Biliary tract 2011

download Biliary tract 2011

of 173

Embed Size (px)

Transcript of Biliary tract 2011

  • Diseases of the Biliary Tract

    Liu BinLiu Bin Professor of surgeryProfessor of surgery

    Director of the Dept. of Surgical oncologyDirector of the Dept. of Surgical oncologyXuzhou Medical College HospitalXuzhou Medical College Hospital

    Tel: 13776791919Tel: 13776791919

    (P535)(P535)

  • ANATOMY

    Intrahepatic Biliary Tract Extrahepatic Biliary Tract The gallbladder

  • ANATOMY

    Intrahepatic Biliary Tract

  • Anatomy of the Biliary System

    ---Extrahepatic Biliary Tract

    The left and right hepatic ductsleft 2.5-4cm,right 1-3cmRelationships between bile duct, artery and portal vein The common hepatic duct2-4cm, diameter 0.4-0.6cm

  • Anatomy of the Biliary System

    ---Extrahepatic Biliary Tract

    The common bile ductlength 7-9cm

    diameter 0.4-0.8cm >1cm pathologic

  • Anatomy of the Biliary System

    ---Extrahepatic Biliary Tract

    Relationship between the CBD and portal vein and hepatic artery

  • Anatomy of the Biliary System ---Extrahepatic Biliary Tract

    The gallbladder fundus, body, and neck

    The cystic duct

  • Anatomy of the Biliary System ---Extrahepatic Biliary Tract

    Pouch of HartmannValves of HeisterTriangle of CalotTriangle of Calot Ampulla of VaterSphincter of Oddi

  • Triangle of CalotTriangle of Calot

  • ANATOMY

    Artery

    Vein Lymph

    tumor metastasis Nerve

    biliary-cardiac reflex

  • Biliary Physiology

    Secretion, composition and function of bile Secretion hepatic cells or bile cells? amount?

    800-1200ml per day

  • Biliary Physiology

    Composition of bilewater (97%)Solids

    Bile salt, chelesterol, lecithin

    or phospholipid (90% of the solids in bile)

    Bilirubin, fatty acids and inorganic salts.

  • Biliary Physiology

    Functions of bile

    Emulsification and absorption of fat,Emulsification and absorption of fat,

    Inhibition of bacterial,

    Stimulation of intestinal movement

    Neutralization of gastric acid

  • Biliary Physiology

    Regulation of bile secretion CCK stimulation of fat protein.

    Metabolism of bile Dissolution of cholesterol Micro Micelles: Vesicle

  • Enterohepatic circulation of bile saltEnterohepatic circulation of bile salt

  • Metabolism Metabolism of bilirubinof bilirubin

  • Biliary Physiology

    Metabolism of bilirubin

    Dissolution of bilirubin Bacteria are involved in their formation via secretion of beta glucuronidase and phospholipase

    calcium bilirubinate

  • Biliary Physiology Physiological function of bile duct---

    regulation of bile discharge

    1.18kPa

    0.98kPa

    3.83kPa

    0.79kPa

    1.18kPa

  • Storage and Secretion of Gallbladder Bile into the IntestinStorage and Secretion of Gallbladder Bile into the Intestin

  • Physiological functions of gall bladder Concentration and storage of bile Discharge of bile Secretion

    What will happen to a patient if his gallblader is resected?

    Biliary PhysiologyBiliary Physiology

  • : 0.6-0.8cm0.6-0.8cm >1cm>1cm Triangle of CalotTriangle of Calot

  • DIAGNOSTIC EXAMINATION DIAGNOSTIC EXAMINATION OF THE BILIARY TREEOF THE BILIARY TREE

  • Diagnostic Approaches

    US B-type Ultrasonography first choicefirst choice Diagnosis of gallstone

    highly echogenic focus with acoustic shadows Differentiation of jaundice

    dilatation of bile duct Detection of gallbladder function Other biliary illness

    Intraoperative US less interference

  • a highly echogenic focusa highly echogenic focus

    acoustic shadows

  • Endoscopic US---EUS

  • Diagnostic Approaches

    Conventional Radiology KUB film 15% radiopaqueporcelain gallbladder

  • Porcelain GallbladderPorcelain Gallbladder

  • Diagnostic Approaches Conventional Radiology

    Oral cholecystography function of gallblandder

    Veinal cholangiography

  • Diagnostic Approaches

    Special RadiologyPTC jaundice PTCD ERCP CT MRI MRCP Intra- or postoprative

    cholangiography

  • Percutaneous transhepatic cholangiographyPTC

  • PTCD

  • ERCP

  • Computed tomography (CT)

  • BUS

    CT

    PTC

    STONE

  • Computed tomography (CT)

  • MRCP

  • MRCP

  • Intra- or postoprative cholangiographyIntra- or postoprative cholangiography

  • Diagnostic ApproachesEndoscopic Examinations Biliary endoscope

    intro- or post-operatiion Diagnosis and treatment

  • CholangioscopyCholangioscopy

  • CholangioscopyCholangioscopy

  • CholangioscopyCholangioscopy

  • BUS CT PTC PTCD ERCP

    MRI MRCP

  • Liu BinDivision of General Surgery

  • Cholelithiasis 11.5%

    (Cholesterol Gallstones) 80%

    (Pigment Gallstones) + +

    + +

    60% 40%

  • Cholecystolithiasis Gall stone

    "4F: Female, fat, fertile forties."

    + 5F family

  • Cholecystolithiasis Gall stone

    Clinical presentationsClinical presentations silent stone , asymptomatic )

    : Mirrizi syndrome

  • Mirrizi syndrome

  • Cholecystolithiasis Gall stoneClinical presentationsClinical presentations

  • Cholecystolithiasis Gall stone

    Diagnosis : BUS 96% + + .

    CT MRI

  • Cholecystolithiasis Gall stone

    Treatment

    ( >3cm >10

  • Cholecystolithiasis Gall stone

    Treatment

    (Laparoscopic cholecystectomy) (Open Cholecystectomy)

  • Laparoscopic CholecystectomyLaparoscopic Cholecystectomy

  • Laparoscopic CholecystectomyLaparoscopic Cholecystectomy

  • Choledocholithiasis

    CBD

  • Etiology:Etiology: + + PathologyPathology

  • Clinical presentationsClinical presentations Charcot Clinical triad of

    Charcot

  • Lab examinations WBC Bilirubin SGPT AKP

    Radiology Findings BUS CT MRI PTC ERCP

  • DiagnosisDiagnosis Charcot +

    DifferentiationDifferentiation

  • ManagementManagement

  • --

    CBD +T BUS

    6

  • T T YY

  • --

    CBD Roux-en-Y + CBD

  • Roux-en-Y choledochojejunostomy

  • --

    Oddi CBD

  • --

    (EST)

  • Hepatolithiasis

    Etiology Pathology

  • Hepatolithiasis

    Clinical presentationsClinical presentations AOSC

  • Hepatolithiasis

    DiagnosisDiagnosis BUS CT PTC

  • Hepatolithiasis

    ManagementManagement + Oddi CBD-

  • Hepatolithiasis

    +

  • Charcot

    T

  • Infection of biliary tract

    Liu BinDivision of HPB Surgery

  • Infection of biliary tract

    Cholecystitis Cholangitis

    Cholecystitis Acute calculous cholecystitis 95% Acute acalculous cholecystitis 5%

  • Acute Calculous Cholecystitis

    Etiology G-Pathology

  • Acute Calculous Cholecystitis

    Clinical presentations

    -

    Murphy sign(+)

  • Acute Calculous Cholecystitis

    Laboratory examination WBC SGPT AKP Bilirubin am

    ylase

    Radiological examination BUS:

    CT MRI

  • Acute Calculous Cholecystitis

    Diagnosis and differentiation

  • Acute Calculous Cholecystitis

    Treatment

  • Acute Calculous Cholecystitis

    Operative treatment

    72

  • Chronic cholecystitis

    Etiology

    Pathology

  • Chronic cholecystitis

    Clinical presentations Signs:

  • Chronic cholecystitis

    Diagnosis BUS:

    Differentiations

  • Chronic cholecystitis

    Treatment

  • Acute Obstructive Suppurative Cholangitis, AOSC

    Acute Cholangitis of Severe Type ACSTEtiology 76-88.5% 8.7-11% T PTC

  • Acute Obstructive Suppurative Cholangitis, AOSC

    Pathology

    +

    >1.96kPa(20cmH2O)

  • Acute Obstructive Suppurative Cholangitis, AOSC

    Clinical presentationsReynolds Reynolds Charcot +

    39-40C

  • Acute Obstructive Suppurative Cholangitis, AOSC

    Clinical presentations T>39-40 C P>120 / BP WBC>20109/L PL PT

    BUS CT MRI MRCP

  • Acute Obstructive Suppurative Cholangitis, AOSC

    Treatment 6h)

  • Acute Obstructive Suppurative Cholangitis, AOSC

    Treatment

    T

    PTCD ERCP--ENBD endoscopic nasobiliary drainage)

  • AOSC

  • Tumor of biliary tract

    (polypoid lesions of gallbladder)-

    BUS

  • Tumor of biliary tract

    Differentiation of benign and malignant tumor

    1cm 1cm

    BUS

  • 1 2 3 10mm 4

  • adenomyomatous hyperplasiaadenomyomatous hyperplasia

    HE100

  • Carcinoma of Gallbladder

    25% 1% =1:1.98 60-70

    Etiology 70-98%

  • Carcinoma of Gallbladder

    Pathology 80%