hepatobiliary pdf - د. سمير الصفار

fourth stage

Surgery

Lec-1

Dr.Samer ALsaffar

18/10/2015

The gall bladder and Bile duct

The Gall bladder ( Surgical anatomy and physilogy):

The gall bladder is:



Pear shaped, 7.5 – 12 cm long



30 to 50 mL capacity



Fundus, body, neck, and infundibulum

The cystic duct:



3cm in length



1-3 mm in diameter



Valves of Heister

a RHD

b LHD
c CHD

d PV

e HAP

f GDA

h CBD

l CD

k Neck GB

j Body

i fundus

m CA

The common hepatic duct:



2.5 cm in length



Union of R & L hepatic ducts

The common bile duct:



7.5cm in length



Union of cystic and CHD



4 parts

Blood supply of gall bladder:



The cystic artery a branch of R hepatic artery



Accessory CA from GD art.



In 15% RHA anterior to CHD



Toutuous RHA and short CA, Caterpillar turn or Moynihan’s hump.

Lymphatics:



Subserosal and submucus lymphatics to the cystic LN of Lund hilum of liver coeliac LN



Subserosal lymphatics to subcapsular lymphatics of liver



Bile:



40ml hour



97% water



Bile salts 1-2%, bile pigments 1%, cholestrol, and fatty acids

Functions of gall bladder:



Reservoir



Concentration of bile, 5 - 10 times



Secretion of mucus– 20ml/day

Investigation of the Biliary tract :



Ultrasound : stones and size



Plain radiograph : calcification



MRCP : anatomy and stones



CT scan : cancer and anatomy



HIDA scan : fucntion



Ultrasonography



Non-invasive



Standard initial imaging for patient suspected to have
a gall stone and in

jaundiced patients

Ultrasonography can demonstrate :



Gall stones



GB size, thickness of its wall, presence of inflammation around it, pericystic edema



Size of CBD, occasionally stones in it.



Tumour of pancreas.

Endoscopic ultrasound <<Stone and obstruction of lower CBD

 Plain radiography :



Radiopaque gall stones in 10%



Prolactine GB , calcified GB , 25% CA



Limey bile



Gas in the wall , emphysematous cholecystitis



Gas in the biliary tree :



Endoscopic sphincterotomy



Surgical bilio-enteric anastomosis



Internal biliary fistula

 Oral cholecystography



Once was of first choice in the dx of gall stones

 Intravenous cholangiography

 Radioisotope scanning:



Tc 99m labelled with derivatives of iminodiactic acid
(HIDA, PIPIDA), that are excreted in the bile.



Dx of acute cholecystitis GB not visulized



Bile Leakage, assessment

Dimethyl iminodiacetic acid (HIDA) scan.



Computerized Tomography scan :



limited usefulness in investigating the biliary tree



Only when there is a possibility of cancer of gall bladder or bile ducts



Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice

Computed tomography scan demonstrating a gallstone within the gall bladder

(arrowed).

 Magnetic Resonance Cholangiopancreatograph: (MRCP)



Standard for biliary tree investigation



Contrast is not

Magnetic resonance cholangio-pancreatography crosssectional image demonstrating a hilar mass

(thick arrow) and gallstones (thin arrow)

 ENDOSCOPIC RETROGRADE CHOLANGIOPANREATOGRAPHY (ERCP)



Side veiwing endoscopie



Cannulation of ampulla of Vater



Injection of contrast to visualize the bile ducts



Also bile can be taken for cytological and microbiological tests



Brushings from strictures

 PERCUTANEOUS TRANSHEPATIC CHOLANGOGRAPHY (PTC):



Preparation :



Normal PT



Antibiotics



DX and therapy :



Visulization of biliary tree



Placement of : catheter

Stenting
Choledochoscope

Peroperative cholangiography

Operative biliary endoscopy
(choledochoscopy)

DISEASES OF GALL BLADDER AND BILIARY PASSAGES



Congenital



Acquired

 CONGENITAL ABNORMALITIES OF THE GB AND BILIARY TREE



Absence of GB



The phrygian cap



Floating GB



Double GB



Absence of CD



Low insertion of CD



An accessory cholecystohepatic duct ( small ducts of Luschka)

 EXTRAHEPATIC BILIARY ATRESIA

Aetiology and pathology:



1 per 14000 live birth



Equal and female



If untreated the child dies before the age of 3 years



20% associated anomalies, cardiac, situs inversus, absent vena cava

Classification:



Type I : atresia restricted to the CBD



Type II :atresia of the CHD



Type III : atresia of the right and left HD

Clinical features:



1/3 jaundiced at birth



All jaundiced by the end of the week



Meconium little bile stained



Pale stool and dark urine



Osteomalacia



Pruritis



Clubbing skin xanthoma

Differential Diagnosis



Alpha 1 antitrypsin deficiency



Choledochal cyst



Inspissated bile syndrome



Neonatal hepatitis



Traetment:



Roux-en Y anastomosis



Kasai procedure

CHOLEDOCHAL CYST



Weaknes of part or whole of the wall of the CBD



Anomalous junction of the biliary pancreatic junction:



High amylase



Repeated attacks of panreatitis

Clinical features : premalignant



At any age, Attacks of : jaundice , cholangitis



Swelling in the right hypochondrium



US –abnormal cyst



MRI– clear anatomy

Treatment: Radical excision of the cyst and reconstruction of the biliary tract using Roux en
Y jejunal loop

TRAUMA



Iatrogenic



Accidental, is rare, penetrating or crushing



Presentation of acute abdomen

Treatment:



GB—cholecystectomy



Bile ducts:



Drainage using T tube



Roux-en-Y

GALL STONES (CHOLELITHIASIS)



Most common pathology



Affecting about 10–15% of the adult population.



Mostly asymptomatic in >80%



Cholecystectomy is one of the most common operations performed by general
surgeons

AETIOLOGY OF GALLSTONES :



Metabolic



Infective



Stasis

RISK FACTORS ASSOCIATED WITH FORMATION OF GALL STONES





Age > 50 years



Female sex (twice risk in men)



Genetic or ethnic variation



High fat, low fibre diet



Obesity



Pregnancy (risk increases with number of pregnancies)



Hyperlipidaemia



Bile salt loss (ileal disease or resection)



Diabetes mellitus



Cystic fibrosis



Antihyperlipidaemic drugs (clofibrate)



Gallbladder dysmotility



Prolonged fasting



Total parenteral nutrition

TYPES OF GALL STONES:



Cholesterol



Pigment stones



Mixed stones

 CHOLESTEROL STONES

Contain mainly pure cholesterol

•Mostly single ( cholesterol solitaire)
•Obesity,
•high-calorie diets
•certain medications

 PIGMENT STONES:



Black stones



Contents: insoluble bilirubin pigment polymer mixed with calcium phosphate
and calcium bicarbonate and < 30% cholesterol



Hemolysis : Hereditary spherocytosis
Sickle cell anaemia



Brown stones:



calcium bilirubinate, calcium palmitate and calcium stearate, as well as
cholesterol



form in the bile duct and are related to bile stasis and infected bile.

 MIXED STONES:



Cholesterol major component



Ca bilirubinate, Ca palmitate, Ca carbonate, Ca phosphate, and proteins



Account for 90%



Multiple



Faceted

INCIDENCE OF GALL STONES



Female



Fat



Fertile



Fifty



Flatulent

CAUSAL FACTORS IN GALL STONE FORMATION



Metabolic



Infective



Stasis

 Metabolic:

Cholesterol

Bile salt

Phospholipid



High cholesterol “Supersaturated” or “lithogenic” bile



Aging



Female contraceptives



Obesity



Clofibrate



Interruption of enterohepatic circulation of bile salts



lead to low bile salts.



 Infection:



Unclear



Radiolucent centre of stone mucus plug as nidus for stone formation



B glucuronidase unconjugated insoluble bilirubin.

 Bile stasis:



Decrease contractility of gall bladder



Estrogen in pregnancy



Parenteral nutrition



Truncal vagatomy

EFFECTS AND COMPLICATIONS OF GALL STONES :



In the GB:



Silent up to 80%



Chronic cholecystitis



Acute cholecystitis



Gangrene



Perforation



Empyema



Mucocele



carcinoma



In the bile ducts:



Obstructive jaundice



Cholangitis



Acute panreatitis



In the intestine:



Acute intestinal obstruction ( gall stone ileus)

ACUTE CHOLECYSTITIS :



Right hypochondrial pain



Radiate to back, chest



Referred right shoulder pain



Occ. Start at epigastrium or left subcostal



Start at night



Other symptoms : Dyspeptic symptoms , Vomiting , fever

ACUTE CHOLECYSTITIS

BILIARY COLIC

1.  Several hours to few days
2.  Fever
3.  leucocytosis

1.  Few minutes to few hours
2.  No fever
3.  No Leucocytosis

DIFFERENTIAL DX



Common:



Appendicitis



Perforated peptic ulcer



Acute pancreatitis



Uncommon:



Acute pyelonephritis



Pneumonia, right lower lobe

DIAGNOSIS



Physical examination:



Murphy’s sign



Palpable tender gall bladder.



Ultrasound



Liver function test : Bilirubin



WBC



CXR pneumonia ,air under diaphragm



ECG



GUE and urine culture

TREATMENT



Conservative



Urgent cholecystectomy



Early cholecystectomy



Elective cholecystectomy

CONSERVATIVE TREATMENT



NPO with IV fluids



NG tube



Analgesia



Antibiotics



Follow up



90% respond to conservative treatment.



Subsequent treatment:



Early cholecystectomy next op. list 5-7 days



Elective cholecystectomy 6 weeks

When to stop conservative treatment : << URGENT

CHOLECYSTECTOMY

- When there is increasing in :



pain and tenderness



pulse and temperature



leucocytosis

Conservative treatment is not advised

<< Uncertinity about the dx

EMPYEMA OF THE GALL BLADDER :



Pus filled gall bladder



A sequel to acute cholecystitis or Mucocele



Treatment:



Cholecystectomy



Disturbed anatomy---- drainage (Cholecystostomy) later cholecystectomy

Acalculous cholecystitis



Acute or chronic



Dx by: Radioisotope in acute cholecystitis



Acute acalculous can occur in patients after major surgery, trauma, burn

CHOLECYSTECTOMY :

 Indications



Symptomatic cholelithiasis



Trauma



Part of other operation -----Whipple’s procedure



Neoplasia of Gall Bladder

 Preparation for operation



Full blood count



Renal profile and liver function tests



Prothrombin time



Chest X-ray and electrocardiogram (if over 45 years or medically indicated)



Antibiotic prophylaxis



Deep vein thrombosis prophylaxis



Informed consent

 procedure



Laparoscopic cholecystectomy (Gold standard )



Open colecystectomy




COMPLICATIONS OF CHOLECYSTECTOMY



Inraoperative:



Biliary injuries



Iatrogenic injuries to near by organs



Bleeding.



Early postoperative:



CBD obstruction------------Jaundice



CBD injury --------------Collection , Biliary peritonitis



Bleeding ---------------Local hematoma, Shock



Missed stone in CBD

COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY



access complications



bile duct injuries

Biliary injury:



Bile leakage



Local collection or excessive bile drainage if drain is present



Biliary peritonitis

PAIN AFTER CHOLECYSTECTOMY
Causes:



Incorrect preoperative diagnosis - for example, irritable bowel syndrome, peptic
ulcer, gastro.oesophageal reflux



Retained stone in the CBD or CD stump



Iatrogenic biliary injury : stricture of common bile duct



Papillary stenosis or dysfunctional sphincter of Oddi

ALTERNATIVE TREATMENT



Criteria for non-surgical treatment of gall stones



Cholesterol stones < 20 mm in diameter



Fewer than 4 stones



Functioning gall bladder



Patent cystic duct



Mild symptoms

SUMMARY POINTS :



Gall stones are the commonest cause for emergency hospital admission with
abdominal pain



Laparoscopic cholecystectomy has become the treatment of choice for gallbladder
stones



Risk of bile duct injury with laparoscopic cholecystectomy is around 0.2%



Asymptomatic gall stones do not require treatment



Cholangitis requires urgent treatment with antibiotics and biliary decompression by
endoscopic retrograde cholangiopancreatography

OBSTRUCTIVE JAUNDICE :

Attributed to CBD obstruction



Stone in CBD



Carcinoma of CBD



Tumor of head of pancreas



FB inside the CBD



Paracitic

MANAGEMENT OF CBD OBSTRUCDTION
Following cholecystectomy



Jaundice ---- immediate action



Ultrasound :



Dilatation



Collection at porta hepatis



Biochemical investigations

Immediate MRCP:



If stone detected endoscopic extraction(ERCP)



If CBD obstruction --- surgery



If bile leakage :



Percutaneous drainage



Stenting

STONES IN THE CBD



Several years after cholecystectomy



CBD infestation by Ascaris lumbricoides or clinorchis sinensis

Clinical presentation:



Asymptomatic



Jaundice



Cholangitis ( Charcoat triad )



Fever and rigor



Jaundice



Pain

Signs : Tenderness upper abdomen and RUQ

Management:





Ultrasound



Liver function test



Liver biopsy



MRCP



ERCP



Resuscitaion



Rehydration



Broad spectrum Antibiotics



Attention to clotting Vit K



Relief of obstruction



Endoscopic sphincterotomy : extraction of stone by Dormia basket or balloon
catheter



Some times stent placement



Percutaneous transhepatic cholangiography:



then drainage



Percutaneous choledochoscopy



Surgery: Choledochotomy

Indication for CHOLEDOCHOTOMY



Preoperative:



Stone in CBD



Dilatation of CBD



History of jaundice



Peroperative:



Palpable stone



Dilated CBD

STRICTURE OF CBD :



Benign stricture: 80% postoperative and 20% inflammatory



Malignant stricture

 CAUSES OF BENIGN BILIARY STRICTURE



Congenital



Biliary atresia



Bile duct injury at surgery



Cholecystectomy



Choledochotomy



Gastrectomy



Hepatic resection



Transplantation



Inflammatory



Stones



Cholangitis



Parasitic



Pancreatitis



Sclerosing cholangitis



Radiotherapy



Trauma



Idiopathic

 POSTOPERATIVE STRICTURE



Technical error during cholecystectomy



Blind control of bleeding in Calot triangle



Failure to identify the anatomy at Calot triangle : acute inflammation



Mirizzi syndrome



Short or absent cystic duct



Anatomical anomalies



CBD obstruction



Deeping jaundice



Partial obstruction delayed jaundice

Radiological investigations:



Ultrasound



MRCP



Cholangiography



Through tube



PTC



ERCP

Treatment



Supportive



Relief of obstruction : temporary



ERCP stenting



Transhepatic external drainage and stenting



For strictures of recent onsent:



ERCP --- guide wire---- balloon dilatation---stent placement



Definite relief of obstruction: Choledocho-jejunostomy

Late complications:



CBD stricture



Stone in CBD



Post cholecystectomy pain syndrome



Wrong preoperative diagnosis



Complication of cholecystectomy

PARASITIC INFESTATION OF THE BILIARYBILIARY TRACT



 Ascariasis



The round worm, Ascaris lumbricoides, commonly infests the intestine



Complications:



strictures,



suppurative cholangitis,



liver abscesses and empyema of the gall bladder

 HYDATID DISEASE



Jaundice:



Cyst near porta hepatis



Rupture of cyst into the biliary passages

TUMOURS OF THE BILE DUCT



Benign tumours of the bile duct:



Rare



Symptoms not distinguished from common biliary problems



Malignant tumours of the bile duct



Rare, but incidence increasing



Presents with jaundice and weight loss



Diagnosis by ultrasound and CT scanning



Jaundice relieved by stenting



Surgical excision possible in 5%



Prognosis poor – 90% mortality in 1 year

The tumour is usually an adenocarcinoma (cholangiocarcinoma), predominantly in the
extrahepatic biliary

RISK FACTORS



ulcerative colitis, hepatolithiasis, choledochal cyst ,sclerosing cholangitis.



liver fluke infestations in the Far East

CLINICAL FEATURES



Jaundice



Abdominal pain, early satiety



weight loss



palpable gall bladder

INVESTIGATIONS :



Biochemical investigations



tumour marker CA19-9



ultrasound and CT scanning define:



the level of biliary obstruction



the locoregional extent of disease



the presence of metastases



percutaneous transhepatic cholangiography



ERCP

TREATMENT : Most patients are inoperable, but 10–15% are suitable for surgical resection

CARCINOMA OF GALL BLADDER :

Risk factors



Comon in india Incidence 9%



Gall stones less than 1%



90% of Ca GB have gall stones

Pathology:



Schirrous adenocarcinoma



Squamous cell



Mixed sq adenocarcinoma

Spread:



Direct invading the liver



Lymphatics



Peritoneal seedlings

Clinical features:



Mostly elderly 70 years



Females more than males 5:1 ratio



Same as cholecystitis



Suspected during cholecystectomy then preoved by histopathology



Jaundice



Mass in liver late sign

INVESTIGATION



non-specific findings such as anaemia, leucocytosis, mild elevation of transaminases
and increased erythrocyte sedimentation



rate (ESR) or C-reactive protein (CRP).



Elevated CA19-9



US and CT scan



percutaneous biopsy



Laparoscopy

Treatment:



Usually discovered after cholecystectomy and so no further surgical treatment
required If tumor confined to mucosa good prognosis



transmural disease, a radical en bloc resection of the gall bladder fossa and
surrounding liver along with the regional lymph nodes

PATHOGENESIS OF STONE FORMATION

 For cholesterol stones:



Supersturation of bile with cholesterol



Low bile acid concentration

 For pigment stones:



Usually accompany haemolysis like in:



Spherocytosis



Sickle cell disease



Prosthetic heart valves

 For mixed(brown) stones:



Stasis



Infection—beta glucuronidase insoluble unconjugated bilirubin

Have Fun
:D