Biliary - The Biliary Tract

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Transcript of Biliary - The Biliary Tract

  • 1. The Biliary Tract
    Raymond W Pryor III M.D.
    July 31, 2008
  • 2. History
  • 3. 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
  • 4. More relevant history
    1420 - Antonio Benevieni 1st account of gallstones
    1687 - Stal Pert Von DerWiel 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 StoughBobbs Single stage cholecystostomy
  • 5. 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 Langenbuchs cholecystectomy became gold standard
    1940s Mirizzi introduced cholangiography for CBD stones
  • 6. Into the Laparoscopic Age
    Trocar insertion 1st described by Ezekiel and Celsus 25 BC AD 50
    Term Trocar coined in 1706
    trocartertroise-quarts
    1901 Dimitri OH gynaecologist, performed 1st endoscopic exam
    1911 Dr Bernheim published Organoscopy in Annals of Surgery
    1938 Veress developed spring-loaded needle
  • 7. Laparoscopic development
    1952 quartz rod to project light
    1959 closed circuit television
    1966 Kurt Semm automatic insufflator device, thermo coagulation, irrigation & aspiration system and endoloop applicator
    1978 Dr Hasson direct placement of trochar
    1982 Liver biopsy via laparoscopy
    1987 Dr Mouret 1st laparoscopic cholecystectomy on human
    By 1989, procedure being done in US
    1992 NIH concluded Laparoscopic cholecystectomy treatment of choice
  • 8. Anatomy
  • 9. Anatomy
  • 10. Variations in Bile Ducts
  • 11. Biliary Physiology
    Overall, the purpose is to modify, store and regulate the flow of bile
    The gallbladder concentrates & stores bile, then releases bile in response to a meal
    Biliary duct secretion of chloride-rich fluid controled by secretin, cholecystokinin (CCK) and gastrin.
  • 12. Gallbladder physiology
    Gallbladder wall has no muscularis mucosa or submucosa
    Predominantly columnar epithelial cells
    Rokitansky-Aschoff sinuses
    Ducts of Luschka
  • 13. Gallbladder physiology
    Normal capacity of 40-50 mL
    Liver secretes >600 mL of bile daily
    Gallbladder mucosa has greatest absorptive capacity per unit area of any structure in body
    Concentrates bile 5-10 fold
    NaCl transport by epithelium is driving force and water passively absorbed
  • 14. Composition of Bile
  • 15. Biliary Motility
    Filling is facilitated by contraction of ampullary sphincter (Sphincter of Otti)
    Goes through cycles of partial emptying of 10-15% of volume to mix & concentrate bile
    After meal, sphincter of Oddi relaxes & CCK releasedcausing contraction of gallbladder
    When stimulated, 50-70% of contents ejected over 30-40 minutes
    Refills over next 60-90 minutes
  • 16. Bacteriology
    Under normal conditions, the biliary tract is sterile
    Positive cultures found:
    11-30% symptomatic stones & chronic cholecystitis
    46% of acute cholecystitis
    58% with gallstones & CBD stones without cholangitis
    94% with gallstones, CBD stones and cholangitis
  • 17. Organisms
    Gram-negative aerobes most common
    E. coli
    Klebsiella
    Pseudomonas
    Enterobacter
    Gram-positive aerobes
    Enterococcus
    Streptococcus viridans
    Anaerobes (~25%)
    Bacteroidesfragilis
    Clostridium
    Fungal
    Candida sp.
    Parasitic
    Opisthorchis sp. (Thailand) (Liver fluke)
    Clonorchis sp. (China)
    Approximately 50% of positive cultures will have 2 or more different bacteria species present
  • 18. Antibiotic Choice 2008 Sanford Guide
    Cholecystitis (E. coli, Klebsiella, Enterococci)
    meropenem (Merrem)
    piperacillin/tazobactam (Zosyn)
    cefepime (Maxipime)
    cefazolin + ampicillin (Ancef + ampicillin)
    ciprofloxacin + metrodazole (Cipro + Flagyl)
    Emphysematous Cholecystitis (Clostridium perfringens +/- E. coli)
    meropenem (Merrem)
    piperacillin/tazobactam (Zosyn)
    ertapenem (Invanz)
    ticarcillin./clavulanate (Timentin)
    Cholangitis
    meropenem (Merrem)
    cefepime (Maxipime)
    piperacillin/tazobactam (Zosyn)
    Tigecycline (Tygacil)
    ampicillin/sulbactam (Unasyn)
    imipenem/cilstatin (Primaxin)
    cefoperazone (Cefobid)
  • 19. Antibiotics (contd)
    PO Treatment of cholecystitis or cholangitis
    clindamycin (Cleocin)
    ciprofloxacin + metronidazole (Cipro + Flagyl)
    levofloxacin (Levoquin)
    moxifloxacin (Avelox)
    Opisthorchis sp. & Clonorchis sp. (Liver fluke)
    praziquantel (Biltricide)
    albendazole (Albenza) **poor response to above organisms
  • 20. Gallstones
  • 21. Cholelithiasis
    Formation represents failure to maintain bile components (cholesterol, Ca, bile pigments) in a solubilized state
    Majority of those with stones are asymptomatic
    1-2% of asymptomatic individuals develop symptoms per year
    Approx 65% of asymptomatic patients remain symptom free after 20 years
  • 22.
  • 23. Cholesterol Gallstones
    75% of all gallstones in United States
    3 stages of formation
    Cholesterol supersaturation
    Crystal nucleation
    Stone growth
    Risk factors
    Female
    Multi gravid
    Estrogen use
    Old age
    Obesity
    Rapid weight loss
    Prolonged TPN
  • 24. Pigment gallstones
    25% of stones in US, 65% in Japan
    Black Pigment
    Made of Ca bilirubinate, bilirubin polymers & bile acids
    Increased concentration of bilirubin & Ca
    Hemolytic disorders & cirrhosis
    Chronic TPN
    Ileal resections
    Exact mechanism unclear, may be due to presence of bacterial b-glucuronidase that deconjugatesbilirubin
    Brown Pigment
    Asian populations
    Infection & bacterial hydrolysis of bilirubin
    More commonly found in bile ducts
  • 25. Biliary Sludge
    Viscous bile
    Precursor to gallstone formation
    Associated with prolonged TPN and fasting
    Often found during ultrasound evaluation
    Usually asymptomatic
  • 26. Is Everyone Still Awake?