Biliary Diseases

Biliary

Diseases

Dr. Wu Yang Dept. of Surgery The First Affiliated Hospital of Zhengzhou University

Anatomy Extrahepatic biliary tree  The extrahepatic bile duct system consists of the hepatic ducts, common hepatic duct, gallbladder, cystic duct and common bile duct.

Anatomy Extrahepatic biliary tree  The common bile duct is lateral to the common hepatic artery and anterior to the portal vein. The distal one-third of the common bile duct passes behind the pancreas to the ampulla of Vater, also called the papilla.  The sphincter of Oddi surrounds the common bile duct as it traverses the ampulla of Vater and controls bile flow.

Anatomy Gallbladder  The gallbladder is a pear-shaped organ adherent to the undersurface of the liver in a groove separating the right and left lobes.

Anatomy Gallbladder  Arterial supply : The gallbladder is supplied by the cystic artery, which is usually (95% of the time) a branch of the right hepatic artery that passes behind the cystic duct.  Venous return is via cystic veins to the portal vein and small veins that drain directly into the liver.

Physiology  Bile is produced by the liver and transported via the extrahepatic ducts to the gallbladder where it is concentrated and released in response to humoral and neural control.  Hepatic production of bile is under neural and humoral control. Approximately 600ml of bile are produced daily.

Physiology  Functions of the gallbladder include: (1)Storage of bile. (2)Concentration of bile. (3)Release of bile.

Diagnosis examination of the biliary disease  B-ultrasound is both sensitive and specific in detecting biliary diseases, such as gallstones, tumor, cystic lesion and obstructive jaundice, and its major advantages are that it is rapid, inexpensive, noninvasive and free risk.

Diagnosis examination of the biliary disease  Plain abdominal films demonstrate the 15% of gallstones that are radiopaque.  Oral cholecystography (OCG) is an alternative method for demonstrating biliary calculi in patients with an equivocal gallbladder sonogram. It is rarely used today.  Intravenous cholangiography (IVC) is no longer performed.

Diagnosis examination of the biliary disease  Percutaneous transhepatic cholangiography(PTC) is useful in evaluating a jaundiced patient. It can localize the site of the obstruction and also allows the placement of biliary drainage catheters.  Endoscopic retrograde cholangiopancreatography (ERCP) is useful in evaluating a patient with biliary disease. The procedure is both diagnostic and therapeutic.

Diagnosis examination of the biliary disease  Hepatobiliary iminodiacetic acid (HIDA) scan make use of a gamma-ray-emitting radioisotope (i.e. 99m Tc) attached to a variety of lidocaine analogs bound to iminodiacetic acid, which is excreted in the bile.

Diagnosis examination of the biliary disease  CT and MRI can be applied for the same situations as B-US but provides little advantage and is more expensive.  Operative and postoperative direct cholangiography. This procedure is frequently performed in the operating room at the time of exploration of biliary tract.

Gallstone & Chronic Cholecystitis

Types of stones  Cholesterol stones is frequently single and light in weight. About 75% of all gallstones in China are the cholesterol type and 80% of which are in the gallbladder.  Pigment stones are black to dark brown. About 37% of all gallstones in China are the pigment type and 75% of which are in bile duct.  Mixed stones are usually brown and multiple. About 6% of all gallstones in China are the mixed type, 60% of which are in the

Symptoms and signs  Biliary colic, the most characteristic symptom, is caused by transient gallstone obstruction of the cystic duct. Nausea and vomiting may accompany the pain.  During an attack, there may be tenderness in the right upper quadrant, and rarely, the gallbladder is palpable.

Laboratory findings  An oral cholecystogram will usually show stones in the gallbladder. Ultrasound scans are as sensitive and specific as oral cholecystogram, and they may be used as an alternative method of diagnosing gallbladder stones.

Differential diagnosis  Duodenal ulcer  Pancreatitis  Myocardial infarction  Gastric tumors

Treatment  Surgical treatment, cholecystectomy, should be performed in most patients with symptoms.  Recently, as the technique of laparoscopic cholecystectomy has been widely spreaded, laparoscopic cholecystectomy is the best choice for most patients.

Treatment The decision whether to explore the duct at the time of cholecystectomy can be made according to the following:  The absolute indications are preoperative demonstration of stone by X-ray and ultrasound, preoperative history of cholangitis with jaundice, and a positive operative cholangiogram.

Treatment The decision whether to explore the duct at the time of cholecystectomy can be made according to the following:  The relative indications are mild jaundice without fever and chills, small stone, and a dilated duct.

Treatment  Other new methods are used to treat gallstone and chronic cholecystitis, such as, chemical cholecystectomy, extracorporeal shock wave lithotripsy (ESWL) and dissolving gallstone or taking off gallstone by percutaneous transhepatic paracentosis, the effection of which is not certainty.

Acute Cholecystitis

Symptoms and signs  The first symptom is abdominal pain in the upper quadrant, sometimes associated with referred pain in the region of the right scapula in 75% of cases.  Nausea and vomiting are present in about half patients, but the vomiting is rarely severe. Mild icterus occurs in 10% of cases. The temperature usually ranges from 38 to 38.5℃.

Symptoms and signs  Right upper quadrant tenderness is present, and about a third of patients the gallbladder is palpable.  If instructed to breath deeply during palpation in the right subcostal region, the patient experiences accentuated tenderness and sudden inspiratory arrest (Murphy’s sign).

Laboratory findings  The leukocyte count is usually elevated to 1215 thousand/uL.  A mild elevation of the serum bilirubin (in the range of 2-4mg/dL) is common.

Imaging studies  A plain X-ray of the abdomen may occasionally show an enlarged gallbladder shadow.  Ultrasound scans show gallstones, sludge, and thickening of the gallbladder wall.

Differential diagnosis  Acute peptic ulcer with or without perforation  Acute pancreatitis  Acute appendicitis  Acute viral hepatitis  Severe pneumonitis in the right lung or acute myocardial infarction

Complication  The major complications of acute cholecytitis are empyema, gangrene, and perforation.

Treatment  Intravenous fluids should be given to correct dehydration and electrolyte imbalance.  A nasogastric tube should be inserted.  Antibiotic should be given. These methods are suitable for preoperative patients and expectant management.

Treatment

 Cholecystectomy is the preferable operation in acute cholecystitis and can be safety performed in about 90% of patients.  There are two approaches to the timing of surgery:(1) Immediate surgery, that is, with in 72 hours of the onset of symptoms. (2) Delayed surgery, that is, after recovery from the acute attack with intravenous fluids and antibiotics. Surgery should be performed approximately 6 weeks after the acute inflammation has resolved.

Treatment  Operative cholangiography should be performed in most cases and the common bile duct explored if appropriate indications are present.

Cholangitis

Etiology  Bacterial infection of the biliary ducts.  The principal causes are choledocholithiasis ascariasis, biliary stricture, and neoplasm.  Less common cause are chronic pancreatitis, ampullary stenosis, duodenal diverticulum, congenital cyst, and parasitic invasion.

Clinical findings  The symptoms of cholangitis (sometimes referred to as Charcot’s triad) are biliary colic, jaundice, and chills and fever. Although a complete triad is present in only 70% of cases.  Laboratory findings include leukocytosis and elevated serum bilirubin and alkaline phosphatase levels.

Clinical findings  Early in an attack, an ultrasound scan will often give useful diagnostic information. Further work-up (PTC, ERCP etc.) can proceed later after the acute manifestations are brought under control.  Direct cholangiography is dangerous during active cholangitis.

Clinical findings  Acute Obstructive Supperative Cholangitis (AOSC)  Acute Cholangitis of Severe Type (ACST).  The diagnosis pentad of ACST consists of abdominal pain, jaundice, high fever and chills, mental confusion or lethargy, and shock.

Treatment  Most cases of cholangitis can be controlled with intravenous antibiotic which include the drugs of anti-anaerobes.

Treatment  For patients with severe cholangitis, the bile duct must be promptly decompressed. In most instances. Laparotomy and common duct exploration are required.

Treatment  Cholangitis accompanying neoplastic obstruction may be managed by insertion of a transhepatic drainage catheter into the bile duct, percutaneous transhepatic cholangiodrainage (PTCD).  Patients with choledocholithiasis may be treated by emergency endoscopic sphincterotomy (EST) or endoscopic papillectomy (EPT).

Treatment  If the patients condition is precarious during laparotomy, the septic process can be halted by inserting a decompressing T tube and concluding the procedure. A second operation will then be necessary when the patient has recovered.

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