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Biliary Tree Lecture

This document provides an overview of the biliary tract, including normal anatomy, common conditions such as gallstones, and complications. It describes the types, symptoms, investigations and treatments of various biliary diseases. These include gallstones, biliary tract cancers, acute pancreatitis, ascending cholangitis, gallstone ileus and acute acalculous cholecystitis. Ultrasound, ERCP and laparoscopic cholecystectomy for gallstones are discussed in detail.

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192 views58 pages

Biliary Tree Lecture

This document provides an overview of the biliary tract, including normal anatomy, common conditions such as gallstones, and complications. It describes the types, symptoms, investigations and treatments of various biliary diseases. These include gallstones, biliary tract cancers, acute pancreatitis, ascending cholangitis, gallstone ileus and acute acalculous cholecystitis. Ultrasound, ERCP and laparoscopic cholecystectomy for gallstones are discussed in detail.

Uploaded by

sgod34
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Biliary Tree

Dr Bina Ravi
Consultant and Associate
Professor
Surgery

Normal biliary anatomy.

Mortel K J , Ros P R AJR 2001;177:389-394

2001 by American Roentgen Ray Society

Biliary Tract
Part of the digestive
system.
:Made up of
Intra hepatic ducts
Extra hepatic ducts
Gallbladder
Common Bile Duct

Overview
Gallstones
Biliary tract tumours
Other conditions
Acute acalculous cholecystitis
Mirizzis syndrome
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Biliary tract cysts
Biliary strictures

Complications
In the gallbladder

Biliary colic
Acute and chronic cholecystitis
Empyema
Mucocoele
Carcinoma

In the bile ducts


Obstructive jaundice
Pancreatitis
Cholangitis

In the Gut
Gallstone ileus

Overview
Gallstones
Biliary tract tumours
Other conditions

Acute acalculous cholecystitis


Mirizzis syndrome
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Biliary tract cysts

Biliary strictures

Overview
Gallstones
Biliary tract tumours
Other conditions
Acute acalculous cholecystitis
Mirizzis syndrome
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Biliary tract cysts

Biliary strictures

Gallstones Frequency
most common and costly of all digestive
diseases
9% of those > 60 years
In USA, 6.3 million men and 14.2 million
women aged 20-74 years have gallbladder
disease
Incidence - 1 million new cases per year
Prevalence is 20 million cases in USA

Gall stones
Sex
Higher among females than males (lifetime risk
of 35% vs 20%, respectively)
Due to endogenous sex hormones (enhance
cholesterol secretion and increase bile cholesterol
saturation)
Progesterone may contribute by relaxing smooth
muscle and impairing gallbladder emptying.

Age
Increased age is associated with lithogenic bile
and increased rate of gallstones

Cholesterol Gall stones

Pigment stones

Gallstones Types
Two main types:
Cholesterol stones (85%):
2 subtypespure (90-100% cholesterol) or
mixed (50-90% cholesterol).
Pure stones often are solitary, whitish, and
larger than 2.5 cm in diameter.
Mixed stones usually are smaller, multiple in
number, and occur in various shapes and
colors.

Stones
Pigment stones (15%) occur in 2 subtypes
brown and black.
Brown stones are made up of calcium
bilirubinate and calcium-soaps. Bacteria
involved in formation via secretion of beta
glucuronidase and phospholipase
Black stones result when excess bilirubin
enters the bile and polymerizes into calcium
bilirubinate (patients with chronic hemolysis)

Gallstones Diverse symptoms


Abdominal pain
Aching or tightness, typically severe and located in the epigastrium
May develop suddenly, last for 15 minutes to several hours, and
then resolve suddenly
Referred pain posterior scapula or right shoulder area
Nausea and vomiting
Jaundice
Pruritus: Itching, typically worse at night
Fatigue, weight loss
Miscellaneous:
Fatty food intolerance, bloating, dyspepsia , gas

Obstructive Jaundice
Blockage of the biliary tree by gallstones
Symptoms
Pain, Jaundice, dark urine, pale stools
Signs
Jaundice.
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP, Hepatitis screen,
Coagulation screen
Ultrasound of abdomen, MRCP
Treatment
Endoscopic Retrograde CholangioPancreatogram

Ultrasound
is a procedure that uses high-frequency sound
waves
to view internal organs and produce images of
the human body.
The human ear cannot hear the sound waves
used in an ultrasound.
Advantage- Noninvasive- does not penetrate the
skin or body openings, Diagnostic- tells what
disease or condition is present
The technical term for ultrasound imaging is
sonography

Ultrasonography for Gall stones

ERCP and MRCP

CBD Stone

Sphincterotomy

Sphincterotomy

Ascending Cholangitis
Obstruction of biliary tree with bile duct infection
Symptoms
Unwell, pain, jaundice, dark urine, pale stools
Charcot triad (ie, fever, right upper quadrant pain, jaundice) occurs
in only 20-70% of cases
Signs
Sepsis (Fever, tachycardia, low BP), Jaundice.
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP, Coagulation screen
Ultrasound of abdomen
Treatment
Intravenous antibiotics
Endoscopic Retrograde CholangioPancreatogram -ERCP

Acute Pancreatitis
Acute inflammation of pancreas and other retroperitoneal tissues.

Symptoms
Severe central abdominal pain radiating to back, vomiting
Signs
Variable None to Sepsis (Fever, tachycardia, low BP),
Jaundice, acute abdomen
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP
Ultrasound of abdomen
MRCP
CT Pancreas
Treatment
Supportive
Endoscopic Retrograde CholangioPancreatogram

Gallstone ileus
Obstruction of the small bowel by a large gallstone
A stone ulcerates through the gallbladder into the duodenum and
causes obstruction at the terminal ileum
Symptoms
Small bowel obstruction (vomiting, abdominal pain, distension, nil pr)
Signs
Abdominal distension, obstructive bowel sounds.
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP, Hepatitis screen, Coagulation
screen
Plain film of abdomen Air in CBD, small bowel fluid levels and stone
Treatment
Laparotomy and removal of stone from small bowel.

Laparoscopic cholecystectomy

Open cholecystectomy

Cholecystectomy
Laparoscopic cholecystectomy
standard of care
Timing
Early vs interval operation
Patient consent
Conversion to open procedure
10%
Bleeding
Bile duct injury
Damage to other organs

Acute Acalculous Cholecystitis


Presence of an inflamed gallbladder in the absence of an obstructed
cystic or common bile duct
Typically occurs in the setting of a critically ill patient (eg, severe
burns, multiple traumas, lengthy postoperative care, prolonged
intensive care)
Accounts for 5% of cholecystectomies
Aetiology is thought to have ischemic basis, and gangrenous
gallbladder may result
Increased rate of complications and mortality
An uncommon subtype known as acute emphysematous cholecystitis
generally is caused by infection with clostridial organisms and
occlusion of the cystic artery associated with atherosclerotic vascular
disease and, often, diabetes.

Biliary Tract TumoursCholangiocarcinoma


Cancer of the Gall Bladder

Biliary Tree Neoplasms


Clinical symptoms:
Weight loss (77%)
Nausea (60%)
Anorexia (56%)
Abdominal pain (56%)
Fatigue (63%)
Pruritus (51%)

Fever (21%)
Malaise (19%)
Diarrheoa (19%)
Constipation (16%)
Abdominal fullness (16%).

Symptomatic patients usually have advanced disease, with spread to


hilar lymph nodes before obstructive jaundice occurs
Associated with a poor prognosis.

Cholangiocarcinoma
Slow growing malignancy of biliary tract which tend to
infiltrate locally and metastasize late.
Gall Bladder cancer = 6,900/yr
Bile duct cancer = 3,000/yr
Hepatocellular Ca = 15,000/yr

Cholangiocarcinoma
Diagnosis and Initial Workup

Jaundice
Weight loss, anorexia, abdominal pain, fever
US bile duct dilatation
Quadruple phase CT
MRCP/MRI
ERCP with Stent and Brush Biopsy
Percutaneous Cholangiogram with Internal Stent and
Brush Biopsy

ERCP: Distal CBD Cancer

Gallbladder Cancer
6th decade
Male:Female, 1:3
Highest prevalence in Israel,
Mexico, Chile, Japan, and
.Native American women
Risk Factors: Gallstones,
porcelain gallbladder, polyps,
chronic typhoid and some drugs

Gallbladder Cancer
Uncommon malignancy
2.5 per 100,000 population
Represents 54% of biliary tract cancers.

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