Gall bladder Biliary tree pdf - د. باسم

Dr. Muayad Abbas
Lec. 4

Gall Bladder & Biliary
Tree
Tues. 10 / 11 / 2015

DONE BY : Ali Kareem

مكتب اشور لالستنساخ

2015 – 2016

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

Management of bile duct injury following cholecystectomy

 Patients with symptoms developing either immediately or delayed after a

cholecystectomy, particularly jaundice ,need urgent investigation.

 immediate ultrasound scan. whether there is intra- or extrahepatic ductal

dilatation.

  The anatomy  defined by MRCP.
  ERCP therapeutic manoeuvres :
  removal of an obstructing stone
   insertion of a stent across a biliary leak.
   If a fluid collection is present in the subhepatic space, drainage catheters

may be required. These can be inserted under radiological control or, if this
expertise is not available, at open operation.

 Small biliary leaks will usually resolve spontaneously, especially if there is no

distal obstruction.

 Should the common bile duct be damaged, the patient should be referred to

an appropriate expert for reconstruction of the duct.

  About 15% of injuries  recognised at the time of operation.
  In 85% of cases, the injury declares itself postoperatively by:
   (1) a profuse and persistent leakage of bile if drainage has been provided,

or bile peritonitis if such drainage has not been provided;

 (2) deepening obstructive jaundice.
 When the obstruction is incomplete, jaundice is delayed until subsequent

fibrosis renders the lumen of the duct inadequate.

 The surgical repair and subsequent outcome is related to the level of injury,

which is determined using the Bismuth classification

Bismuth classification

o  Type I Low common bile duct; stump > 2 cm
o  Type II Middle common hepatic duct; stump < 2 cm
o  Type III Hilar – confluence of right and left ducts intact

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

o Type IV Right and left ducts separated
o Type V Involvement of the intrahepatic ducts

Treatment

o In the debilitated patient,
o temporary external biliary drainage by passing a catheter percutaneously

into an intrahepatic duct.

o stents may be passed through strictures at the time of ERCP and left to

drain into the duodenum.

o  When the general condition improved,
o  Definitive surgery can be undertaken.
o  The principles of surgical repair are
o  maintenance of duct length and restoration of biliary drainage.
o  For benign stricture or duct transection, the preferred treatment is

immediate Roux-en-Y choledochojejunostomy by an experienced surgeon.

o For a stricture of recent onset through which a guidewire can be passed,

balloon dilatation with insertion of a stent.

o The outcome of such surgery is good, with 90% of patients having no

further cholangitis or stricture formation.

Stones in the bile duct

 PRIMARY STONES:occure years after a cholecystectomy or development of

new pathology, such as infection of the biliary tree or infestation by Ascaris
lumbricoides or Clonorchis sinensis.

 Secondary stone (missed stone )from gall bladder
 Any obstruction to the flow of bile can give rise to stasis with the formation

of stones within the duct.

 The consequence of duct stones is either obstruction to bile flow or

infection.

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

 Stones in the bile ducts are more often associated with infected bile (80%)

than are stones in the gall bladder

Symptoms

  The patient may be asymptomatic
  May has bouts of pain,
  jaundice and fever. The patient is often ill and feels unwell. The
  term ‘cholangitis’ is given to the triad of pain, jaundice and fevers,
  sometimes known as ‘Charcot’s triad’.

Signs

  Tenderness may be elicited in the epigastrium and the right hypochondrium.
  In the jaundiced patient, it is useful to remember
  Courvoisier’s law – in obstruction of the common bile duct
  due to a stone, distension of the gall bladder seldom occurs; the
  organ is usually already shrivelled. In obstruction from other
  causes, distension of the gall bladder is common by comparison.

Management

 Full supportive measures are required with rehydration, correction of

clotting abnormalities and treatment with appropriate broad-spectrum
antibiotics.

 Once the patient has been resuscitated, relief of the obstruction is essential.
 Endoscopic papillotomy is the preferred first technique with a

sphincterotomy, removal of the stones using a Dormia basket or the
placement of a stent if stone removal is not possible.

 If this technique fails, percutaneous transhepatic cholangiography can be

performed to provide drainage and subsequent percutaneous
choledochoscopy.

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

 Surgery, in the form of choledochotomy, is now rarely used for this

situation, as most patients can be managed by minimally invasive
techniques

Choledochotomy

 The aim of this surgery is to drain the common bile duct and remove the

stones by a longitudinal incision in the duct.

 When the duct is clear of stones, a T-tube is inserted and the duct closed

around it;

 the long limb of the T-tube is brought out on the right side, and the bile is

allowed to drain externally.

 When the bile has become clear and the patient has recovered, a

cholangiogram is performed, usually 7–10 days following operation.

 If residual stones are found, the T-tube is left in place for 6 weeks so that

the track is ‘mature’. The retained stones can be removed percutaneously
by an interventional radiologist (Burhenne technique)

Stricture of the bile duct

Causes of benign biliary stricture

o Congenital

 Biliary atresia

o Bile duct injury at surgery

  Cholecystectomy
  Choledochotomy
  Gastrectomy
  Hepatic resection
  Transplantation

o Inflammatory

 Stones

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

  Cholangitis
  Parasitic
  Pancreatitis
  Sclerosing cholangitis
  Radiotherapy

o Trauma
o Idiopathic

Radiological investigation of biliary strictures

o  Ultrasonography
o  Cholangiography via T-tube, if present
o  ERCP
o  MRCP
o  PTC
o  Multidetector row CT

TUMOURS OF THE BILE DUCT

  Benign tumours of the bile duct
  Uncommon
  less than 0.1% of biliary tract operations.
  clinical presentation may  mimic the more common conditions such as

cholecystitis, choledocholithiasis,cancer of the bile duct and pancreatic
cancer.

Benign neoplasms classificationas follows:

o papilloma and adenoma;
o multiple biliary papillomatosis;

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

o  granular cell myoblastoma;
o  neural tumours;
o  leiomyoma;
o  endocrine tumours.

Malignant tumours of the bile duct

Carcinoma may arise at any point in the biliary tree, from the common bile
duct to the small intrahepatic ducts

Incidence

o rare malignancy accounting for 1–2% of new cancers in a western practice.

o two-thirds of patients being older than 65 years.

o the tumour is usually an adenocarcinoma

o (cholangiocarcinoma), predominantly in the extrahepatic biliary system.

o Patients with a history of followings are at increased risk of developing the

disease.

o ulcerative colitis,

o hepatolithiasis,

o Choledochal cyst or

o sclerosing cholangitis

o longstanding history of sclerosing cholangitis increases the risk of

developing biliary tract cancer by 20-fold compared with the normal
population.

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

o liver fluke infestations in the Far East are also associated with

cholangiocarcinoma. Opisthorchis viverrini infestation is important in
Thailand, Laos and western Malaysia.

o These parasites induce DNA changes and mutations through production of

o carcinogens and free radicals, which stimulate cellular proliferation in the

intrahepatic bile ducts and can ultimately lead to invasive cancer.

Clinical features

 slow-growing tumours that invade locally and metastasise to local lymph

nodes.

  Distant metastases to the peritoneal cavity, liver and lung may occur.
  Jaundice is the most common presenting feature.
  Abdominal pain, early satiety and weight loss are also commonly seen.
  On examination,
  Jaundice is evident,
  cachexia often noticeable
  a palpable gall bladder is present if the obstruction is in the distal common

bileduct (Courvoisier’s sign).

 Investigations
 Biochemical investigations will confirm the presence of obstructive jaundice

(elevated bilirubin, alkaline phosphatase and gamma-glutamyl transferase).

  The tumour marker CA19-9 may also be elevated.
  Non-invasive studies such as ultrasound and CT
  scanning define the level of biliary obstruction, the locoregional extent of

disease and the presence of metastase



For proximal tumours, percutaneous transhepatic cholangiography is the
most useful modality.

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

PTC



outlines the anatomy of the tumour and the intrahepatic biliary system.



it allows percutaneous biliary drainage,



samples can be obtained for cytology to confirm the diagnosis.



For distal tumours, an ERCP is preferred



as an endobiliary stent can be placed across the obstructing lesion.



Again, cytology or biopsies can be taken for diagnosis.

Treatment

  depends on the site and extent of disease.
  ONLY 10–15% are suitable for surgical resection.
  Most patients are inoperable,
  Depending on the site of disease,
  resection may involve partial hepatectomy and reconstruction of the biliary

tree.

  Distal common duct tumours may require a pancreaticoduodenectomy.
  The perioperative mortality rate is now less than 5%.
  The median survival is 18 months, with 20% of patients surviving 5 years

post resection.

 Survival appears to be better for distal tumours compared with those

involving the upper third of the biliary tree.

 Adjuvant chemotherapy or radiotherapy has a limited role and is not

considered standard therapy.

Bile duct cancer

o Rare, but incidence increasing

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

o  Presents with jaundice and weight loss
o  Diagnosis by ultrasound and CT scanning
o  Jaundice relieved by stenting
o  Surgical excision possible in 5%
o  Prognosis poor – 90% mortality in 1 year

Carcinoma of the gall bladder

  Incidence
  This is a rare disease
  variable by geographical region and racial/ethnic groups.
  The highest incidence is in Chileans,
  American Indians and in parts of northern India, where it accounts for as

much as 9.1% of all biliary tract disease.

 In western practice, gall bladder cancer accounts for less than 1% of new

cancer diagnoses.

 The patients are usually older, in their sixties or seventies.

The aetiology is unclear, association with

  preexisting gallstone disease.
   Calcification of the gall bladder is associated
  with cancer  in 10–25% cases.
  Infection may promote the development of cancer as the risk of carcinoma

in typhoid carriers is significantly increased .

Pathology

 The majority of cases are adenocarcinoma (90%).

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

 the tumour is most commonly nodular and infiltrative, with thickening of

the gall bladder wall, often extending to the whole gall bladder.

 The tumour spreads by direct extension into the liver, seeding of the

peritoneal cavity and involvement of the perihilar lymphatics and neural
plexuses.

 At the time of presentation, the majority of tumours are advanced.

Clinical features

o Patients may be asymptomatic at the time of diagnosis.

o . If symptoms are present, they are usually indistinguishable from benign

gall bladder disease such as biliary colic or cholecystitis, particularly in the
older patient.

o Jaundice and anorexia are late feature.

o A palpable mass is a late sign

Investigation

o Laboratory findings

o may be consistent with biliary obstruction

o or non-specific findings such as anaemia, leucocytosis, mild elevation in

transaminases and increased erythrocyte sedimentation

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

o The level of serum CA19-9 is elevated in 80% of patients.

o The diagnosis is made on ultrasonography

o defined by a multidetector row CT scan,

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

o percutaneous biopsy confirming the histological diagnosis.

o laparoscopy is useful in staging the disease, as it can detect peritoneal or

liver metastases that would preclude further surgical resection.

Treatment and prognosis

o Occasionally, the diagnosis is made by histological examination of a gall

bladder removed for ‘benign’ gallstone disease.

o For early stage disease confined to the mucosa or muscle of the gall

bladder, no further treatment is indicated.

o However, for transmural disease, a radical en bloc resection of the gall

bladder fossa and surrounding liver along with the regional lymph nodes
should be performed.

o The disease has a very poor prognosis with the median survival less than 6

months and a 5-year survival of 5%.

o The value of adjuvant therapy is unproven.

Gall bladder cancer

o  Rare
o  Presents as for benign biliary disease (gallstones)
o  Diagnosis by ultrasound and CT scanning
o  Excision in less than 10% – remainder palliative treatment
o  Prognosis poor – 95% mortality in 1 year

Preperation of a Patient with Obstructive Jaundice for Surgery

1) Correct Anaemia if Present

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015

2) Good Hydration with i.v. fluids to prevent dehydration & maintain the

Renal Function

3) Mannitol i.v. infusion to maintain osmotic diuresis and prevent Bilirubin

from precipitating in the tubules.

4) Vitamine K injectable to activate important clotting factors (fat soluble

vitamines are not absorbed)

5) Add 5% Glucose Water to help build up Liver glycogen

6) Antibiotics Broad Spectrum

TRAUMA of biliary tree

o  blunt or penetrating abdominal trauma.
o  Operative trauma is perhaps more frequent than external trauma.
o  physical signs are those of an acute abdomen.
o  Management depends on the location and extent of the biliary and

associated injury.

o In the stable patient, a transected bile duct is best repaired by a Roux-en-Y

choledochojejunostomy.

o Injuries to the gall bladder can be dealt with by cholecystectomy.

END …

DONE BY

Ali Kareem

Gall Bladder & Biliary Tree Dr. Muayad Abbas

10-11-2015