Biliary system

Prof. Weilin Wang wam@zju.edu.cn

Department of Hepatobiliary Pancreatic Surgery

The First Affiliated Hospital

Anatomy of Biliary System1

Methods of Investigation2

Disorders of Gallbladder3

Disorders of Bile Duct4

Case discussion5

Anatomy of Biliary System1

Extrahepatic Biliary Tract

Bifurcation Common hepatic duct

Common bile ductCystic ductGallbladder

The liver secrete bile, bile flow from liver to right and left hepatic ducts.

These ducts drain into the common hepatic duct.

The common hepatic duct then joins with the cystic duct to form the common bile duct.

Transportation of Bile

About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder.

When food is taken, the gallbladder contracts and release stored bile into the duodeum to help digest the fats.

Transportation of Bile

Calot triangle

The triangle is bounded by the cystic duct, the common hepatic duct, and the inferior border of the liver.

Important structures including: the cystic artery, the right hepatic artery, and the cystic duct lymph node.

Papilla of Vater

Tthe opening of the bile duct and panceatic duct in the descending part of the duodenum.

Through the papilla, bile and pancreatic juice pass to to bowel.

obstructive jaundice or pancreatitis will happen when papilla of Vater was blocked by stones and tumors,

Normal gallbladder

Agenesis of the gallbladder is extremely rare, with a prevalence of 0.03-0.07 percent.

Double gallbladder occurs in about 0.03 per cent, usually with a shared cyctic duct, and the accessory gallbladder is often diseased.

Gallbladder Anatomical Variants

Variations of biliary branching

A Typical anatomy of the confluence.

B Trifurcation of left, right anterior, and right posterior hepatic ducts.

C Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct.

Methods of Investigation2

Ultrasonography (B-US) CT, Computed Tomographic Magnetic Resonance Cholangiopancreatography Endoscopic Retrograde Cholangopancreatography Percutaneous Transhepatic Cholangiography T-tube cholangiography Radiographs Intraoperative cholangiography Endoscopic ultrasound ……

Methods of investigation

Fast, real-time, non-invasive, and no ionizing radiation, cheap and could be available even in countryside.

95% sensitivity for detection of cholelithiasis.

--Found a mobile, hyperechoic with acoustic shadowing

>90% sensitivity for detection of acute cholecystitis.

--Gallbladder wall thickening, pericholecystic fluid

B-US

Normal GallbladderGallbladder, with sludge

and stone present

Gallstones can be seen on CT, but it is not used primarily for this purpose.

CT can be used in situations where ultrasound is difficult --such as in obese patients. It can also be used if the ultrasound is

not definitive.

CT scan

Plain CT shows multiple gallstones.

Multiple stones were found in the left intrahepatic bile duct.

Becoming a more viable imaging technique

New tool for non-invasive evaluation of the pancreatic and biliary ductal systems.

Gradually replacing PTC and ERCP for diagnostic purposes.

MRCP

MRCP showed slight dilation of CBD

Pancreatic duct

Common bile duct

Stones was detected in the bile duct by MRCP.

Stones in CBD

ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct.

ERCP

Left: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct.

Right: Radiographic result after the contrast medium was injected into the CBD.

ERCP: Instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments.

ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct.

Stones in CBD Endoscope

Pancreatic duct

Large stone was drawing out from CBD during ERCP was performing.

Show the procedure of removal the stones using endoscope .

ERCP.wmv

PTC

The catheter was placed into the intrahepatic bile duct through patient’s skin guiding by B-US and fixed on the skin.

The radiographic image was taken.

Obstructive lesion can be seen in this picture.

Obstructive lesion

Left : After injection of dye, showing a large gallstone trapped in the duct.

Right: After removal of the stone through the drainage catheter.

Before After

Postoperatively

Injection of contrast medium through a T-tube catheter

placed in the CBD

Easy way to show whether there are remaining stones or any stricture

T-tube cholangiography

T-tube graphyT-tube graphy

Old technique used in the past, widely replaced by the ultrasound and MRCP.

Can be used to visualize calcified stones by abdominal x-ray film.

Radiographs

Abdominal x-ray demonstrating stones in the gallbladder

Stones

Stones

Disorders of Gallbladder3

Acute cholecystitis Gallbladder stones and sludge Adenomyomatous hyperplasia Gallbladder polyps Gallbladder carcinoma ……

Disorders of Gallbladder

Calculous cholecystitis: over 90%

Clinical manifestation: --Pain in right upper quadrant --Radiates to right shoulder & back --Nausea & vomiting --Chill and/or fever --Abdominal tenderness --Murphy's sign (+)

Acute Cholecystitis

Acute Cholecystitis: B-US

The gallbladder contains small stones in the neck and its wall shows oedematous thickening (>5 mm thickness).

Other B-US signs are:

--Gallbladder over distension

--Pericholecystic fluid

--GB wall thickening

-- ……

Less accurate than B-US

The CT findings : --Gallbladder wall thickening

--Subserosal oedema --Gallbladder distension --Pericholecystic fluid --Gallstones

Acute Cholecystitis: CT

•Fine, nonshadowing dependent echoes.

•Composed of calcium bilirubinate granules, cholesterol crystals.

•Gallstones will develop in 5-15 percent.

Sludge

Gallbladder, with sludge and stone present

Stone

Sludge

Gallbladder polyps

The majority of polyps are cholesterol

Cholesterol polyps are usually 2-10mm in size

They appear as small echogenic nonshadowing foci adherent to the gallbladder wall

Lack of mobility indicates polyp

The affected segment often contains bright echoes

Often associated with ‘comet-tail’

Gallbladder-Adenomyomatosis

Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct.

May result in biliary obstruction and jaundice

If not recognized preoperatively, it can result in significant morbidity and

mortality

Mirrizzi syndrome

Symptomatic cholelithiasis

Non-functioning gallbladders (Full of stones)

Malignant considered: GB polyps (>1.2cm) or others

Indication for Cholecystectomy

The first case was performed in 1882

One safe and effective method

Direct visualization and palpation

Open Cholecystectomy

A less invasive way to remove the gallbladder

Smaller incisions and less pain

Shorter hospital stay and a shorter recovery time

Laparoscopic Cholecystectomy

Laparoscopic Cholecystectomy

Gallbladder Carcinoma

Gallbladder carcinoma is associated with stones in over 90% of patients

There is a female to male ratio of 3:1

Few patient was diagnosed prior to surgery

Gallbladder Carcinoma

Gallbladder CarcinomaGallbladder Carcinoma

TNM classification

TNM classification

Direct invasion of the liver by gallbladder cancer in a 66-year-old woman

Should differentiate gallbladder cancer from acute cholecystitis

T?N?M?

Quiz

Treatment

Radical surgery including segment liver resection, bile duct resection and extensive lymphadenectomy

Poor prognosis in patients with unresectable tumor

External radiation therapy may provide palliative benefit.

5-Fu and Gemcitabine can be used as chemotherapy.

Gall-Bladder.mp4

LC.mp4

Disorders of Bile Duct4

Disorders of Bile DuctDisorders of Bile Duct

AOSC

Choledocholithiasis/Hepatolithiasis

Choledochal cyst

Cholangiocarcinoma

Pancreatic and ampullary tumor

Acute obstructive suppurative Cholangitis (AOSC)

Emergency disease carries high mortality

Common obstructing factors: stones, tumor

Complete obstruction and suppurative infection

May result in septicemia & septic shock; MSOF

AOSC

Abrupt onset of pain in upper quadrant

Chill, high fever, may nausea and vomiting

Jaundice

May shock, and/or Acute renal failure and ARDS

Clinical manifestation

Charcot triad

Correct the fluid and acid-base balance

Systemic administration of antibiotics

Anti-shock treatment

Drain the biliary tract: ERCP or PTCD

Emergency operation

Treatment

Choledocholithiasis/Hepatolithiasis

Small shadowing stone (Arrow) in dilated bile duct.

CT show multiple stones in hepatic bile duct

Choledocholithiasis/Hepatolithiasis

ERCP: demonstrating stone in the duct (arrow)

Stones

Choledocholithiasis/Hepatolithiasis

Cystic dilatation of the extrahepatic bile ducts

Female to male is about ration 4:1

The majority are now diagnosed in childhood

Classified into five types

Associated with various biliary tumors

Choledochal cysts

Type I

Type II

Type III

Type IV

Type V

Choledochal cysts

CT MRCP

Cholangiocarcinoma

Pancreatic and ampullary tumours

……

Bile Duct CancerBile Duct Cancer

Most commonly at the hepatic duct bifurcation (Klatskin tumor)

Present with jaundice Clinical Presentation: --Jaundice (around 90% ) --Pruritus --fever --mild abdominal pain --fatigue --…… Surgical resection offer a chance for long-term disease-free

survival

Cholangiocarcinoma

B-US: nodules or focal bile duct wall thickening

CT: nodules are usually isodense or slightly hypodense

MRCP: show the proximal extent of the stricturing

Cholangiocarcinoma

Small hilar cholangiocarcinoma (Arrowhead) producing obstruction of the right posteral sectoral duct (Short arrow). Right anterior sectoral duct (long arrow) and left hepatic duct. (A) Thick oblique coronal MRCP. (B) Axial portal phase CT (C) Longitudinal US. (D) Transverse color Doppler US (Open arrow, normal left portal vein).

Type I: confined to the common hepatic duct

type II: involve the bifurcation Type IIIa and IIIb: extend into

either the right or left secondary intrahepatic ducts, respectively

Type IV: involve the secondary intrahepatic ducts on both sides

Bismuth Classification

I II

III IV

II

IV

I II

IVIII

I II

IVIII

I II

IV

I

IVIII

I

IV

II

III

I

IV

Type?

Quiz

Distal lesions are usually treated with Whipple

Intrahepatic lesions are treated by hepatic resection

Perihilar (Klatskin) tumor:

--Type I and II: Resection of the extrahepatic bile ducts and gallbladder

--Type III and IV: Curative resection is difficult

Radiation therapy improves survival for patients

Treatment

Resection of the extrahepatic bile ducts and gallbladder with 5-10 mm bile duct margins, and regional lymphadenectomy with Roux-en-Y hepaticojejunostomy.

Typical operation I

Typical operation II: Whipple

Before After

The head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct are excised, usually to relieve obstruction caused by tumors. Continuity is reestablished between the biliary, pancreatic, and GI systems.

Case discussion5

42-year-old woman patient was admitted to our emergency department because of repeated upper abdominal pain for 2 years and aggravated for three days.

With nausea, vomiting, chill and fever. The highest temperature reached to 39.5 . She also found dark urine and skin turned ℃yellow.

PE: BP 85/52 mmHg. Yellow stained was found in the skin and sclera.

Case: Clinical manifestationCase: Clinical manifestation

Which examination should be performed for diagnosis?

Laboratory test: --Blood routine test

--Liver function and serum electrolyte --Serum Amylase

Imaging test: --B-US (First choice. Why?) --MRCP --CT

Examination neededExamination needed

Laboratory test: --BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l

--Liver function: ALT 154 U/l TB/DB 194/153 mmol/l --Serum Amylase : Normal

Imaging test: --MRCP

Examination findingExamination finding

DiagnosisDiagnosis

Acute Cholecystitis?

Gallstone pancreatitis?

Cholangitis?

No

No

Yes

AOSC, Septic shock

Anti-shock treatment Antibiotic drug Drainage: Emergency ERCP

was performed and ENBD was placed

…….

TreatmentTreatment

Most important!!

CT scan show multiple stone in CBD and hepatic duct. The catheter can be seen.

When the general condition is stable and the TB level declined to 50mmol/l, choledocholithotomy was carried out and stones were removed.

The patient recovery very well without any episode.

TreatmentTreatment

Questions?Questions?