+ine cystic obstrction or patency"

CholedocholithiasisCommon dct stones may be sin*le or mltiple and are +ond in 1 to 42 percent o+

cases sb/ected to cholecystectomy" 'ost common dct calcli are +ormed #ithin the

*allbladder and mi*rate do#n the cystic dct into the common bile dct" ?ess

commonly stones are tho*ht to +orm #ithin the dcts" These are classi+ied as

primary stones in contradistinction to the secondary stones +ormed in the *allbladder"

Primary stones are sally so+t non+aceted yello#ish bro#n and +riable" !n patients

in+ected #ith tropical parasites sch as Clonorchis sinensis and in the Asian

poplation o+ the 3ar East stones may +orm #ithin the hepatic dcts or the common

bile dct itsel+" Altho*h small stones may pass ,ia the common dct into the

dodenm the distal dct #ith its narro# lmen 2 to 0 mm5 and thic@ #all

+re.ently obstrcts their passa*e" Edema spasm or +ibrosis o+ the distal dctsecondary to irritation by the calcli contribte to biliary obstrction" Both


15/32

extrahepatic and intrahepatic bile dcts become dilated and there is e,idence o+

la@in* in the biliary radicles o+ the li,er" There is also thic@enin* o+ the dct #alls and

in+lammatory cell in+iltration" Chronic biliary obstrction may case secondary biliary

cirrhosis #ith bile thrombi bile dct proli+eration and +ibrosis o+ the portal tracts"

Also associated #ith chronic obstrction is the de,elopment o+ in+ection #ithin the

bile dct *i,in* rise to ascendin* cholan*itis and occasionally extendin* p to theli,er resltin* in hepatic abscesses" The o++endin* or*anism is almost al#ays E" coli"

Gallstone pancreatitis is *enerally associated #ith the presence or passa*e o+ common

bile dct stones" The best e,idence +or this is the +re.ency #ith #hich stones can be

+ond i+ the stool is +iltered at the time o+ an attac@" The +re.ency #ith #hich stones

are +ond in the common dct ,aries +rom 4 percent to percent dependin* on the

time o+ the operation" At the time o+ exploration the pancreas may appear entirely

normal or it may demonstrate edema and rarely necrosis necroti$in* pancreatitis5"


The mani+estations o+ calcli #ithin the common dct are ,ariable" Stones may bepresent #ithin the extrahepatic dct system +or many years #ithot casin*

symptoms" Characteristically the symptom complex consists o+ colic@y pain in the

ri*ht pper .adrant radiatin* to the ri*ht sholder #ith intermittent /andice

accompanied by pale stools and dar@ rine" Biliary obstrction is sally chronic and

incomplete bt may be acte or complete" !+ obstrction is complete /andice

pro*resses bt is rarely intense" !n contrast to patients #ith neoplastic obstrction o+

the common bile dct or the amplla o+ :ater the *allbladder is sally not distended

becase o+ associated in+lammation Cor,oisier>s la#5" ?i,er +nction tests

demonstrate the pattern o+ obstrcti,e /andice and the al@aline phosphatase le,el

sally becomes ele,ated earlier and remains abnormal +or lon*er periods than the

serm bilirbin le,el" The prothrombin time is +re.ently prolon*ed becase the

absorption o+ ,itamin F is dependent on bile enterin* the intestine bt a normal le,el

can sally be achie,ed #ith parenteral ,itamin F" Tests o+ hepatocelllar +nction

*enerally ha,e normal reslts" !n patients #ith ascendin* cholan*itis Charcot>s

intermittent +e,er accompanied by abdominal pain and /andice is characteristic" The

dia*nosis may be established by ERCP or PTC"

Treatment

The indications +or the remo,al o+ common dct stones are< 45 their presence as

de+ined preoperati,ely in a symptomatic patient or by palpation or

cholan*io*raphically at the time o+ operation= 25 a dilated extrahepatic dct= 05/andice= 15 recrrent chills and +e,ers s**esti,e o+ cholan*itis= and 75 *allstone

pancreatitis"

Common dct stones can be remo,ed by ERCP and the per+ormance o+ an ade.ate

destrction o+ the sphincter o+ &ddi #ill permit stones that #ere not extracted or +orm

at a later date to pass into the dodenm #ithot obstrction in the extrahepatic dcts"

!n a patient nder*oin* an electi,e cholecystectomy in #hom common dct stones are

tho*ht to be present a preoperati,e ERCP and sphincterotomy can be +ollo#ed by

laparoscopic cholecystectomy" !n some elderly patients ERCP and sphincterotomy

ha,e constitted de+initi,e treatment and the *allbladder #as not remo,ed"


16/32

!+ common dct stones are detected drin* laparoscopic cholan*io*ram they can be

remo,ed by sbse.ent ERCP or drin* the procedre by trans-cystic dct retrie,al or

pshin* them into the dodenm" Alternati,ely the common dct can be opened the

stones extracted and a T tbe inserted" !+ common dct stones are sspected or

detected drin* open cholecystectomy the same alternati,es apply" The se o+ the

choledochoscope and reteral bas@ets +acilitates the procedre" !n the patientpoplation as a #hole concomitant choledochostomy at the time o+ cholecystectomy

increases the operati,e mortality by less than 4 percent" !n addition in the +ace o+

dilated common dct and mltiple stones a choledochododenostomy can pro,ide

de+initi,e treatment"

Retained Common )ct Stones

!+ stones are noted to be present #hen a T-tbe cholan*io*ram is per+ormed

postoperati,ely 3i*" 29-415 se,eral approaches can be entertained" Small stones

particlarly those located in the branches o+ the hepatic dct may be disre*arded= the

ma/ority #ill remain asymptomatic and +or those that do *enerate symptoms

operati,e extraction is not associated #ith si*ni+icantly increased morbidity" Anotherapproach employs either +lshin* or chemical dissoltion" Capml 624 a mono-

octanoin is the a*ent o+ choice" The se o+ heparin 27 nits in a 27-m?

soltion in+sed e,ery 6 h +or 7 days has been sccess+l"

The mechanical extraction o+ the retained stone can be per+ormed nder radio*raphic

control" 'a$$ariello reported a 98 percent sccess rate +or 468 cases and Brhenne

and associates reported a 94 percent sccess rate +or 842 patients mana*ed at 06

hospitals #ith no deaths and no si*ni+icant complications" The T tbe is *enerally le+t

in place +or at least 1 #ee@s a+ter the operation= it is then extracted and a polyethylene

catheter is sed to instill radiopa.e material into the common dct" A )ormia bas@et

is then ad,anced thro*h the catheter to entrap the stone 3i*" 29-475"

The most commonly sed approach is transdodenal papillotomy #ith extraction o+

the stone nder endoscopic ,isali$ation 3i*" 29-485" The sccess rate +or extraction

or spontaneos passa*e a+ter this procedre #as 68 percent +or 04 collected cases" A

complication rate o+ percent #as noted bt t#o-thirds o+ complications #ere treated

conser,ati,ely" The mortality rate related to the techni.e #as 4"27 percent" &perati,e

inter,ention is indicated in some cases i+ there is e,idence o+ obstrction or

cholan*itis or i+ nonoperati,e methods +ail"

Some calcli remain #ithin the li,er and may case irre,ersible dama*e" The mostcommon location is a le+t main hepatic dct that +orms a cisterna and sccess+l

treatment is best achie,ed in this circmstance by resection o+ the le+t lobe o+ the

li,er" !n occasional patients #ith recrrent hepatic dct stones a Rox-en-( limb can

be anastomosed to the hepatic dct sally the le+t main dct5 and positioned so that

it can be entered nder radio*raphic *idance to permit stone extraction"

Biliary Enteric 3istla and Gallstone !les

A stone in the amplla o+ the *allbladder Hartmann>s poch5 can encroach pon and

erode the common bile dct" This is @no#n as 'iri$$i>s syndrome" &perati,e

mana*ement depends on the extent to #hich the common dct has been

compromised" !+ there is only a pressre e++ect cholecystectomy is s++icient" !+ thecommon dct se*ment is partially or completely destroyed a reconstrcti,e procedre


17/32

is mandated and may re.ire a Rox-en-( limb anastomosis to the proximal normal

dct" Dhen biliary enteric +istlas de,elop they sally rn bet#een the *allbladder

and the dodenm bt 47 percent are cholecystocolic +istlas" 'echanical obstrction

o+ the *astrointestinal tract cased by *allstones is a relati,ely in+re.ent occrrence"

Gallstone iles cases 4 to 2 percent o+ mechanical small-intestine obstrctions= the

mortality rate is less than 4 percent"

Since cholelithiasis occrs three to six times more commonly in the +emale than in the

male a hi*her incidence o+ *allstone iles in the +emale is to be anticipated"

Preponderance in the +emale is actally hi*her than one #old expect and in se,eral

series all patients #ere +emale" !t is characteristically a disease o+ the a*ed #ith an

a,era*e a*e o+ sixty-+or and is nsal nder the a*e o+ +i+ty"

The process sally be*ins #ith +ormation o+ the stone #ithin the *allbladder bt

cases ha,e been reported in #hich the *allbladder #as not present ha,in* been

remo,ed se,eral years prior to the intestinal obstrction" A+ter the *allstone has le+t

the *allbladder it may obstrct the alimentary tract in one o+ t#o #ays" Typicallyintralminal obstrction is prodced by the entrance o+ the stone into the

*astrointestinal tract" Rarely the stone enters the peritoneal ca,ity casin* @in@in* or

in+lammation and extrinsic obstrction o+ the intestine" The stone may enter the

dodenm ,ia the common dct bt this is nsal and almost al#ays the o++endin*

calcls enters thro*h a cholecystenteric +istla" The +istlos tract may connect the

*allbladder #ith the stomach dodenm /e/nm ilem or colon" !n addition

internal biliary +istlas may commnicate #ith the pleral or pericardial ca,ities

tracheobronchial tree pre*nant ters o,arian cyst renal pel,is and rinary bladder"

!n a series o+ 48 +istlas cased by *allstones the dodenm #as in,ol,ed in 44

the colon in 00 the stomach in and mltiple sites in44"

The +istla probably ori*inates #ith a stone obstrctin* the cystic dct acte

cholecystitis empyema and the +ormation o+ adhesions bet#een the *allbladder and

ad/acent ,iscera" Per+oration then occrs bet#een the intimately adherent or*ans and

the stone tra,erses the +istla" The cholecystenteric +istla then +re.ently closes and

only a +ibros remnant remains" Ha,in* entered the alimentary tract the *allstone

#hich is sally sin*le may be ,omited or passed spontaneosly ,ia the rectm" The

si$e o+ the stone is important since stones smaller than 2 to 0 cm sally pass" Dhen

obstrction occrs the site is sally at the terminal ilem #hich is the narro#est

portion o+ the small intestine" &+ 471 cases the dodenm #as obstrcted in 8 the

/e/nm in 41 the proximal ilem in 8 the middle ilem in 04 the terminal ilem in66 the colon in 0 and the rectm in 2" Dhen a *allstone bloc@s the small intestine

the morbid anatomic and physiolo*ic e++ects o+ a mechanical obstrction obtain"

There are ,ery lar*e losses o+ +lid into the intestine" Edema lceration or necrosis o+

the bo#el may occr and per+oration may reslt"


A past history s**esti,e o+ cholelithiasis is present in 7 to 7 percent o+ patients"

Symptoms o+ acte cholecystitis immediately precedin* the onset o+ *allstone iles

occr in one-.arter to one-third o+ the cases" A history o+ /andice is present in abot

4 percent o+ the cases" &ccasionally there may be an initial episode o+ pain

s**esti,e o+ biliary colic bt ma/or pain is sally not experienced ntil theintestinal colic reslts" There is associated crampin* nasea and ,omitin* #hich


18/32

may be intermittent" Dhen complete small intestinal obstrction occrs the ,omitin*

increases and obstipation reslts" :omitin* is present in almost 4 percent cramps in

9 percent distention in 9 percent obstipation in 6 percent and +eclent ,omitin*

in 8 percent" Serm electrolyte le,els re,eal the pattern o+ lo#er intestinal

obstrction #ith mar@ed hypochloremia hyponatremia hypo@alemia and an ele,ated

carbonate le,el"

The correct preoperati,e dia*nosis is in+re.ently made ran*in* bet#een 40 and 0

percent in se,eral series" The sal dia*nosis is that o+ intestinal obstrction o+

n@no#n case" Radiolo*ic examination may be dia*nostic i+ *as is demonstrated

#ithin the biliary tract 3i*" 29-45" 3lat pri*ht and lateral +ilms pls spot +ilms o,er

the li,er are indicated i+ the dia*nosis is considered" The plain x-ray +ilm re,eals the

pattern o+ small-intestine obstrction and a stone is ,isali$ed in less than 2 percent

o+ the cases" The dia*nosis has also been based on the mi*ration o+ a pre,iosly

obser,ed radiopa.e *allstone"

TreatmentBiliary enteric +istlas are mana*ed by cholecystectomy and closre by primary repair

o+ the intestinal openin*" The patient #ith *allstone iles o+ten re.ires +lid and

electrolyte replacement in order to correct de+iciency and a naso*astric tbe is sed to

decompress the stomach" )e+initi,e therapy consists o+ locatin* the stone or stones

enterotomy proximal to the stone and remo,al o+ the o++endin* calcli #ith closre o+

the intestine" The recrrence rate o+ *allstone iles is 7 to 9 percent and it is

important to palpate the entire small intestine *allbladder and common dct +or

retained stones particlarly i+ the obstrctin* stone is +aceted" Either concomitant or

planned inter,al cholecystectomy and closre o+ the +istla i+ patent is indicated

since recrrent symptoms or complications de,elop in one-third o+ the patients"

Carcinoma o+ the *allbladder has also been present or de,eloped 7 to 48 years a+ter

remo,al o+ the obstrctin* *allstone" Per+ormance o+ concomitant cholecystectomy is

determined by the patient>s *eneral condition" 'any o+ these patients are extremely ill

and depleted and prolon*ation o+ the operati,e procedre may be contraindicated"

!%3?A''AT&R( A%) &THER BE%!G% ?ES!&%S

Acte Cholecystitis

Acte cholecystitis is sally associated #ith an obstrction o+ the nec@ o+ the

*allbladder or cystic dct cased by stones impacted in Hartmann>s poch" )irect

pressre o+ the calcls on the mcosa reslts in ischemia necrosis and lceration

#ith s#ellin* edema and impairment o+ ,enos retrn" These processes in trnincrease and extend the intensity o+ the in+lammation" The lceration may be so

extensi,e that the mcosa is +re.ently hard to de+ine on microscopic examination

and se*mented le@ocytes are +ond in+iltratin* all layers" The reslts o+ necrosis are

per+oration #ith pericholecystic abscess +ormation +istli$ation or bile peritonitis" !n

the past acte cholecystitis secondary to systemic in+ection occrred most commonly

#ith typhoid +e,er bt this is no# rare" A bacterial case has been proposed and

positi,e bile cltres ha,e been noted in 8 percent o+ patients" E" coli Flebsiella

species streptococci Enterobacter aero*enes salmonellae and clostridia ha,e all

been implicated"

Acte cholecystitis cased by *enerali$ed sepsis or by stasis or impaction o+ acalcls may occr #hile the patient is reco,erin* +rom trama or an operation"


19/32

Amon* other cases o+ acte cholecystitis are the ,asclar e++ects o+ colla*en disease

terminal states o+ hypertensi,e ,asclar disease and thrombosis o+ the main cystic

artery" Acte cholecystitis in #hich the *allbladder is de,oid o+ stones is @no#n as

acalclos cholecystitis" ?ess than 4 percent o+ actely in+lamed *allbladders contain

a mali*nant tmor that may play a role in casin* obstrction" The incidences o+

common dct calcli are similar in acte and in chronic cholecystitis a,era*in* to47 percent"


'ost attac@s o+ acte cholecystitis occr in patients #ho *i,e a history compatible

#ith chronic cholecystitis and cholelithiasis" Acte cholecystitis can occr at any a*e

bt the *reatest incidence is bet#een the +orth and ei*hth decades and patients o,er

the a*e o+ sixty comprise bet#een one- .arter and one-third o+ the *rop" Cacasians

are a++licted more +re.ently than blac@s and #omen more than men"

The onset o+ acte symptoms is +re.ently related to a ,i*oros attempt o+ the

*allbladder to empty its contents sally a+ter a hea,y +atty or +ried meal" 'oderateto se,ere pain is experienced in the ri*ht pper .adrant and epi*astrim and may

radiate to the bac@ in the re*ion o+ the an*le o+ the scapla or in the interscaplar area"

The patient is o+ten +ebrile and ,omitin* may be se,ere" Tenderness sally alon*

the ri*ht costal mar*in o+ten associated #ith rebond tenderness and spasm is

characteristic" The *allbladder may be palpable or a palpable mass in the re*ion may

be the reslt o+ omentm #rapped arond the *allbladder" 'ild icters may be present

and may be cased by calcli #ithin the amplla and edema encroachin* on the

common dct" 'oderate to mar@ed /andice particlarly #ith a serm bilirbin le,el

*reater than 8 m*d? s**ests the presence o+ associated choledocholithiasis bt can

occr #ith isolated cholecystitis"

The di++erential dia*nosis incldes per+oration or penetration o+ peptic lcer

appendicitis pancreatitis hepatitis myocardial ischemia or in+arction pnemonia

plerisy and herpes $oster in,ol,in* an intercostal ner,e"

The hemo*ram sally demonstrates le@ocytosis #ith a shi+t to the le+t" Radio*raphs

o+ the chest and abdomen are indicated to rle ot pnemonia" A radiopa.e calcls

is noted in less than 2 percent o+ cases" The serm bilirbin le,el may determine the

presence o+ common dct obstrction" Altho*h an ele,ated amylase le,el is

*enerally re*arded as e,idence o+ acte pancreatitis le,els as hi*h as 4 Somo*yi

nits ha,e been associated #ith acte cholecystitis ncomplicated by pancreatitis" Torle ot myocardial ischemia an electrocardio*ram shold be per+ormed on any

patient o,er the a*e o+ +orty-+i,e bein* considered +or sr*ical treatment" Acte

cholecystitis may be responsible +or some electrocardio*raphic chan*es" &ral

cholecysto*raphy is o+ limited ,ale becase o+ impaired absorption o+ dye" An

ltrasono*ram may demonstrate calcli andor a thic@ened #all o+ the *allbladder and

is the dia*nostic procedre o+ choice" Radionclide scannin* #ith )!S!)A

diisopropyl iminodiacetic acid5 or P!P!)A %-para-isopropyl-acetanilide-

iminodiacetic acid5 is the most e++ecti,e dia*nostic stdy in this sitation"

Treatment

There ha,e been con+lictin* opinions on the mana*ement o+ acte cholecystitisparticlarly on the optimal time +or sr*ical inter,ention" 3or the prposes o+


20/32

discssion early operation is de+ined as one per+ormed #ithin 2 h a+ter the onset o+

symptoms= intermediate operation is one carried ot bet#een 2 h and the cessation o+

clinical mani+estations= delayed operati,e mana*ement permits the acte

in+lammatory process to sbside= and schedled electi,e sr*ery is per+ormed a+ter an

inter,al o+ 8 #ee@s to 0 months" 'ost sr*eons no# +a,or early operation i"e" #ith

21 to 16 h" The mortality rate +or emer*ent cholecystectomy ran*es +rom to 7percent" !n the ma/ority o+ cases laparoscopic cholecystectomy is sccess+l bt the

incidence o+ con,ersion to open cholecystectomy is *reater in this *rop o+ patients

#hen compared to those #ithot acte in+lammation" !n rare instances o+ extremely ill

patients cholecystostomy nder local anesthesia is applicable"

Emphysematos Cholecystitis

Emphysematos cholecystitis is a rare +orm o+ acte sally *an*renos

cholecystitis associated #ith the presence o+ *as in the *allbladder 3i*" 29-465"

nli@e ordinary acte cholecystitis #hich is more pre,alent amon* #omen

emphysematos cholecystitis is more o+ten +ond in men #ith incidences o+ 7

percent +or males and 27 percent +or +emales" Patho*enesis is related to actein+lammation o+ the *allbladder #hich o+ten be*ins aseptically complicated by a

secondary in+ection #ith *as- +ormin* bacilli" These may reach the *allbladder by bile

dcts bloodstream or lymphatic channels and *ro# in an anaerobic en,ironment" The

clinical mani+estations are similar to those o+ acte cholecystitis" !n approximately

hal+ the patients a history o+ pre,ios *allbladder attac@s can be elicited"

Cholelithiasis is also present in hal+ the patients #ho are +re.ently diabetic"

The dia*nosis is sally made on the basis o+ radio*raphs that sho# a *loblar *as-

+illed shado# in the re*ion o+ the *allbladder" ?ater intramral or sbmcosal *as

may appear and *as may also appear in the pericholecystic area denotin* extension

o+ the patholo*ic process otside the con+ines o+ the *allbladder" The treatment o+

choice is early operation since the incidence o+ +ree per+oration is reported to be 1 to

8 percent" Cholecystectomy is indicated bt i+ it is not +easible cholecystostomy

shold be per+ormed" !n 9 percent o+ cases choledocholithiasis is present and

exploration o+ the common dct may be re.ired" Altho*h positi,e bile cltres are

+ond in only hal+ the cases antibiotics directed to#ard the clostridial and coli+orm

or*anisms are indicated" The mortality rate is si*ni+icantly *reater than that +or

nonemphysematos cholecystitis"

Chronic Cholecystitis

Chronic in+lammation o+ the *allbladder is *enerally associated #ith cholelithiasisand consists o+ rond cell in+iltration and +ibrosis o+ the #all" Bried crypts o+ mcosa

Ro@itans@y-Ascho++ sinses5 may be seen dippin* into the mcosa 3i*" 29-495"

&bstrction by *allstones o+ the nec@ o+ the cystic dct may prodce a mcocele o+

the *allbladder hydrops5" The bile is initially sterile bt may be secondarily in+ected

#ith coli+orm bacilli Flebsiella species streptococci and occasionally clostridia or

Salmonella typhi" Secondary e++ects o+ cholecystitis inclde obstrction o+ the

common dct cholan*itis per+oration o+ the *allbladder #ith +ormation o+ a

pericholecystic abscess or a cholecystenteric +istla bile peritonitis and pancreatitis"

There may be associated carcinoma o+ the *allbladder"



21/32

The patients *enerally present #ith moderate intermittent abdominal pain in the ri*ht

pper .adrant and epi*astrim occasionally radiatin* to the scapla and

interscaplar re*ion" There is sally a history o+ intolerance o+ +atty or +ried +oods

and the patient may ha,e noted intermittent nasea and anorexia" !+ the patient is not

experiencin* acte pain there may be no dia*nostic +indin*s on physical examination"

&ccasionally tenderness is elicited o,er the *allbladder" )ia*nosis is sallyestablished by ltrasond scannin* or an oral cholecysto*ram #hich demonstrates

either the absence o+ +illin* o+ the *allbladder or the presence o+ stones"

Hyperplastic Cholecystoses

Hyperplastic cholecystoses are characteri$ed by the proli+eration o+ normal tisse

elements" The t#o most common o+ these lesions are cholesterolosis and

adenomyomatosis" !n patients #ith cholesterolosis there is e,idence o+ cholesterol

deposition #ithin the epithelial cells o+ the lamina propria" The bile o+ these patients

contains si*ni+icantly more cholesterol than that o+ normal adlts and the abnormality

presmably arises +rom some aberration in cholesterol transport and absorption by the

*allbladder epithelim" The deposition o+ cholesterol #ithin the #all *i,es rise to the*ross description o+ the stra#berry *allbladder" Adenomyomatosis is characteri$ed

by hyperplasia o+ the mscle and mcosa o+ the *allbladder" 'ali*nant de*eneration

is nsal and it is nclear #hether these disorders can trly be the sorce o+

symptoms" Cholecystectomy shold be o++ered to these patients only i+ #arranted by

symptoms"

Treatment

The treatment o+ chronic cholecystitis and cholelithiasis is cholecystectomy and the

reslts are sally excellent" ?aparoscopic cholecystectomy is the procedre o+

choice" Early cholecystectomy is particlarly important +or the diabetic patient"

&perati,e mortality o+ less than 4 percent has been reported +or lar*e series" Se,enty-

+i,e percent o+ patients nder*oin* cholecystectomy +or cholelithiasis are completely

relie,ed o+ all preoperati,e symptoms and the remainin* 27 percent ha,e only mild

symptoms that are apparently nrelated to the biliary system"

Acalclos Cholecystitis

Acte and chronic in+lammatory disease o+ the *allbladder can occr #ithot stones"

Acte acalclos cholecystitis +re.ently is a complication o+ brns sepsis mltiple

system +ailre cardio,asclar disease diabetes prolon*ed illness or a ma/or

operation"

The incidence o+ chronic acalclos cholecystitis is di++iclt to establish" !t is present

in o,er 7 percent o+ children and 07 percent o+ %i*erians #ith *allbladder disease

and the accepted incidence o+ adlts in the nited States is less than 7 percent o+ cases

o+ cholecystitis" Possible cases inclde 45 anatomic conditions sch as @in@in*

+ibrosis and obstrction o+ the cystic dct by tmor or anomalos ,essels= 25

thrombosis o+ ma/or blood ,essels prodcin* ischemia and *an*rene= 05 spasm or

+ibrosis o+ the sphincter o+ &ddi in patients #ith a common channel #ith or #ithot

associated pancreatitis= 15 systemic diseases sch as diabetes mellits and colla*en

diseases= 75 speci+ic in+ections sch as typhoid +e,er actinomycosis and parasitic

in+estation= and 85 scarlet +e,er and a #ide ,ariety o+ +ebrile illnesses in yon*

children" The )!S!)A or P!P!)A scan and the ltrasond scan are occasionallynormal in these patients bt characteristically the ltrasond demonstrates thic@enin*


22/32

o+ the #all" Perctaneos cholecystostomy has been sed sccess+lly 6 percent5 +or

dia*nosis and treatment o+ acalclos cholecystitis"

Treatment

Cholecystectomy is pre+erable bt in one series the patient>s condition mandated

cholecystostomy in 41 o+ 48 cases" !n children #ith acte +ebrile illnesscholecystostomy has been particlarly e++ecti,e and sbse.ent cholecystectomy has

not been re.ired in many o+ these patients"

Cholan*itis

!n+ection #ithin the biliary dct system is most +re.ently associated #ith

choledocholithiasis bt also has accompanied choledochal cysts and carcinoma o+ the

bile dct and has +ollo#ed sphincteroplasty" !n+ection and in+lammatory chan*es may

extend p the dct system into the li,er and *i,e rise to mltiple hepatic abscesses"

Clinically the condition is characteri$ed by intermittent +e,er pper abdominal pain

exacerbation o+ /andice prrits and at times ri*or"

!n patients #ith common dct stones in #hom there is ascendin* cholan*itis a broad-

spectrm antibiotic directed particlarly at E" coli #hich is the most common

o++endin* or*anism shold be *i,en +or se,eral days be+ore sr*ical treatment"

Antibiotics sally control the in+ection bt i+ the patient>s temperatre does not +all

sr*ical draina*e shold not be delayed" This can be accomplished perctaneosly by

the transdodenal or transhepatic rotes or operati,ely"

Acte Spprati,e Cholan*itis

Spprati,e cholan*itis in #hich there is *ross ps #ithin the biliary tract constittes

one o+ the most r*ent cases +or laparotomy in patients #ith obstrcti,e /andice"

The condition #as +irst described in 46 by Charcot #ho s**ested a dia*nostic

triad o+ /andice chills and +e,er and pain in the ri*ht pper .adrant" To these

Reynolds and )ar*an added shoc@ and central ner,os system depression as speci+ic

identi+yin* +eatres o+ the condition"

The disease occrs almost exclsi,ely in patients o,er years o+ a*e" All patients

are +ebrile and a ma/ority are /andiced" Hypotension con+sion or lethar*y occrs

in abot 2 percent o+ cases" A #hite blood cell cont o+ less than 42mm0 has

been reported in o,er hal+ the patients probably related to the a*e and lac@ o+ marro#

response" Bilirbin SG&T and al@aline phosphatase le,els are characteristically

ele,ated bt the serm amylase le,el is sally normal" The correct dia*nosis hasbeen made in less than one-third o+ the patients" Patients ha,e been mana*ed

emer*ently by establishin* initial draina*e ,ia ERCP or PTC +ollo#ed by de+initi,e

operation"

At operation all patients demonstrate *ross distention o+ the common bile dct #ith

+ran@ ps +re.ently nder considerable pressre and choledocholithiasis or a tmor

obstrctin* the distal bile dct" !+ the *allbladder is present it is in,ariably distended

and in+lamed" Spontaneos per+oration o+ the bile dcts has been reported" Sr*ical

treatment is directed at rapid decompression o+ the dct system and is combined #ith

lar*e doses o+ antibiotics particlarly those that achie,e hi*h le,els in the bile" !n a

re,ie# o+ the literatre it #as reported that all patients #ho #ere not operated on


23/32


24/32

Treatment

Patients are *enerally prepared #ith antibiotics" Sr*ical therapy ho#e,er shold not

be delayed +or the patient #ho is /andiced and has pain and pyrexia" The operation

consists o+ remo,al o+ the stones and debris +rom the extrahepatic bile dcts +ollo#ed

by establishment o+ open draina*e bet#een the in,ol,ed dcts and intestine sally

#ith a Rox-en-( limb" Anchorin* the Rox-en-( limb to the anterior abdominal#all +acilitates sbse.ent repeated dilatation and stone extractions"

!+ lar*e hepatic abscesses are noted draina*e shold be per+ormed" ?e+t hepatic

lobectomy has been carried ot on occasion #hen there has been *ross dilatation o+

the dcts and abscess +ormation in the le+t lobe #hile the ri*ht #as apparently normal"

The pro*nosis is *enerally *arded since recrrence is not ncommon" !n one stdy

common dct exploration transhepatic intbation and hepatotomy #ere associated

#ith recrrence rates o+ 21 0 and 7 percent respecti,ely" Hepatic resection had a

+ailre rate o+ only 1 percent and none o+ the patients had recrrent stones" !n

ad,anced cases particlarly #ith mltiple abscesses the pro*nosis is poor and thepatient e,entally sccmbs to li,er +ailre septicemia or cholan*iocarcinoma"

Sclerosin* Cholan*itis

Sclerosin* cholan*itis is an ncommon disease that in,ol,es all or part o+ the

extrahepatic biliary dct system and o+ten a++ects the intrahepatic biliary radicals as

#ell" The disease has also been called obliterati,e cholan*itis and stenosin*

cholan*itis in re+erence to a pro*ressi,e thic@enin* o+ the bile dct #alls encroachin*

pon the lmen" !t may be associated #ith *allstones bt se,eral series ha,e been

presented in #hich there #ere no stones in the *allbladder or the common dct" A

si*ni+icant nmber o+ cases ha,e been associated #ith lcerati,e colitis Crohn>s

disease Riedel>s strma retroperitoneal +ibrosis and porphyria ctanea tarda"

The case o+ sclerosin* cholan*itis is n@no#n" Histolo*ic sections in se,eral cases

+ailed to re,eal any *ranlomatos lesion metaplasia or neoplasia" !n se,eral series

none o+ the patients had pre,ios sr*ical treatment and there+ore local trama #as

exclded as an etiolo*ic a*ent= irritation o+ the common dct by passa*e o+ calcli is

nli@ely *i,en that there are sally no stones present in either the common dct or

the *allbladder" !t has been s**ested that the disease may be cased by local

response to ,iral in+ection since a relati,e lymphocytosis #ith atypical lymphocytes

has been noted" !mmne response and colla*en disease ha,e also been considered as

possible cases" A positi,e celllar immne response to biliary anti*ens has beendemonstrated" The disease has been noted in patients #ith H!: in+ection"

Patholo*y

Grossly there is di++se thic@enin* o+ the #all o+ the extrahepatic biliary tract and

sometimes o+ the intrahepatic dcts #ith a concomitant encroachment on the lmen

resltin* in mar@ed lminal narro#in*" The dct system may be completely in,ol,ed

or the hepatic dcts may be spared and the disease restricted to the entire len*th o+ the

common dct" The *allbladder is sally not in,ol,ed bt the lymph nodes in the

re*ion o+ the common dct and +oramen o+ Dinslo# are sally mar@edly enlar*ed

and scclent" 'icroscopic analyses o+ the a++ected dct sho# that the #alls are as

mch as ei*ht times thic@er than normal" The areas o+ in+lammation and +ibrosis are inthe sbmcosal and sbserosal portions #ith an edematos +ield bet#een them" The


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mcosa is intact thro*hot" Biopsy examination o+ the li,er may re,eal bile stasis or

in lon*-standin* cases biliary cirrhosis" The histolo*ic e,alation is critical since it is

di++iclt to di++erentiate this disease +rom sclerosin* carcinoma o+ the bile dcts"


The dia*nosis is to be considered in patients particlarly middle-a*ed men5 #ith aclinical and laboratory pictre o+ extrahepatic /andice" andice is sally associated

#ith intermittent pain in the ri*ht pper .adrant nasea ,omitin* and occasionally

chills and +e,er" !n lon*-standin* cases #ith biliary cirrhosis the mani+estations o+

portal hypertension sch as bleedin* ,arices and ascites may be apparent" The

dia*nosis has been established by ERCP" At operation a dense in+lammatory reaction

in the re*ion o+ the *allbladder and *astrohepatic li*ament is noted" Palpation o+ the

dct re,eals a cordli@e strctre that may +eel li@e a thrombosed blood ,essel bt the

#all o+ the common dct is ob,iosly thic@ened and cts #ith di++iclty" The ed*es o+

the incision characteristically pot ot" sally only a +ine probe or small Ba@es

dilator can be inserted into the lmen" Cholan*io*raphy may ,i,idly demonstrate the

extensi,e narro#in* o+ the lmen 3i*" 29-245"

Treatment

The appropriate mana*ement o+ sclerosin* cholan*itis remains nclear" %o dr*

therapy has achie,ed consistent or e,en sal sccess"

The asymptomatic anicteric patient is not treated and is not stdied #ith repeated

cholan*io*rams i+ /andice or cholan*itis does not de,elop" The prritic and icteric

patient is treated +or 1 to 8 #ee@s #ith prednisone= i+ there is no impro,ement or i+

cholan*itis is present or de,elops an operation is per+ormed #ith a preoperati,e

cholan*io*ram as a *ide" !+ there is minimal intrahepatic in,ol,ement and dilatation

o+ a se*ment o+ the common dct or common hepatic dct proximal to mar@ed

stenosis the stenotic se*ment is excised as a biopsy section to rle ot

cholan*iocarcinoma and a direct mcosa-to-mcosa anastomosis is e++ected bet#een

the dilated se*ment o+ dct and a Rox-en-( limb o+ /e/nm pre+erably #ithot a

stent" Strictre o+ the con+lence o+ the hepatic dcts is mana*ed by excision o+ the

distal dcts +or patholo*ic e,alation and anastomosis o+ the hepatic dcts to the

Rox-en-( limb o+ /e/nm by the mcosa-to-mcosa techni.e" !+ the hepatic dcts

are s++iciently dilated no stent is sed" !+ these dcts are small transhepatic stents

are sed bt no attempt is made to dilate intrahepatic dcts"

)ata +rom se,eral lar*e centers s**est that selected patients #ith primarilyextrahepatic disease can be sccess+lly mana*ed #ith hepatico/e/nostomy and lon*-

term stentin*" !n patients #ith more di++se or ad,anced parenchymal disease hepatic

transplantation has become the procedre o+ choice" The role o+ transplantation mi*ht

be extended as #e be*in to nderstand more +lly the ris@ o+ cholan*iocarcinoma

de,elopin* in patients #ith sclerosin* cholan*itis"

3ibrosis or Stenosis o+ the Sphincter o+ &ddi

!n 4661 ?an*enbch only 2 years a+ter reportin* the +irst sccess+l remo,al o+ a

*allbladder s**ested transdodenal di,ision o+ the di,erticlm o+ :ater in cases

o+ cicatricial stenosis +or chronic in+lammation" !n 494 &pie called attention to the

common channel theory as the case o+ pancreatitis and in 4940 Archibalds**ested sphincteroplasty as the treatment +or pancreatitis"


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The patho*enesis o+ +ibrosis or stenosis o+ the sphincter o+ &ddi and the papilla o+

:ater is not +lly nderstood" ?on*-standin* spasm may play an important role and

in+ection o+ the biliary tract or pancreas has also been implicated" !rritation +rom

stones #ithin the common dct may also lead to +ibrosis" !n a series o+ 7 patients in

#hom sphincteroplasty #as per+ormed becase a small Ba@es dilator cold not bepassed thro*h the sphincter o+ &ddi biopsy analysis re,ealed no abnormalities in 46

#hile 46 sho#ed in+lammatory in+iltration 4 had minimal +ibrosis and 2 had di++se

+ibrosis" %o de+inite correlation cold be +ond bet#een the ,arios mani+estations o+

biliary tract disease and the histolo*ic chan*es"


The main symptom o+ +ibrosis or stenosis o+ the sphincter o+ &ddi is abdominal pain

sally colic@y and +re.ently associated #ith nasea and ,omitin*" The pain be*ins

in the ri*ht pper .adrant and radiates to the sholder and it may be intermittent"

&,er hal+ the patients *i,e a history o+ intermittent /andice and many indicate that

they ha,e had pre,ios cholecystectomy #ithot relie+ o+ symptoms"

Treatment

The dia*nosis is *enerally made #hen there is di++iclty in passin* a %o" 0 Ba@es

dilator thro*h the amplla o+ :ater" Cholan*io*raphy and pressre stdies on the

common bile dct ha,e theoretical application" !+ a 0-mm dilato

Documents

Chapter 29 g b & Extrabiliary System