GALLBLADDER AND EXTRAHEPATIC BILIARY SYSTEM

HOUSSAM OSMAN

ANATOMY

The Gallbladder: Pear-shaped sac. 30-50 ml. Located in the fossa on the inferior surface of the liver 4 anatomic areas. Blood supply: cystic artery ( triangle of calot). Venous drainage: small veins enter directly to the liver. Lymphatic: nodes at the neck of the GB.

ANATOMY

The Gallbladder: Pear-shaped sac. 30-50 ml. Located in the fossa on the inferior surface of the liver 4 anatomic areas. Blood supply: cystic artery ( triangle of calot). Venous drainage: small veins enter directly to the liver. Lymphatic: nodes at the neck of the GB.

The Bile ducts: The extra hepatic components. Common bile duct portions. Blood supply: gastroduodenal and R hepatic arteries.

Anomalies: The classic description applies only in one third of the patients G.B: abnormal portions, intrahepatic, rudimentary, or duplicated. Bile ducts: duct of Luschka, accessory right hepatic duct. Arteries:

• In 50 % of population• Right hepatic artery from SMA (20%)• 2 right hepatic arteries (5%)• Cystic artery can arise from left hepatic, common hepatic,

gastroduodenal, or SMA(10%).

PHYSIOLOGY

Bile Formation and composition: Produced by the liver ( 500-1000 ml/day). Production is stimulated by vagus, food particles in the duodenum, and

secretin. Composed of water, electrolytes, bile salts, bile pigments, protein, lipids. Cholesterol -> primary bile acids -> ( conjugation + Na) -> bile salts -> small

intestine :*80% absorbed in terminal ileum.*deconjugated (secondary bile acids) -> absorbed in colon

95% of the bile acid pools is reabsorbed (enterohepatic circulation)

G.B Function: Store and concentrate bile. Secrete glycoprotein and hydrogen ion. Contraction stimulated by CCK and vagus nerve and inhibited by

sympathetic stimulation, VIP, and somatostatin

Sphincter of oddi: Regulates bile flow, prevents back flow, and diverts bile into G.B. Basal resting pressure of 13 mm Hg above duodenal pressure. CCK causes relaxation

DIAGNOSTIC STUDIES

Blood Tests: WBC LFTN.B in pt with biliary colic blood tests will be typically be normal.

Ultrasonography: Operator dependant. Stones (>90% s&s) -> acoustic shadow, move Thickened wall. Evaluate extra hepatic biliary tree. Can evaluate tumor invasion and flow in the portal pain.

Oral Cholecystograhy.

HIDA: Radionuclide is injected IV Detected in liver within 10 min. GB, ducts, and duodenum are visualized

within 60 min. Acute cholecystitis -> nonvisulaized G.B. (95% s&s). To evaluate biliary leak.

CT: The major application is to define the biliary tree and near by structure. Test of choice to evaluate for malignancy.

PTC: To evaluate the intrahepatic biliary system Useful in pt with duct strictures and tumors. Risk of bleeding, cholangitis, and bile leak.

MRI: MRCP is used to delineate the anatomy of the bile and pancreatic ducts.

ERCP: Require pt sedation. Direct visualization of the ampullary region and direct access to the distal CBD. Can be used for therapeutic intervention. Used mainly to evaluate complicated duct stones. Complications include pancreatitis and cholangistis.

GALLSTONE DISEASEINTRODUCTION: Prevalence 11-36%. Risk factors:1. Obesity2. Pregnancy3. Crohn’s disease.4. Terminal ileum resection.5. Gastric surgery.6. Hereditary spherocytosis, sickle cell disease, thalassemia.7. Female.8. 1st degree relative.

Natural History: Most pt remain asymptomatic 3% become symptomatic per year (biliary colic) 3-5% develop complications per year; acute cholecystitis,

choledocholithiasis, cholangitis, pancreatitis, cholecystocholedochal fistula, and cholecystoenteric fistula.

Prophylactic cholecystectomy may indicated for elderly pts with DM, individual who will be isolated from medical care for extended period of time, and in population with increased risk of cancer.

Porcelain G.B. is an absolute indication for cholecystectomy.

Gallstones formation: Form as a result of settling out of solution. Can be classified into:1- cholesterol stones

*80% of gallstones.* Secondary to supersaturation of bile with cholesterol due to cholesterol hypersecretion. *10% -> pure, and present as single large stone with smooth surface.*most contain bile pigments and Ca, and are usually multiple, variable size*color range from whitish yellow and green to black.*most are radiolucent.

2-pigment stones:*black are usually small, brittle and speculated. Formed secondary to

supersaturation with Ca bilirubinate .*brown stones are usually less than 1 cm, soft, and mushy. Usually formed

secondary to bacterial infection due to bile stasis.

SYMPTOMATIC GALLSTONES

CHRONIC CHOLECYSTITIS: About two thirds of patients with gallstone disease present with chronic

cholecystitis . Aschoff-Rokitansky sinuses. Clinical presentation:

*The patient suffers discrete attacks of pain and N/V between which they feel well.*RUQ tenderness.*Atypical presentation.

Hydrops: due to an impacted stone in the cystic duct. Diagnosis: clinical presentation + US Management: dietary modification and elective cholecystectomy.

ACUTE CHOLECYSTITIS: Causes:1- stones 90-95% 2-acalculous 3-tumor. Clinical manifestation:

*80% give a history compatible with chronic cholecystitis.*RUQ or epigastric pain that may radiate to the right upper part of the back or the interscapular area.*fever, complains of anorexia, nausea, and vomiting.*RUQ tenderness and Murphy's sign.

Diagnosis:*WBC: 12-15, LFT*US*HIDA*CT

Treatment:*intravenous fluids, antibiotics (G –ve and anaerobes), and analgesia. *Cholecystectomy; early Vs delayed.* unfit for surgery; a percutaneous cholecystostomy or an open cholecystostomy under local analgesia can be performed.

CHOLEDOCHOLITHIASIS: Common bile duct stones; primary or secondary. Clinical manifestation:May be silent or can present with biliary colic, cholangitis, gallstone

pancreatitis, or obstructive jaundice. Diagnosis: US, MRC, ERCP Treatment:

*ERCP followed by lap chole*Intra operative cholangiogram and lap CBD ex*Open CBD ex and T-tube placement

CHOLANGITIS: Is an ascending bacterial infection in association with partial or complete

obstruction of the bile ducts. (Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis, and Bacteroides fragilis)

Clinical presentation:Charcot's triad and Reynolds pentad . Diagnosis:

*Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases .*US*ERCP , PTC*CT, MRI

Treatment:*intravenous antibiotics and fluid resuscitation*the obstructed bile duct must be drained as soon as the patient has been stabilized

BILIARY PANCREATITIS: Severe: ERCP with sphincterotomy and stone extraction, Once the

pancreatitis has subsided, the gallbladder should be removed during the same admission

Mild: cholecystectomy and an intraoperative cholangiogram or a preoperative ERC.

Cholangiohepatitis: recurrent pyogenic cholangitis

OPERATIVE INTERVENTION FOR GALLSTONE DISEASE

Cholecystostomy: Decompresses and drains the distended, inflamed, hydropic, or purulent

gallbladder. It is applicable if the patient is not fit to tolerate an abdominal operation Ultrasound guided percutaneous drainage with a pigtail catheter is the

procedure of choice.

Laparoscopic Cholecystectomy: The treatment of choice for symptomatic gallstones. Absolute contraindications: uncontrolled coagulopathy, end stage liver disease. Complication: bile duct injury

Open Cholecystectomy

Intra Operative Cholangiogram or Ultrasound: Routine intraoperative cholangiography; detect stones , outlining the

anatomy and detect injury. Selective intraoperative cholangiogram : abnormal LFT, pancreatitis,

jaundice, a large duct and small stones, a dilated duct on preoperative ultrasonography, and if preoperative endoscopic cholangiography for the above reasons was unsuccessful.

Choledochal Exploration: To manage CBD stones Laparoscopic choledochal exploration: can be carried as part of lap chole

*Irrigation and flushing toward the duodenum*Stones can be retrieved through balloon catheter, wire basket , flexible choledochoscope , or choledochotomy followed be T-tube.

Choledochal Drainage Procedures: When the stones cannot be cleared and/or when the duct is very dilated. Choledochoduodenostomy, choledochojejunostomy,

hepaticojejunostomy

Transduodenal Sphincterotomy: Replaced by endoscopic sphincterectomy. May be feasible when an open procedure is carried out.

OTHER BENIGN DISEASES AND LESIONS

Acalculous Cholecystitis: Typically develops in critically ill patients in the intensive care unit Unknown cause. Clinical feature: similar to acute cholecystitis in alert pt while in sedated pt

can be suspected with fever, WBC, T bili, and ALP. US, CT, HIDA Cholecystotmy.

Biliary Cysts: Congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary

tree. Five types : Type I, fusiform or cystic dilations of the extrahepatic biliary

tree(the most common type), Type II, saccular diverticulum of an extrahepatic bile duct, Type III, bile duct dilatations within the duodenal wall (choledochoceles), Types IVa and IVb, multiple cysts, Type V, intrahepatic biliary cysts.

Adults commonly present with jaundice or cholangitis. Less than one half of patients present with the classic clinical triad of abdominal pain, jaundice, and a mass

US, CT, ERCP, MRC Types I, II, and IV -> excision of the extrahepatic biliary tree, including

cholecystectomy, with a Roux-en-Y hepaticojejunostomy.

Sclerosing Cholangitis: Inflammatory strictures involving the intrahepatic and extrahepatic biliary tree. Can result in secondary biliary cirrhosis. Associated with ulcerative colitis, Riedel's thyroiditis, and retroperitoneal

fibrosis. Risk for developing cholangiocarcinoma 10-20% The usual presentation is intermittent jaundice, fatigue, weight loss, pruritus,

and abdominal pain. ERCP Treatment?

Stenosis of the Sphincter of Oddi: Associated with inflammation, fibrosis, or muscular hypertrophy. Episodic biliary pain and abnormal LFT. Dilated common bile duct that is difficult to cannulate with delayed emptying

of the contrast. Sphincterotomy

Bile Duct Strictures: Causes: operative injury, fibrosis due to chronic pancreatitis, common bile

duct stones, acute cholangitis, biliary obstruction due to cholecystolithiasis (Mirizzi's syndrome), sclerosing cholangitis, cholangiohepatitis, and strictures of a biliary-enteric anastomosis.

Recurrent cholangitis, secondary biliary cirrhosis, and portal hypertension Pt presents with cholangitis or jaundice. US, CT, MRC, PTC, ERCP. Endoscopic dilatation and/or stent placement, Roux-en-Y

choledochojejunostomy , hepaticojejunostomy , or choledochoduodenostomy.

INJURY TO THE BILIARY TRACT

The Gallbladder: Uncommon Penetrating or nonpenetrating. Cholecystectomy.

The Extrahepatic Bile Ducts: Majority is iatrogenic. Factors associated injury during laparoscopic cholecystectomy: acute or

chronic inflammation, obesity, anatomic variations, bleeding, inadequate exposure and failure to identify structures.

Techniqual tips: The use of an angled laparoscope instead of an end-viewing one will help visualize the anatomic structures, in particular those around the triangle of Calot. An angled scope also will aid in the proper placement of clips. Careless use of electrocautery may lead to thermal injury. Dissection deep into the liver parenchyma may cause injury to intrahepatic ducts, and poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile duct

If a bile duct injury is suspected during cholecystectomy, a cholangiogram must be obtained to identify the anatomic features.

Diagnosis: 25% are recognized at the time of the operation (intraoperative bile

leakage, recognition of the correct anatomy, and an abnormal cholangiogram)

> 50% present in the first post operative month with elevated LFT or bile leak -> US, CT, HIDA

The reminder present late with recurrent cholangitis or cirrhosis.

Management: depends on the type, extent, and level of injury, and the time of its

diagnosis. <3 mm or those draining a single hepatic segment can safely be ligated > 4mm or larger needs to be reimplanted. Lateral injury to the common bile duct or the common hepatic duct is

managed with a T-tube placement. Major bile ducts injury -> biliary enteric anastomosis . Cystic duct leaks can usually be managed with percutaneous drainage of

intra-abdominal fluid collections followed by an endoscopic biliary stenting .

Major injuries diagnosed postoperatively require transhepatic biliary catheter placement for biliary decompression as well as percutaneous drainage of intra-abdominal bile collections, if any. When the acute inflammation has resolved 6 to 8 weeks later, operative repair is performed.

TUMORSCarcinoma of the Gallbladder: Rare, aggressive and poor prognosis. High risk : porcelain gallbladder (20%), chronic inflammation, stones > 3

cm, symptomatic gallstones, polypoid lesions , choledochal cysts, sclerosing cholangitis, anomalous pancreaticobiliary duct junction, and exposure to carcinogens (azotoluene, nitrosamines).

Pathology: adenocarcinomas, squamous cell, adenosquamous, oat cell, and other anaplastic lesion.

Lymphatic, venous, and direct invasion. Clinical feature: indistinguishable from cholecystitis and cholelithiasis. US, CT Treatment: Surgery remains the only curative option, however, palliative

procedures for patients with unresectable cancer can be performed. 5-year survival rate of all patients with gallbladder cancer is less than 5%

Bile Duct Carcinoma: Rare tumor and about two third are located at the hepatic duct

bifurcation Risk factors: primary sclerosing cholangitis, choledochal cysts, ulcerative

colitis, hepatolithiasis, biliary-enteric anastomosis, and biliary tract infections with Clonorchis or in chronic typhoid carriers.

95% are adenocarcinoma Anatomical division:

*intrahepatic ; treated like HCC*perihilar (Klatskin tumors)*proximal*distal

Clinical manifestation: painless jaundice , Pruritus, mild right upper quadrant pain, anorexia, fatigue, and weight loss also may be present. About 10% present with cholangitis .

LFT, US, CT, PTC, ERCP, MRI Treatment:

*surgical resection*surgical bypass for biliary decompression and cholecystectomy for pt with metastasis or unresectable disease.*nonoperative biliary decompression is performed for pt with unresectable disease on diagnostic evaluation.

The greatest risk factors for recurrence after resection are the presence of positive margins and lymph node, and surgery is not recommended in recurrence.