gall bladder and biliary tree


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impressive presentation on gall bladder complications.
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1 : Gall bladder and biliary tree By -Swathi Kanchan
2 : Anatomy Gall bladder is a pear shaped organ situated in a fossa on the inferior surface of the right lobe of liver. Dimensions – length : 7-10cm,width:3-5cm. Capacity - 30to60ml. Parts -: 1) Funds 2) Body 3) Neck.
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4 : Biliary tree Biliary tree consists of right and left hepatic ducts , common hepatic duct , cystic duct and the bile duct. The right and left hepatic ducts emerge at the porta hepatis from the right and left lobes of liver. The union of the right and left hepatic ducts forms the common hepatic duct. It is 3cm long and joins with the cystic duct to form the bile duct.
5 : cystic duct Its about 1-5cm in length and lumen about 1-3mm in diameter. Begins at the neck of gall bladder , runs downwards , backwards and to left and ends by joining common hepatic duct. The mucus membrane of the cystic duct forms a series of 5-12 crescentic folds spirally called spiral valve of Hesiter. {not the true valve}
6 : bile duct It’s the union of the cystic duct and the common hepatic duct near the porta hepatis. Its 7.5cm long and width of 6mm. Four parts: 1)Supraduodenal part 2)Retroduodenal part 3)Infraduodenal part 4)Intraduodenal part.
7 : Surgical Anatomy
8 : Blood supply Arteries-Cystic artery branch of right hepatic artery. -Accessory cystic artery -Gastroduodenal artery -Postero superior pancreaticoduodenal artery -Retroduodenal artery Venous drainage – Portal vein*
9 : Calot’s triangle Boundaries- Lateral- cystic duct and gall bladder Medial- common hepatic duct Above- inferior surface of the right lobe of the liver Contents- Right hepatic artery and its branches with cystic artery Cystic lymph node of lund.
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11 : Lymphatic drainage Subserosal and submucosal nodes drain into cystic lymph node of lund * NERVE SUPPLY Cystic plexus Pain from gall bladder travel along the vagus , sympathetic nerves or phrenic nerves.
12 : Function of gall bladder The gallbladder concentrates and stores hepatic bile during the fasting state and delivers bile into the duodenum in response to a meal. Capacity -30 to 60 mL but can store upto 600 ml. the net effect of concentrating bile is an increased tendency for cholesterol nucleation. gallbladder epithelial cell secretes- mucus and hydrogen ions.
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14 : compositions
15 : Bile circulation Entero hepatic circulation
16 : Congenital anomalies Bilobed gall bladder Septated Gall bladder Phrygian cap Cystic duct anomalies Gall bladder diverticula
17 : Cystic duct anomalies
18 : Cystic artery variations
19 : Extra hepatic biliary atresia Incidence-1 in 14000 live births Male and female incidences are same Occurs due to progressive destructive inflammatory process that starts at birth, intrahepatic changes also occurs resulting in biliary cirrhosis and portal hypertension
20 : TYPES- I-atresia restricted to Common Bile Duct II- atresia of Common Hepatic Duct III- atresia of right and left hepatic ducts Associated anomalies Cardiac lesion, polysplenia, situs invertus, absent vena cava and preduodenal portal vein
21 : Clinical features Jaundice at birth, deepens progressively Meconium-bile stained Stool- pale Urine-dark Biliary rickets- osteomalacia Prurities- severe Clubbing Skin xanthomas
22 : treatment Type I- directRoux-en-Y *anastmosis, but disadvantage is progressive fibrosis occurs Type II&III- kasai’s procedure */ postro-entrostomy. Prognosis is good when done before 8 weeks Post operative complications
23 : Post operative complications Baterial cholangitis Repeated hepatc fibrosis 50% of survior develop portal hypertension with 1/3rd variceal bleed Some need liver transplant
24 : Choledochal cyst It is a congenital cyst of common bile duct due to partial or complete weakness of the wall of CBD
25 : Todani classification Type1- fusiform dilation of CBD Type2-lateral saccular diverticulum of CBD Type3-dilatation of intraduodenal segment of CBD Type4- dilatation of CBD+ intrahepatic biliary dilatation Type5- multiple intrahepatic cyst/ caroli’s disease*
26 : TODANI CLASSIFICATION
27 : Caroli’s disease Also called as congenital dilation of intrahepatic ducts It is rare, non familial condition characterized by multiple irregular saccular dilatation of intrahepatic duct separated by segments of normal or stenotic ducts
28 : Clinical features Age of presentation- 1-2 years Females: male- 4:1 Abdominal distention- large cyst Slow progressive jaundice Recurrent attacks of abdominal pain and fever
29 : management Investigation Ultrasonography- abnormal cyst MRI- to define relation of the cyst CT-scan-know intrahepatic and extrahepatic dilatation ERCP-can be done
30 : Treament Type1- excision of cyst followed by Roux-en-Y hepaticojejunostomy Type2- excision of diverticulum with suturing of CBD Type3- endoscopy sphinterctomy (choledochocele) Type4-total excision is not possible due to recurrebnt cholangitis there is adhesion between cyst and portal vein ,so posterior wall of the cyst is left behind -Lilly’s technique* + surgery for intrahepatic dilatation
31 : Type 5-When limited to one lobe of liver- LOBECTOMY. Hepatectomy and liver transplant is done when multiple lobes are involved
32 : complications Recurrent cholangitis with high fever resulting in biliary cirrhosis Rupture of cyst- biliary peritonitis CBD stones Carcinomas of cyst in 25to 30% of cases
33 : trauma Injuries are Rare Occurs in penetrating and crush injuries Operative trauma are more common Signs of acute abdomen Treatment Gallbladder injuries- cholecystectomy Bileduct injuries-Roux-en-Y choledojeunostomy is done
34 : Torsion of gall bladder Rare Occurs in old patient with large Mucocele of gall bladder Signs of acute abdomen Immediate exploration is needed with cholectectomy is the only treatment
35 : Calculous Biliary Disease
36 : Gall stones or cholelithiasis Incidence -of 11% to 36% in autopsy reports
37 : Predisposing Factors for Gallstones Metabolic Obesity and Rapid weight loss Female sex and Childbearing Pregnancy Increasing age Hypomotility of gall bladder First-degree relatives
38 : Infections Drugs: ceftriaxone, estrogens,octreotide Ethnicity: Native American (Pima Indian), Scandinavian Ileal disease(crohn’s disease),resection or bypass
39 : Haemolytic anaemias Saint’s triad-gall stones, haitus hernia, diverticulosis of colon Parasites {FATTY, FERTILE,FLATULENT, FEMALE in FORTIES}
40 : pathogenesis Bile contains-85-95% of water. Cholesterol which is insoluble in water is secreted by canalicular membrane in phospholipid vesicles. Solubilitty of cholesterol depends on conc of phospholipids and bile acids. Miscelles formed by the phospholipids hold the cholesterolin s stable thermodynamic state
41 : When cholesterol in bile is increased or bile acid concentration is decreased unstable vesicles are formed from which cholesterol crystal may precipitates. Promoting factors- insufficient emptying of gall bladder, bile stasis.
42 : Stone formation is related to deconjugation of bilirubin deglucunoride by bacterial beta-glucuronidase?insoluble unconjugated bilirubinate? precipitates? static foreign bodies are formed in bile duct called”stents” The pathogenesis of cholesterol gallstones involves three stages: 1. Cholesterol supersaturation in bile 2. Crystal nucleation 3. Stone growth
43 :
44 : Types of gall stones Cholesterol stones - Constityte about 10% of all stones Seen in patients with high cholesterol due to its precipitation It is single, solitary ,occurs in aseptic bile, sometimes can be multiple Silent for years, radiolucent
45 : Brown pigment stones Rare in gall bladder, occur in bile duct Composed of calcium bilirubinate, calcium palmitate and calcium stearate+ cholesterol Occurs due to bile stasis caused due to foreign bodides, endoparasite, clonorchis sinensis and ascaris lumbricoides
46 : Mixed stones They constitue 80% of the gall stones Contains alternating layers of cholesterol and pigment with epithelial debris or vegetations from infective organisms Are multiple, small, faceted by mutual pressure
47 : Pigmented stones Incidence 5-10% Formed by insoluble bilirubin pigment polymer mixed with calcium phospate or calcium bicarbonate Seen in haemolytics and cirrhotics Black, multiple, small, irregular concreations or sludge particle
48 : complications In gall bladder Silent stones Flatulent dyspepsia Acute cholecystitis Chronic cholecystitis Mucocele, Empyema Carcinoma of gall bladder Mirizzi’s syndrome Gangrene and perforation
49 : In bile duct Obstructive jaundice Cholangitis White bile Acute pancreatitis In intestine Gall stone ileus
50 : 1) Silent stones Single, cholesterol stone- symptom less Accidently discovered on USG Left untreated
51 : 2)Flatulent dyspepsia Patient complaints of gaseous distention, intolerance to fatty food, discomfort in abdomen, heartburn, belching – one should suspect gall stones
52 : 3)Acute cholecystitis Defined as acute bacterial infection of gall bladder with or without stones. Types -Calculous - Acalculous - Acute emphysematous cholecystitis
53 : Differential diagnosis Perforated peptic ulcer Acute pancreatitis High retrocaceal appendicytis Amoebic liver abcess Lobar pneumonia basal
54 : 4)Chronic cholecystitis Recurrent attacks of cholecystitis results in fibrosed, non-functional, contracted, shrunken gall bladder, with thickened walls
55 : Clinical features- -At night,stone tends to block the cystic duct in supine position? severe pain (due to spasm) in right hypochondrium?radiate to the back / shoulder. - Vomiting-(reflux pylorospasm), restlessness, sweating, fever - Flatulent dyspepsia symptoms - Qualitaive dyspepsia - inducing vomiting - Jaundice absent
56 : Signs- - Murphy’s sign- diagnostic for cholecystitis - Boas’s sign - Upper abdominal gaurding, rigidity - Vauge mass
57 :
58 : 5)cholecystoses Chronic condition of gall bladder where there is chronic inflammatory changes and hyperplasia of all tissue elements Types- a) Cholesterosis( stawberry GB) aggregation of cholesterol crystal in submucosa yellow specks are seen on opening GB
59 : b) Cholesterol polyposis (GB polyp) polyp projects from the mucosa of the GB when >1cm, requires surgery c) Cholecystitis glandularis proliferans granulomatous thickening and hyperplasia of all layers of GB d) Diverticulosis Treatment- cholecystectomy
60 : 6)mucocele Occurs when neck of GB is obstructed Bile is absorbed and replacedby mucous Also occurs in Ca that occlude cystic duct. ‘ cholangiocarcinoma’
61 : 7)empyema GB filled with “pus” Result of mucocle becoming infected. Treatment- drainage and then cholecystectomy
62 : 8) Mirizzi’s syndrome Type 1-compression of CBD without lumen narrowing Type2- compression causing CBD lumen narrowing Type3- compression causing CBD wall necrosis Type4-cholecysto-choledochal fistula
63 : 8) Carcinoma of gall bladder Very rare, occurs due to squamous metaplasia of epithelium. Typhoid gall bladder
64 : Gallstones ileus Passage of a stone through a biliary-enteric fistula leading to a mechanical bowel obstruction Nausea, vomiting, and abdominal pain and of obstruction Tumbling obstruction Rx- proximal enterotomy , biliary-enteric fistula is repaired and cholecystectomy
65 : investigations Plain radiograph Porcelian gall bladder Lymey bile Emphymatous cholecystitis
66 :
67 : Oral cholecystography/ graham- cole test - Iopanoic acid BP is taken night before and then several X-rays are taken - It is now discarded b’coz inaccurate , depends on the absorption, excretion in the gall bladder, and conc in bile
68 : Intravenous cholangiography/ Biligram- meglumine ioglycanate It clearly defines the ducts and the gall bladder, delineating the presence of stones Contrast can cause allergic reactions
69 : Ultrasonography Its non-invasive and standard procedure Used for demonstration of biliary calculi, size of gall bladder and CBD, thickness of the wall, presence of inflammation around gall bladder, Stone sin biliary tree and carcinoma of the head of pancreas
70 :
71 : Radio-isotope scanning - Using technetiu-99m as it is secreted in bile. - Used when biliary enteric anastmosis are functioning inadequately as it will show the extent of obstruction at the anastmosis and indicate the delay in excretion
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73 : Computerised tomography (CT) Mainly used to detect the extent of invasion , metastasis, and lymphadenopathy in carcinoma gall bladder and bile duct
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75 : Magnetic resonance cholangiopancreatography (MRCP) Standard for biliary tree investigation Gives clear outline of biliary tree without a necessity of contrast Sensitive and specific diagnosis of bile duct stones
76 : Endoscopic retrograde cholangiopancreatography (ERCP) Acute cholangitis can occur due to contrast that fills dilated and obstracted gall bladder, so antibiotics are given prophylactically Used more becauses it is therapeutic as it used to remove stones and stenting of strictures
77 : MRCP ERCP
78 :
79 : Percutaneous transhepatic cholangiography (PTC) Prerequisites- exclude bleeding tendency, check BT,CT, prophylactic antibiotics are given Provides external biliary drainage via catheter in bile duct, insertion of indewelling stents. A fixed choledoscope can be passed intrahepatically to diagnoses stricture, take biopsy, and remove stones
80 : Peroperative cholangiography During cholecystectomy a catheter is placed in cystic duct and a contrast is injected into the biliarytree. It defines anatomy and exclude presence of stones in biliary tree
81 :
82 : treatment Conservative treatment followed by cholecystectomy 90% of the symptoms are relieved by conservative treatment Nasogastric aspiration and i.v fuilds administration Analgesics Broad spectrum Antibiotics Management of fever Fat free diet when switched to oral When inflammation reduces cholecystectomy done
83 : Indications for Cholecystectomy Urgent Acute cholecystitis Emphysematous cholecystitis Empyema of the gallbladder Perforation of the gallbladder Previous choledocholithiasis with endoscopic duct clearance Elective Biliary dyskinesia Chronic cholecystitis Symptomatic cholelithiasis
84 : Contraindiations to lc Absolute Unable to tolerate general anesthesia Refractory coagulopathy Suspicion of gallbladder carcinoma Relative Previous upper abdominal surgery Cholangitis Diffuse peritonitis Cirrhosis and/or portal hypertension Chronic obstructive pulmonary disease Cholecystoenteric fistula Morbid obesity Pregnancy
85 : Indications of open cholecystectomy Poor pulmonary or cardiac reserve Suspected or known gallbladder cancer Cirrhosis and portal hypertension Third-trimester pregnancy
86 : Advantages and Disadvantages of LC Compared to OC
87 : Obstructive jaundice
88 : aetilogy Causes in the lumen Stones in the common bile duct Ova, cyst, ascaris, clinorchis worms Hydatid cyst of biliary tree Stones in the pancreatic duct Causes in the wall Periampullary carcinoma Choledochal cyst
89 : Stenosis of sphincter of oddi Klatskin’s tumor Bile duct stricture Causes outside the wall Carcinoma head of pancreas Chronic pancreatitis Lymph nodes at porta hepatis obstructing bile tree
90 : SYMPTOMS asymtomatic Charcot’s triad due to cholangitis? pain ,jaundice and fever SIGNS Tenderness in right hypochondrium and epigastrium Couurvoisier’s law* Reynold’s pentad of acute obstructive jaundice
91 : investigations Hb%, DC, TC, BT, CT , PT, Urine- urobilinogen USG abdomen CT-scan Barium meal and Endoscopy PTC MRCP/ ERCP
92 : treatment Transduodenal sphincterotomy Choledochoduodenostomy laparoscopic Choledochoduodenostomy Cholecystectomy+ choledocholithotomy+ Choledochoduodenostomy
93 : Biliary strictures
94 :
95 : aetiology Postoperative Strictures Laparoscopic cholecystectomy Open cholecystectomy Common bile duct exploration Injury at other operative procedures- Gastrectomy Hepatic resection Portacaval shunt Biliary-enteric anastomotic stricture Blunt or penetrating trauma
96 : Post inflammatory - Primary sclerosing cholangitis Chronic pancreatitis Cholelithiasis and choledocholithiasis Parasitic disease-ascaris, clonorchis Congenital biliary abnormality Cholangiocarcinoma
97 : Clinical feature H/O Cholecystectomy Slow Progressive painless jaundice Hepatomegaly Recurrent cholangitis USG,ERCP,MRCP,PTC INVESTIGATION
98 : TREATMENT T-Tube on endoscopic stent Choledochojejunostomy or hepaticojejunostomy
99 :
100 : Sclerosing cholangitis It is characterized by development of multiple strictures and dilatation of CBD with features of fibrous thickening. Types- primary and secondary Complications- obstruction, biliary cirrhosis, cholangiocarcinoma Diagnosis-USG, MRCP, ERCP Treatment- Stenting
101 : Gall bladder carcinoma Disorder of gallbladder: Cholelithiasis in 64-98% Porcelain gallbladder (in 4-60%): Chronic cholecystitis Gallbladder polyp: a polyp >2 cm Disorder of bile ducts: Primary sclerosing cholangitis Congenital biliary anomalies Inflammatory bowel disease Familial polyposis coli
102 : Histology 85% cases- adenocarcinoma Undifferentiated and squamous Commonly nodular, infiltrates the entire gall bladder and adjucent structures
103 : Clinical feature Significant weight loss, jaundice, hard irregular mass in upper right quadrant. Obstructive jaundice, ascitis, bleeding are late features CA19-9 is elevated USG, and USG guided FNAC CT-scan for staging INVESTIGATION
104 : Replacement of gallbladder by mass (gallbladder replaced by mass with irregular margins + heterogeneous echotexture (= tumor necrosis)
105 : TREATMENT Mucosa alone- Cholecystectomy Wall involved- extended Cholecystectomy Radiation- rarely any benefits Chemotherapy- 5FU, Mitomycin C, Doxorubicin 5 Year survival is very poor. Highly aggressive, early spread by lymphatic , blood, neural and intraperitoneal routes PROGNOSIS
106 : bibliography Chamberlain__Blumgart_-_Hepatobiliary_Surgery__2002_ MAINGOT ABD SURGERY Sabiston Textbook of Surgery, 18th edition Manipal text book of surgery-3rd edition Bailey and love’s 24th edition Principles of surgery schwartz-7th edition
107 : THANK YOU

 

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