Upload
api-3866881
View
112
Download
5
Tags:
Embed Size (px)
DESCRIPTION
biliary tract lecture
Citation preview
WILLIAM L. OLALIA, M.D., FPCS, FPSGSAssociation Professor, Department of Surgery
UST Faculty of Medicine & Surgery
Anatomy & PhysiologyAnatomy & Physiology Gallstone formationGallstone formation
– Types of stonesTypes of stones Diagnostic StudiesDiagnostic Studies Gallstone DiseaseGallstone Disease
– Natural historyNatural history– ComplicationsComplications
Acute/chronic cholecystitisAcute/chronic cholecystitis CholedocholithiasisCholedocholithiasis CholangitisCholangitis Biliary pancreatitisBiliary pancreatitis
Operative interventionsOperative interventions
AnatomyAnatomy
GallbladderGallbladder Bile ductsBile ducts ArteriesArteries
N.B. Anatomical variations N.B. Anatomical variations commoncommon
AnatomyAnatomy
AnatomyAnatomy
Gall BladderGall Bladder – pear-shaped sac in the fossa of pear-shaped sac in the fossa of
the liverthe liver– 7-10 cms long7-10 cms long– 30-50 ml average capacity 30-50 ml average capacity – divides the liver into right and divides the liver into right and
left left lobeslobes
AnatomyAnatomy
Blood supply of the gall bladderBlood supply of the gall bladder
cystic arterycystic artery – a branch of the – a branch of the right right hepatic artery in 90% hepatic artery in 90% of casesof cases
AnatomyAnatomy
The bile ductsThe bile ductsExtrahepatic ductsExtrahepatic ducts
right and left hepatic ductsright and left hepatic ductscommon hepatic ductcommon hepatic ductcystic ductcystic ductcommon bile ductcommon bile duct
* The arterial supply to the bile ducts is * The arterial supply to the bile ducts is from the from the Gastroduodenal and Right Gastroduodenal and Right Hepatic ArteriesHepatic Arteries
AnatomyAnatomy
Common hepatic ductCommon hepatic duct
- 1 to 4 cms length - 1 to 4 cms length
- approx. 4 mm diameter- approx. 4 mm diameter
N.B.: the common hepatic duct is N.B.: the common hepatic duct is joined at an acute angle by the joined at an acute angle by the cystic duct to form the cystic duct to form the common common bile ductbile duct
AnatomyAnatomy
Cystic duct Cystic duct – variable length variable length – contains contains spiral valves of spiral valves of
HeisterHeister
AnatomyAnatomy
Common bile ductCommon bile duct is about 7- 11 cm in is about 7- 11 cm in length and length and 5 to 10 mm5 to 10 mm in diameter in diameter
Ampulla of VaterAmpulla of Vater- opening of the - opening of the common bile duct into the duodenumcommon bile duct into the duodenum
Sphincter of Oddi-Sphincter of Oddi- surrounds the surrounds the common bile at the ampulla of vater common bile at the ampulla of vater
it controls bile flow it controls bile flow
AnatomyAnatomy
AnatomyAnatomy
Gallbladder
DUODENUM
CBD
stomach
pancreas
jejunum
PhysiologyPhysiology
Bile formation and CompositionBile formation and Composition 500- 1000 mL of bile/day500- 1000 mL of bile/day mainly composed of water, electrolytes, mainly composed of water, electrolytes,
bile salts, proteins, lipids, and bile bile salts, proteins, lipids, and bile pigmentspigments
Enterohepatic circulation (95% of bile Enterohepatic circulation (95% of bile acid pool)acid pool)
Digestion and absorption of fats in the Digestion and absorption of fats in the intestinesintestines
PhysiologyPhysiology
Gallbladder functionGallbladder function– Concentrate & store hepatic Concentrate & store hepatic
bilebile– Deliver bile into the duodenum Deliver bile into the duodenum
in response to a mealin response to a meal
Gallstone DiseaseGallstone Disease
One of the most common problems of One of the most common problems of the GIT (11-36%)the GIT (11-36%)
Predisposing factors:Predisposing factors:– age, gender, ethnic backgroundage, gender, ethnic background– obesity, pregnancy, dietobesity, pregnancy, diet– terminal ileal resection, gastric surgery, terminal ileal resection, gastric surgery,
hemolytic disordershemolytic disorders* * FemalesFemales are three times more likely are three times more likely
to to develop gallstonesdevelop gallstones* 4F’s (fat, female, fetus, family history)* 4F’s (fat, female, fetus, family history)
Gallstone formationGallstone formation
Dependent on the concentrations Dependent on the concentrations of :of :– Bile saltsBile salts– CholesterolCholesterol– LecithinLecithin
Gallstones form as a result of Gallstones form as a result of solid settling out of solutionsolid settling out of solution
Gallstone formationGallstone formation
Two major typesTwo major types– Cholesterol stones (80% of Cholesterol stones (80% of
cases) cases) – Pigment stones (15-20%)Pigment stones (15-20%)
Black pigment stones (hemolytic Black pigment stones (hemolytic disorders)disorders)
Brown pigment stones (bacterial Brown pigment stones (bacterial infection, parasites)infection, parasites)
Gallstone FormationGallstone Formation
Cholesterol stonesCholesterol stones– usually multiple, variable size, hard usually multiple, variable size, hard
and faceted or irregular, mulberry- and faceted or irregular, mulberry- shaped and soft. shaped and soft.
– supersaturation of bile with cholesterolsupersaturation of bile with cholesterol common primary event in the formation of common primary event in the formation of
cholesterol stonescholesterol stones caused by cholesterol hypersecretioncaused by cholesterol hypersecretion
Cholesterol Stones
Gallstone FormationGallstone Formation
Pigmented stonesPigmented stones
- small, brittle, black and - small, brittle, black and sometimes sometimes spiculatedspiculated
- formed by supersaturation of - formed by supersaturation of calcium calcium bilirubinate, carbonate bilirubinate, carbonate and and phosphatephosphate
- secondary to hemolytic disorders- secondary to hemolytic disorders
Pigmented StonesPigmented Stones
Gallstone DiseaseGallstone Disease
Most patients with gallstones will Most patients with gallstones will remain asymptomaticremain asymptomatic
About 3% become symptomatic About 3% become symptomatic per yearper year
3 to 5% of symptomatic patients 3 to 5% of symptomatic patients develop complicationsdevelop complications
Few patients develop Few patients develop complications without previous complications without previous biliary symptomsbiliary symptoms
Natural History
Diagnostic StudiesDiagnostic Studies
Ultrasound of Ultrasound of LGBPSLGBPS
Sensitivity and Sensitivity and specificity of over specificity of over 90%90%
Posterior acoustic Posterior acoustic shadowingshadowing Posterior
Acoustic shadow
Diagnostic StudiesDiagnostic Studies
Oral cholecystographyOral cholecystography– stones noted on film as filling stones noted on film as filling
defects defects– seldom utilized nowadaysseldom utilized nowadays
Biliary Radionuclide Scanning Biliary Radionuclide Scanning (HIDA Scan)(HIDA Scan)– acute cholecystitisacute cholecystitis– biliary leak after biliary surgery biliary leak after biliary surgery – non-visualized gall bladder with non-visualized gall bladder with
filling filling of the common duct and of the common duct and duodenumduodenum
– Specificity and Sensitivity is Specificity and Sensitivity is 95%95%
Diagnostic StudiesDiagnostic Studies
Diagnostic StudiesDiagnostic Studies
Endoscopic Endoscopic Retrograde Retrograde CholangiographyCholangiography
- both diagnostic and - both diagnostic and therapeutictherapeutic
- invasive- invasive
- direct visualization of - direct visualization of the ampullary region the ampullary region & distal CBD& distal CBD
- success rate 90%- success rate 90%
Diagnostic StudiesDiagnostic Studies
Endoscopic Retrograde Endoscopic Retrograde CholangiographyCholangiography
Success rate 90%Success rate 90% Complications:Complications:
- occur in 5% of cases- occur in 5% of cases
- pancreatitis - pancreatitis
- cholangitis- cholangitis
Diagnostic StudiesDiagnostic Studies
Computed Computed Tomography ( CT Tomography ( CT Scan)Scan)
- defines the course and - defines the course and status of the extra-status of the extra-hepatic biliary tree hepatic biliary tree and adjacent and adjacent structuresstructures
- - test of choice in test of choice in evaluating patients evaluating patients with suspected with suspected malignancy of biliary malignancy of biliary tree and pancreas tree and pancreas
cholecystitis
Diagnostic StudiesDiagnostic Studies
Percutaneous Percutaneous Transhepatic Transhepatic CholangiographyCholangiography– Intrahepatic bile Intrahepatic bile
duct is accessed duct is accessed percutaneously with percutaneously with a needle under a needle under fluoroscopyfluoroscopy
– It defines the biliary It defines the biliary tree proximal to the tree proximal to the affected segment affected segment
Diagnostic StudiesDiagnostic Studies
Magnetic Resonance Magnetic Resonance Cholangiopancrea-Cholangiopancrea-tographytography– Offers a single non Offers a single non
invasive test for the invasive test for the diagnosis of biliary diagnosis of biliary tract and pancreatic tract and pancreatic diseasedisease
– Sensitivity is 95%Sensitivity is 95%– Specificity is 89%Specificity is 89%
CBDPancreaticduct
Gallstone DiseaseGallstone Disease
Acute /chronic cholecystitisAcute /chronic cholecystitis CholedocholithiasisCholedocholithiasis CholangitisCholangitis Gallstone pancreatitisGallstone pancreatitis Biliary-enteric fistulae (gallstone Biliary-enteric fistulae (gallstone
ileus)ileus) Gallbladder carcinomaGallbladder carcinoma
Complications
Symptomatic Symptomatic GallstonesGallstones
Acute CholecystitisAcute Cholecystitis– secondary to gallstones in 90-secondary to gallstones in 90-
95%95%– initiated by obstruction of the initiated by obstruction of the
cystic duct by a stonecystic duct by a stone– Distention Distention inflammation/edema inflammation/edema
secondary bacterial infection secondary bacterial infection– Thickened gall bladder wall, Thickened gall bladder wall,
pericholecystic fluid on ultrasoundpericholecystic fluid on ultrasound
Symptomatic Symptomatic GallstonesGallstones Acute CholecystitisAcute Cholecystitis
– may progress to acute may progress to acute gangrenous cholecystitis, gangrenous cholecystitis, empyema, or emphysematous empyema, or emphysematous cholecystitischolecystitis
– Positive Murphy’s signPositive Murphy’s sign– Mild to moderate leukocytosis Mild to moderate leukocytosis
(12-15,000 wbc) (12-15,000 wbc)
Symptomatic Symptomatic GallstonesGallstones Acute CholecystitisAcute Cholecystitis
Diagnosis:Diagnosis:- Clinical profileClinical profile- UltrasonographyUltrasonography- Biliary radio nuclide scanning Biliary radio nuclide scanning (HIDA)(HIDA)
Symptomatic Symptomatic GallstonesGallstones
Acute CholecystitisAcute Cholecystitis
Treatment:Treatment:- Fluid resuscitationFluid resuscitation- Antibiotics VS gram (-) aerobes and Antibiotics VS gram (-) aerobes and
anaerobesanaerobes- AnalgesicsAnalgesics- Cholecystectomy is the definitive Cholecystectomy is the definitive
treatmenttreatment- Early cholecystectomy preferred over Early cholecystectomy preferred over
interval/delayed cholecystectomyinterval/delayed cholecystectomy
Symptomatic Symptomatic gallstonesgallstones
- gallbladder - gallbladder wall becomes wall becomes grossly grossly thickened and thickened and reddish with reddish with subserosal subserosal hemorrhages hemorrhages
Symptomatic Symptomatic GallstonesGallstones
Chronic CholecystitisChronic Cholecystitis– recurrent episodes of painrecurrent episodes of pain– pain due to pain due to stone obstructing the cystic stone obstructing the cystic
ductduct– pain in the epigastrium or RUQ area pain in the epigastrium or RUQ area
radiating to the backradiating to the back– pain associated with fatty/ heavy mealpain associated with fatty/ heavy meal– pathologic changes do not correlate well pathologic changes do not correlate well
with symptomswith symptoms– hydrops of the gallbladderhydrops of the gallbladder
Symptomatic Symptomatic GallstonesGallstones
Chronic CholecystitisChronic Cholecystitis
DiagnosisDiagnosis:: same as acute same as acute cholecystitischolecystitis
Symptomatic Symptomatic GallstonesGallstones Chronic CholecystitisChronic Cholecystitis
Treatment:Treatment:- elective open or laparoscopic - elective open or laparoscopic
cholecystectomy (relief in about cholecystectomy (relief in about 90%)90%)
- dietary advice while waiting for surgery- dietary advice while waiting for surgery
- diabetic patients should have - diabetic patients should have prompt prompt cholcystectomycholcystectomy
Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis
– Found in 6 to 12% with gallbladder stonesFound in 6 to 12% with gallbladder stones– 20-25% of patients > 60 years old with 20-25% of patients > 60 years old with
symptomatic gallstonessymptomatic gallstones– Majority are Majority are secondarysecondary stones stones– Primary CBD stones more common Primary CBD stones more common
among among asiansasians
Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis
Clinical Profile:Clinical Profile:– Maybe silent or asymptomaticMaybe silent or asymptomatic– Biliary colic just like in gallbladder stonesBiliary colic just like in gallbladder stones– Symptoms maybe intermittent (ball valve Symptoms maybe intermittent (ball valve
mechanisms) mechanisms) bilirubin, alkaline phosphatase & transaminasesbilirubin, alkaline phosphatase & transaminases– Impacted stone Impacted stone progressive jaundice progressive jaundice– Small stone may pass thru the ampulla Small stone may pass thru the ampulla
spontaneously spontaneously
Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis
Diagnosis:Diagnosis:– Ultrasonography: stones in the gallbladder, Ultrasonography: stones in the gallbladder,
dilated CBD (> 8mm)dilated CBD (> 8mm)– Biliary colic, jaundice, gallbladder stones on Biliary colic, jaundice, gallbladder stones on
ultrasoundultrasound– Magnetic Resonance Cholangiography (MRC) Magnetic Resonance Cholangiography (MRC)
95% & 89% sensitivity and specificity 95% & 89% sensitivity and specificity – ERCP – gold standard in diagnosing CBD ERCP – gold standard in diagnosing CBD
stones with therapeutic options stones with therapeutic options
Symptomatic Symptomatic GallstonesGallstones CholedocholithiasisCholedocholithiasis
Treatment:Treatment:Plan APlan A
pre-op endoscopic cholangiographypre-op endoscopic cholangiography
sphincterotomy + stone removalsphincterotomy + stone removal
laparoscopic cholecystectomylaparoscopic cholecystectomy
Symptomatic Symptomatic GallstonesGallstones
CholedocholithiasisCholedocholithiasis
Treatment:Treatment:Plan BPlan B
open cholecystectomy open cholecystectomy intraoperative cholangiogramintraoperative cholangiogram
open common bile duct explorationopen common bile duct exploration
t-tube placementt-tube placement
Symptomatic Symptomatic GallstonesGallstones
Acute CholangitisAcute Cholangitis– Ascending bacterial infection from bile Ascending bacterial infection from bile
duct obstructionduct obstruction– Stones, strictures, parasites, Stones, strictures, parasites,
instrumentationinstrumentation– Fever, abdominal pain & jaundice Fever, abdominal pain & jaundice
(Charcot’s triad)(Charcot’s triad)– May lead to septicemia and disorientation May lead to septicemia and disorientation
(Reynolds pentad)(Reynolds pentad)– Leukocytosis, increased bilirubin and Leukocytosis, increased bilirubin and
alkaline phosphatasealkaline phosphatase
Symptomatic Symptomatic GallstonesGallstones
Acute CholangitisAcute Cholangitis
Treatment:Treatment:– Fluid resuscitation, IV antibioticsFluid resuscitation, IV antibiotics– ERCP/PTC diagnostic/therapeuticERCP/PTC diagnostic/therapeutic– About 15% will require emergency biliary About 15% will require emergency biliary
decompression decompression ERCPERCP PTCPTC T-tube choledochostomy/cholecystostomyT-tube choledochostomy/cholecystostomy
– Definitive treatment done laterDefinitive treatment done later
Symptomatic Symptomatic GallstonesGallstones
Biliary PancreatitisBiliary Pancreatitis– Another complication of CBD stoneAnother complication of CBD stone– Obstruction of the pancreatic duct by Obstruction of the pancreatic duct by
an impacted stonean impacted stone– Temporary obstruction by a stone Temporary obstruction by a stone
passing thru the ampulla passing thru the ampulla – Ultrasound of biliary tree essential in Ultrasound of biliary tree essential in
patients with pancreatitispatients with pancreatitis
Symptomatic Symptomatic GallstonesGallstones Biliary PancreatitisBiliary Pancreatitis
Treatment:Treatment:– Severe pancreatitis: ERCP with Severe pancreatitis: ERCP with
sphincterotomy & stone extractionsphincterotomy & stone extraction– Cholecystectomy (open or laparoscopic later Cholecystectomy (open or laparoscopic later
/same admission)/same admission)– Mild pancreatitis: elective cholecystectomyMild pancreatitis: elective cholecystectomy
N.B. possibility of spontaneous passage N.B. possibility of spontaneous passage of of stone thru ampulla stone thru ampulla
Operative Operative Interventions Interventions
CholecystostomyCholecystostomy– decompresses and drains the decompresses and drains the
distended, inflamed, hydropic, or distended, inflamed, hydropic, or purulent gall bladderpurulent gall bladder
– applicable to patients not fit to applicable to patients not fit to undergo abdominal operationundergo abdominal operation
– done either by open or done either by open or percutaneous ultrasound or CT percutaneous ultrasound or CT guidedguided
Operative Operative InterventionsInterventions
CholecystectomyCholecystectomy
ISSUEISSUE: OPEN vs. LAPAROSCOPIC : OPEN vs. LAPAROSCOPIC CHOLECYSTECTOMY CHOLECYSTECTOMY
Parameters:Parameters:
Operative Operative InterventionsInterventions
CholecystectomyCholecystectomyOPEN OPEN
vs.vs. LAPAROSCOPICCHOLECYSTECTOMYLAPAROSCOPICCHOLECYSTECTOMY
Parameters:Parameters:– Patient’s choice Patient’s choice – Technical expertise Technical expertise – Patient’s conditionPatient’s condition– Cost Cost – Length of hospital stayLength of hospital stay– Complications Complications
Open cholecystectomyOpen cholecystectomy
Safe and effective Safe and effective treatment of acute treatment of acute and chronic and chronic cholecystitischolecystitis
Carl Langenbuch Carl Langenbuch performed the first performed the first cholecystectomy in cholecystectomy in 18821882
Laparoscopic Laparoscopic cholecystectomycholecystectomy
Introduced by Philippe Mouret in Introduced by Philippe Mouret in 19871987
Pneumoperitoneum is introduced Pneumoperitoneum is introduced to the abdominal cavity using to the abdominal cavity using carbon dioxidecarbon dioxide
Surgery is video assisted using Surgery is video assisted using trocars and special instruments trocars and special instruments
Laparoscopic Laparoscopic cholecystectomycholecystectomy
The mortality rate of for The mortality rate of for laparoscopic cholecystectomy is laparoscopic cholecystectomy is 0.1% 0.1%
Conversion to open Conversion to open cholecystectomy is 5%cholecystectomy is 5%