Upload
specialclass
View
4.485
Download
4
Tags:
Embed Size (px)
DESCRIPTION
gastroenterology 3rd year
Citation preview
Disease of the Biliary Tract
Anatomy
Calot triangle:• The triangle bounded by the common hepatic
duct medially,the cystic duct inferiorly and the inferior surface of the liver superiorly is known as Calot triangle.
• The fact that cystic artery ,right hepatic artery & para-right hepatic duct run within the triangle makes an important area of dissection during cholecytectomy.
Anatomy
• The sphincter of Oddi: The proximal bile and pancreatic ducts
and the common channel are surrounded by circular and longitudinal smooth muscle, this muscle complex is known as the sphincter of Oddi.
Special Investigation of the biliary Tract
• Ultrasound:
Non-invasive,painless,
Easily performed
First choice for biliary tract disease
Ultrasound
• Bile duct stones:
Stones in gallbladder:
High echo which cast an acoustic shadow and which move with changes in posture
Ultrasound
• Jaundice differential diagnosis:
Dilatation of the ducts
CBD: diameter > 1.0cm
• Other disease: cholecytitis, tumor ect.
• During surgery: to detect bile duct stones
Radiology
• Plain abdominal radiograph:
Radio-opaque gallstones
Air in the biliary tree
• Oral cholecystography:
Biliary contrast medium
A fatty meal
Radiology
• Intravenous cholangiography• Percutaneous transhepatic cholangi-
ography (PTC) show intra and extra hepatic biliary
duct clearly complication: bile leakage cholangitis hemorrhage
Radiology
• Endoscopic retrograde cholangio-pancreatography(ERCP)
outline the biliary tree and pancreatic duct
inspect the ampulla of Vater
exam of the fluid of duodenum ,bile, pancreatic fluid.
Radiology
• Endoscopic sphincterotomy(EST)• Endoscopic naso-biliary drainage (ENBD) • Computed tomography(CT)• Magnetic resonance cholangio-
pancreatography (MRCP)• Cholangiopancreatography during &
operation
Special Investigation of the Biliary Tract
• Hepatobiliary nuclear imaging
99m-Tc-EHIDA
• Choledochoscopy
Operation
Post opertion
Cholelithiasis
• Including :
gallstones
biliary duct stones
Cholelithiasis
In China:• before 1981 gallstones < biliary duct stones cholesterol stones < pigment stones• now gallstones > biliary duct stones
cholesterol stones > pigment stones
Classification of stones
• Cholesterol stones: hard,layed on cross-section
• Pigment stones:crumble when squashed
• Mixed stones: radio-opaque
• Black stones
Formation of stones
• Cholesterol stones:
cholesterol insoluble in water and relative proportion of cholesterol,bile salts, and phospholipid in bile .
Formation of cholesterol stones
• Increase of cholesterol and decrease of bile salts leads to supersaturation of bile with cholesterol ,which results in the formation of liquid crystalline phase of cholesterol
Formation of cholesterol stones
• Nucleation:cholesterol will crystallize if there is a nidus on which the crystals can form.
• Nucleating factors: mucus glycoprotiens from cyst wall
and bilirubinate• Gallbladder function: the motility of the cyst wall
Clinical feature of gallstones
• 20-40% patient without symptom which is called asymptomatic gallstones
• Chronic cholecystitis
• Biliary colic
• Acute cholecystitis
Symptoms
• Gastrointestinal tract symptoms:
upper abdominal discomfort,
nausea,
after meals, eap. fatty meals.
Symptoms
Biliary colic: most commom symptom• A large or fatty meals and changing in position
when sleeping can precipitate the pain• Due to impaction of stone in the neck of the
gallbladder: the pressure increase.• Occurs in the mid or the upper-right portion of
the upper abdomen.• Severe pain starts abruptly, continuous,with
restlessness, vomitting,sweating.• Pain radiate to the right back and shoulder.
Symptoms
Mirizzi syndrome:
• Obstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmann’s pouch
• Press on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula
Sign
• Right upper area of the abdomen tenderness, rigidity,
rebound tendeness.• Gallbladder palpable• Murphy sign: inspiratory arrest during
subcostal palpation• Jaundice:common bile duct stones or Mirizzi
syndrome• Fever and chill with infection
Exam
• Jaundice (choledocholithiasis):
blood test of the liver function, elevation of the enzyme alkaline phosphate and bilirubin
• WBC count is high
• Ultrasoud: the main diagnosis exam.
• Oral cholecytography.
Diagnosis
• History
• Physical exam
• Ultrasoud exam: high echo with an acoustic shadow and moving with changes in posture
Treatment
• The first choice is operation:
symptomatic gallstones
gallstones with complications
Treatment
Asymptomatic gallstones:• oral cholecytography without showing
of gallbladder • diameter of stones > 2.0-3.0 cm• diabetes mellitus• elder or cardiac and respiratory
problemsNeed operation.
Treatment
CBD exploration:
Preoperation
• CBD stones
• Cholangitis and biliary colic repeatedly
• Pancreatitis
• Jaundice and bile duct dilatation
Treatmen
• Operation: the final method• Emergency surgery 1. onset in 48-72 hours2. invalidation of nonsurgical
treatment3. gangrene, perforation, pancreatitis,
or inflammation of the common bile duct occurs