!!! bile ducts
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The Biliary TractSviatoslav Balaka
(by Raymond W Pryor III M.D.)
History
History Circa 200 AD – Galen – the gallbladder
as a subsidiary organ for the liver & responsible for yellow bile
Renaissance period – Gallbladder seat of many emotions (gall)
1652 - Thomas Bartholin – gallbladder part of bile tract from liver to intestine
1654 - Thomas Glisson – formed more detailed anatomy of liver & biliary tract
More relevant history 1420 - Antonio Benevieni – 1st account of
gallstones 1687 - Stal Pert Von Der Wiel – 1st operation
on gallstones 1733 – Jean-Louis Petit -1st successful
removal of gallstones with fistula formation 1859 – J.L.W. Thudichum – Two stage
cholecystostomy July 15, 1867 – Dr John Stough Bobbs –
Single stage cholecystostomy
Still More relevant History 1630 & 1667 – Zambecarri & Teckoff – proved
the gall bladder not essential to life 1878 - Theodor Kocher – refined
cholecystostomy procedure July 15, 1882 – Dr Langenbuch – 1st open
cholecystectomy 1886 – cholecystotomy 27% mortality vs 12%
mortality for Langenbuch’s cholecystectomy – became gold standard
1940’s – Mirizzi introduced cholangiography for CBD stones
Anatomy
Anatomy
Variations in Bile Ducts
Gallbladder physiology Gallbladder wall has
no muscularis mucosa or submucosa
Predominantly columnar epithelial cells
Rokitansky-Aschoff sinuses
Ducts of Luschka
Biliary Physiology
1.Storage and concentration of hepatic bile
2.Secretion of water and electrolytes
3.Empting bile into the common bile duct
controled by secretin, cholecystokinin (CCK) and gastrin.
Storage and concentration Normal capacity of 40-50 mL Liver secretes >600 mL of bile
daily Greatest absorptive capacity Concentrates bile 5-10 fold NaCl transport by epithelium is
driving force and water passively absorbed
Composition of BileCharacteristic (mEa/L) Hepatic GallbladderNa 160 270K 5 10Cl 62-112 1-10HCO3 45 10Ca 4 25Water 95-98% 85-90%Bilirubin 1.5 15Protein (mg/dL) 250 700Bile Acids 3-50 290-340Phospholipids 8 40Cholesterol (mg/dL) 60-70 350-930Total Solids -- 125pH 7.0 - 7.8 6.0 - 7.2
Biliary Motility Contraction of ampullary sphincter
(Sphincter of Oddi) After meal, sphincter of Oddi relaxes &
CCK released — contraction of gallbladder
When stimulated, 50-70% of contents ejected over 30-40 minutes
Refills over next 60-90 minutes
Gallstones
Cholelithiasis 10-20% of Europeans and
Americans carry gallbladder stones
Majority are asymptomatic Symptoms and severe
complications - 25% 1-2% of asymptomatic
individuals develop symptoms per year
Each year, an estimated 700,000 cholecystectomies (US)
$6.5 billion (US)
Classification of gallstones
Cholesterol Gallstones
Pigment gallstones
Is Everyone Still Awake?
Diagnosis of cholelithiasis Abdominal plain film Ultrasound
› 95-98% sensitive, 98% specific Radionuclide scan – hepatobiliary iminodiacetic
acid (HIDA)› Acute cholecystitis: 94% sensitive, 65-85% specific› Chronic cholecystitis: 65% sensitive, 6-10% specific
CT scan› 50-70% sensitive› More expensive
MRCP› Cost prohibitive
Ultrasound
More images
CT Scan
MRCP
MRCP with morphine
Chronic Calculous Cholecystitis Recurrent cystic duct obstruction & inflammation Presents with biliary colic Association with meals present in only 50% Symptoms
› Pain duration 1-5 hours (rare >24 hrs or <1 hr)› Nausea & vomiting present 60-70% of time› Bloating & belching in 50%› Fever & jaundice rare
Exam may be normal unless during attack Laboratory values usually normal Differentials include: GERD, PUD, IBS, pancreatitis Treatment is elective laparoscopic cholecystectomy
Chronic Calculous Cholecystitis
Xanthogranulomatous cholecystitis
Variant of chronic cholecystitis lipid-laden inflammatory process Marked wall thickening with intramural
nodules visible on CT and US Cannot distinguish radiographically from
gallbladder carcinoma
Porcelain gallbladder Rare disorder where chronic cholecystitis
causes mural calcification of gallbladder wall Cholecystectomy is warranted as there is a
30-65% risk of underlying gallbladder carcinoma
Gallstone Ileus Large gallstone the obstructs small bowel (distal ileum
at ileocecal valve) Fistula between gallbladder and duodenum (can be
colon or stomach) Most commonly in elderly (>70) females History of gallstone-related symptoms present in only
50% Only account for <1% of SBO cases <0.1% of those with gallstones will develop Up to 25% of SBO in elderly patients who have not had
previous abdominal surgery or have a hernia Treat with Ex-lap and enterotomy with removal of stone.
Take back for takedown of biliary-enteric fistula & cholecystectomy when more stable
Gallstone Ileus
Intrahepatic Stones Most common in East
Asian population Most associated with
biliary strictures, primary sclerosing cholangitis, choledochal cysts & biliary tract tumors
Spontaneous in <10% of cases
Treatment depends on location & underlying condition(s)
Choledocholithiasis 7-15% of patients
undergoing cholecystectomy have CBD stones
Findings of jaundice, lightening of stool & dark urine
Fevers & elevated WBC indicate cholangitis
Serum Bilirubin has PPV of 28-50%
Biliary obstruction may be partial or transient, so labs may be normal in up to 30%
Choledocholithiasis (cont’d) May have overlying pancreatitis (up to 45% of all cases
of pancreatitis) Dilated CBD in 58% of patients Ultrasound only 60-70% sensitive for CBD stones MRCP 95% sensitive & 89% specific ERCP Gold Standard
› Can both diagnose and treat 90% of time› Pancreatitis occurs in up to 5% of Patients
If unable to remove stone with ERCP (or none available) need to do laparoscopic or open CBD exploration
Stone found in CBD within 2 years of cholecystectomy is termed retained, >2 years is recurrent
Mirizzi Syndrome Rare cause of biliary
duct obstruction Large stone
contained within gallbladder compresses the CBD
Local spread of inflammation from gallbladder to CBD may also result in duct narrowing
Classification
Type I - no fistula present: Type IA - presence of
the cystic duct. Type IB - jbliteration of
the cystic duct. Types II-IV - fistula
present: Type II - defect smaller
than 33% of the CBD diameter.
Type III - Defect 33-66% of the CBD diameter. Type IV - Defect larger than
66% of the CBD diameter
Wake up!
Cholangitis Acute bacterial infection of biliary tract Most common cause of biliary obstruction as often associated with
choledocholithiasis Occurs in 4-7% of ERCP and PTC (Percutaneous transhepatic
cholangiography) Other causes of obstruction associated with cholangitis:
› Strictures, neoplasms (rare), chronic pancreatitis, congenital cysts, duodenal diverticula
Presentation of fever, RUQ pain, jaundice › Charcot’s triad
May also have Hypotension & mental status change› Reynold’s pentad
Lab findings: Leukocytosis, elevated alk phos, AST, ALT, Bilirubin (direct)
Blood cultures positive 40-50% CT scan or Ultrasound can help make diagnosis
Treatment of Cholangitis Immediate IV antibiotics and fluid
resuscitation Biliary decompression necessary
› Endoscopic or percutaneous› May need open CBD exploration & T-tube
placement (higher mortality) Overall mortality 2% (5% with toxic
cholangitis)
Primary Sclerosing Cholangitis
Choleststic liver disease characterized by fibrotic strictures in the intrahepatic and extrahepatic biliary tree in ABSENCE of any known cause.
Associated with HLA B8/DR3, IDDM, Graves’ Disease, Sjögren’s syndrome, & Myasthenia gravis
Clinical presentation highly variable› Jaundice, pruritus, fatigue, abnormal LFT’s
Mean age 30-50 years Male : female 3:1 Diagnosis by ERCP Median survival after diagnosis 10-12 years Primary treatment is liver transplantation
Sclerosing cholangitis Sclerosing
cholangitis caused by stones, cholangitis or operative trauma termed Secondary sclerosing cholangitis
Choledochal cysts Rare congenital
dilation of biliary tract
1 : 150,000 incidence in Western countries
Much more common in Japan
Female : male 8:1 Most often diagnosed
in infancy Treatment is
resection
Biliary Strictures & Bile duct injury 80-90% caused by iatrogenic
injuries Laparoscopic cholecystectomy
most common Present days to weeks after
surgery May be years after surgery as
scar tissue obstructs duct Treatment is decompression,
drainage, possible surgical resection.
Stenting being used with increasing frequency
With ligation of CBD & strictures, need Roux-en-Y hepaticojejunostomy
Gallbladder Cancer 5th most common GI tract malignancy 2-3 times more common in females 75% over age 65 5,000 new cases in US annualy Found incidentally in 1% to 3% of
cholecystectomy specimens Majority of the time, diagnosed in late stages
with distant mets Cholelithiasis present in 75-90% of cases
› Only 0.4% of those with gallstones develop cancer
Gallbladder Cancer Over 90% are adenocarcinoma
› 60% scirrhous, 25% papillary, 15% mucoid Squamous cell, oat cell, undifferentiated,
adenosquamous & carcinoid tumors less common Only 10% are correctly diagnosed preoperatively 1-3 out of every 100 cholecystectomy
specimens will show carcinoma at pathology
At diagnosis:› 25% contained to gallbladder wall› 35% metastases to regional lymph nodes› 40% have metastasized to distant sites
Average survival is 6 months after diagnosis
Lymphatic drainage & spread Initial drainage to
cystic duct node Descents along CBD
nodes Nodes at posterior
head of pancreas Interaortocaval
nodes Can also spread by
direct invasion into liver
Gallbladder Cancer Most commonly presents with RUQ pain Weight loss, jaundice, palpable mass very late findings Many report change in quality or frequency of biliary colic episodes US sensitivity 70-99% CT approx 75% sensitive MRI 90-99% sensitive
Management & Prognosis Tumor confined to mucosa or
submucosa (T1a) or to muscularis (T1b) have overall 5-year survival of 100% & 85%
Spillage of bile during cholecystectomy can seed abdomen
Invasion beyond muscularis (T2 & T3) need extended cholecystectomy with lymph node dissection
Stage III has ~15% 5-year survival Stage IV has median survival of 1-
3 months from diagnosis Majority of cases, therapy is
palliative Chemo & radiation hot been
shown to increase survival
Survival following radical resection of T2 gallbladder
cancer vs simple cholecystectomy
Cholangiocarcinoma Uncommon tumor anywhere along intrahepatic or
extrahepatic biliary tree 60-80% occur at bifurcation Most present with obstructive jaundice, hepatomegaly,
palpable gallbladder (Courvoisier’s sign) or cirrhosis (advanced disease)
2,500-3,000 new cases in US annualy Mean age in 50’s, men & women equal Increased risk with choledochal cysts, intrahepatic
stones, Liver flukes, dietary nitrosamines & exposure to dioxin
Following biliary-enteric anastomosis, 5% will develop Tend to spread by direct extension
Staging & classification Intrahepatic tumors
(Klatskin tumors)treated like hepatocellular carcinoma (hepatectomy)
Perihilar treated with resection with local hepatic resection
Distal treated like periampullary tumors with pancreatoduodenectomy (Whipple)
TNM staging
Diagnosis Intrahepatic easily
visualized on CT scan Perihilar & distal
tumors difficult to visualize on US and CT
ERCP & MRCP have near equal sensitivity (85-95%)
Most patients have serum Bilirubin >10, elevated Alk Phos & CA 19-9
Treatment
Preoperative placement of stents in hepatic & hilar tumor
Resected Left lobe & hilum with reconstruction
Prognosis Long-term survival highly
dependant on stage & treatment
For resectable intrahepatic tumors, overall 5-year 30-40%
Resectable peri-hilar tumors 10-20%
Resectable distal tumors 28-45%
Median survival for all unresectable tumors is 6-7 months
Thanks God it’s the weekend!
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