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1、Diseases of Biliary Tract,Anatomy and Pathophysiology Diagnostic techniques Stones of Biliary tract Infection of Biliary tract Biliary Tumors,Anatomhy of biliary tract,Intrahepatic bile duct: Biliary tract extrahepatic bile duct: Left hepatic duct Right hepatic duct,Common hepatic common bile duct,G
2、allbladder cystic duct,Calot trangle:Liver : upper border Common hepatic duct diameter =0.4-0.6cmCystic duct lower border length 3cm,The cystic artery runs in this triangle,Common bile duct,Diameter 0.6-0.8cm 1cm abnormalLength 7-9cmsupraduodenal segmentretro duodenal segmentretro pancreatic segment
3、duodenal wall segment,The papilla of Vater,pancreatic sphincter common sphincter biliary sphincter,The sphincter of oddi,Gallbladder,Length:8-12cmwidth:3-5cm variablesize:40-60mlshape: pearshaped fundus body the neck,The physiological function of Gallbladder,Store and concentrate hepatic bile Secret
4、ion of water and electrolytesEmpty bile into the common bile duct,Bile secretion,Hepatocytes secrete bile 800-1200mlBile composition: bile acids, bile pigments,cholesterol, phospholipids,inorganic electrolytes ,water,Diagnostic techniques,Abdominal ultrasonography,1.untraumal2.low cost3.flexibicity4
5、.first choice,Abdominal ultrasonography,Diagnose biliary stoneIdentify the cause of jaundice PTCD by -ultrasound guidedDoppler blood flow,Percutaneous Transhepatic Cholangiography,Show the dilated bile duct above obstruction siteDrainage of bile by PTCDTraumatic methods,Complications,Bile leakageHae
6、morrhage Sepsis,Endoscopic Retrograde Cholangiopancreatography ERCP,Directly observe papilla lesion and biopsyShow the entire biliary tractShow the biliary tract proximal to obstruction site Drain bile,Complications,acute pancreatitis postprocedure cholangitisOther complications,Operative and postop
7、erative direct cholangiography,Show the entire biliary tractDisplay the stone and stenosisTube cholangiography done before biliary drainge with drawn,CT and MRI,High resolutionMore accurateExpensiveShow the stone ,tumor, dilated ductMRCP show the entire biliary tree,Plain radiographs,show radio-opaq
8、ue calcuiair in the biliary treecalcification of the gallbladder,Oral cholecystography,Show the function of gallbladder Show the stones polyps and tumor contraindicationsSensitivity to iodineLiver and renal disease pregnancy,Choledochoscope,Intraoperative use:Explore the CBD stone Tumor,stenosisRedu
9、ce retained stone rate Remove stone biopsy,Other examination,Intravenous cholangiogramAngiographyIsotopic studies,How to choose,1.B ultrasound2.MRCP and CT3.ERCP and PTC,Infections of biliary tract,1.Cholecystitis2.Cholangitis obstruction stone infection core,Acute cholecystitis,Acute calculous chol
10、ecystitis 95%Acute acalculous cholecystitis 5%,Etiology,1.Cystic duct obstructed by a gallstone impacting in Hartmanns pouch2.Bacteial infection of the stagnant bile Aerobic enteric-derived organisms Escherichia coli, klebsiella pneumoniae, streptococcus faecalis gallstone impaction mucosal damage L
11、ecithin lysolecithin phospholipases,Pathology,Cystic duct obstruction gallbladder Edema suppurate gangrene pericholecystic abscess perforation Cholecyst-enteric fitula Peritonitis intestinal obstruction Acute chronic atrophy,Clinical features,1.Sudden and severe pain mainly in the right hypochondriu
12、m radiate to the right scapular region fatty foods2.Nausea and vomiting3.Fever4.Tenderness and rigidity in the right upper quadrant5.Positive Murphys sign6.Jaundice7.A palpable gallbladder mass (1/4),Mirrizzis Syndrome,The common hepatic is obstructed due to stones impacted in or extruded from Hartm
13、ans pouch of the gallbldder or the cystic duct.Cholecystobiliary or cholecystoenteric fistulae are common complication.,Differential Diagnsis,Perforated peptic ulcerAcute pancreatitisRetrocaecel appendicitisRight low lobe pneumoniaHepatic abscessAcute viral hepatitis,Laboratory Test,Leukocytosis in
14、the range of l0000-15000Serum bilirubin or normalAlkaline phosphatase or normalTransaminase or normalSerum amylase or normal,Treatment,Conservative treatment1.Intravenons fluid and electrolyte replacement2.Nasogastric suction3.Systemic antibiotics4.Parenteral analgesia5.fast,Surgical Treatment,1.Att
15、ack within 48-72 h of diagnosis2.Deterioration in patients general condition3.Complications are present Perforation Peritonitis Acute obstructive suppurative cholangitis Acute pancreatitis,Surgical methods,Open cholecystectomyLaparoscopic cholecystectomy,Acalculous Cholecystitis,Complications of maj
16、or trauma, burns and sepsisComplications of parenteral feedingNot easy to make a clear diagnosisNeed prompt surgical interventionover 70% with atheroscclerotic cardiovascular diseaseBiliary scintiscanning helpful for diagnosis,Acute cholangitis and acute obstructive suppurative cholangitis,Etiology,
17、Choledocholithiasis 80%Benign stricturesObstructed biliary anastomotic stricturesMalignant obstructionAscarid,Pathophysiology,Biliary obstruction intraductal pressure 20mH20biliary stagnation bacteremia,bacteria proliferationreflux into hepatic veins and perihepatic lymphaticssystemic signs of chola
18、ngitis,Clinical presentation,Fever and chillJaundice charcots triad)Right upper-quadrant painHypotensionMental obtundation Reynolds,Physical examination,TendernessAbdominal guardingSwollen gallbladderHepatomegaly,Laboratory Test,LeukocytosisHyperbilirubinemiaAlkaline phosphatase Aminotransferases Le
19、ukopeniaProfound gram-negative sepsis and immunosuppression lmmunosuppressionSerum amylase ,Radiological Evaluation,UltrasonographyCTMRCPPTC ERCP,General support,Cessation of oral intake ,fastAntibiotics Keep liquid and electrolyte balanceIntravenous fluids,Treatment,Biliary decompression,Percutanec
20、us transhepatic biliary drainageEndoscopic drainage papillotomy and placement of a nasobiliary tubeOperative decompressionCBD exploration and T tube drainage,Cholelithiasis,Classification of gallstone,Cholesterol stones: light brown, smooth or faceted, single or multiple cross-section laminated/crys
21、tallineappearancePigment stone: small, black or brown, irregular cross- section a morphous/crystallineMixed stone,Location,Gallbladder stonesCommon bile duct stoneIntrahepatic bile duct stone,Extrahepatic bile duct stone,Clinical presentation,Dyspepsia Right upper quadrant abdominal pain in associat
22、ion with or shortly after a heavy or fatty mealA feeling of gaseous bloatingBiliary colic,Physical examination,Usually normalChronic hydrops of gallbladdermassSome times tenderness,Radiological Test,A plain abdominal roentgenogramOral cholecystography Ultrasonography the initial diagnostic studyCTMR
23、I,Complications,Acute cholecystitisJaundiceCholangitisPancreatitisMtrizzi syndromecancer,Surgical Indication,Accelerating symptomsPoor visualization or non-visulization on oral cholecystographyDiabetasPorcelain gallbladderstone2-3cm,Laparoscopic Cholecystectomy,Indications:Chronic, uncomplicated cho
24、lecystitisCholelithiasisGB polypsBenefits:Reducing hospitalization and associated costsDecreasing painImproved cosmetic outcomeReduced post-operative recovery,Other treatment,Dietary therapy a low-fat diet, avoidance of heavy mealsAntispasmodic medicationChenodeoxycholic acid and ursodeoxycholic aci
25、d Extracorporeal shock wave lithotripsy,Carcinoma of Gallbladder,IncidenceThe commonest form of biliary tract malignancy the fifth most common gastrointestinal cancerEncountered in 1-2% of cholecystectomy specimensPredominantly occurs in elderly femalesOver 90% of patients are were 50 years of ageTh
26、e peak age of incidence is 70-75% yearsA male to female ratio of 1:3,Etiology,CholelithiasisBenign adenomaPolypoid gallbladder lesions (polyp greater than 1cm)Anomalous pancreaticbiliary junctionChronic inflammatory bowel disease,Pathology,Adenocarcinoma 80% carcinoid tumoursUndifferentiated carcino
27、ma 6% sarcomaSquamous carcinoma 3% melanomaMixed tumor or acanthoma 1% lymphoma,UICC, stage: mucosa and muscular stage: total layer of the gallbladder stage: invasion into liver 2cm B stage: spread to distal organ and lymph node,Clinical Features,The diagnosis of gallbladder cancer is usually made w
28、hen the disease is well advanced. There are no characteristic features at an early and curative stage,Laboratory invesitigations,Cant provide diagnostic informationProvide some helpful cluesAnaemiaSerum alkaline phosphatase CEACA19-9CA125 ,Radiological Diagnosis,Plain abdominal radiographyOral chole
29、cystographyPTCERCPCTMRI MRCP,Other methods for diagnosis,FNACultrasound,Treatment,UICC UICC UICC IVAUICC B,cholecystectomy,Curative excision procednre,extended curative excision,Palliative proceduresBilliary or duodenal bypass,Prognosis,Piehler and crichlow Report of 6000 patients : 1 year survivial rate 11.8% 5 year survival rate 4.1%,Palliative procedure,1.Excra bile drainge T tube U tube PTCD2.Intra-drainge Biliary-enteric bypass or intubation Non-operative endoprosthetic insertion,Thank you,
