Biliary tract

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  • 1. Bile is a bi-product of degraded heme part ofold red cells. It is secreted by the liver ,transported throughbiliary channels to gall bladder where it isstored, concentrated and later delivered to theduodenum.

2. ANATOMY OF BILIARY TREEBiliary tree is divided into: Intrahepatic ducts Extrahepatic ductsINTRAHEPATIC DUCTS These comprise of ductular and canalicular networkfrom the acini . The smallest interlobular ducts join toform segmental bile ducts which finally unite to formthe left and right hepatic ducts. They travel with branches of portal vein & hepaticartery in portal triads. 3. The Rt.hepatic duct drains four segments ofRt.lobe of liver through two segmental divisions,an anterior division drains segment 5 & 8 andposterior division drains segment 6 & 7. The Lt.Hepatic duct drains segment 2,3 & 4 ofleft lobe. Caudate lobe has a variable drainage patternbut in majority, 78% drainage is into both mainducts. 4. EXTRA HEPATIC BILE DUCTS The right and left hepatic ducts fuse at thehilum ,anterior to bifurcation of the portal vein toform Common Hepatic Duct which is then insertedby cystic duct from the gall bladder and becomesCommon Bile Duct The CBD passes inferiorly posterior to the firstpart of duodenum and pancreatic head to enter thesecond part of duodenum along with the mainpancreatic duct at Ampulla of Vater 5. ARTERIAL SUPPLYThree segments of supply. Supply to the Supraduodenal part is essentially axialfrom Retroduodenal artery, Rt.hepatic artery, Cysticartery and Gastroduodenal artery. Hilar biliary ducts recruit their supply from a networkin continuity with the Supraduodenal supply. Retropancreatic part of common bile duct is derivedfrom Retroduodenal artery. 6. DEVELOPMENTAL INTRAHEPATICBILIARY ANOMALIESVariations occur: Triple confluence of the Rt.posterior sectoral, Rt.anteriorsectoral and main Left Hepatic duct(12%) Direct insertion of Rt.sectoral duct into main bile duct(20%) Insertion of Rt.sectoral duct into Lt.hepatic duct(3%) Insertion of Rt.posterior sectoral duct into Cystic duct or gallbladder may occur.Failure to recognise these anatomical variations atcholangiography or surgery may result in biliary leaks orimpaired drainage lead to cholangitis. 7. EXTRAHEPATIC BILIARY ANOMALIESA number of anomalies with important radiologicalimplications are; Agenesis of gall bladder. Bilobar gall bladder. Folded gall bladder. Congenital diverticulum. Duplication of cystic duct with a unilocular gall bladder. Septum of gall bladder. Anomalies of gall bladder position i.e it may lie in anintrahepatic, suprahepatic or retrohepatic site or herniatethrough epiploic foramen.These anomalies if complicated by disease carry high morbidity. 8. INVESTIGATIONRadiological investigations comprise of : Plain radiograph Ultrasound Computed tomography Magnetic resonance imaging Radionuclide imaging Indirect cholangiography 9. Plain Radoigraph Plain radiograph is usually taken as part ofsequence of investigation of abdominalpain. It gives information about radiopaquestones, mural calcification, mural gas andgas in biliary tree. 10. ULTRASOUND the first line investigation particularly calculous disease(over98% accuracy). Preperation:Fasting for a minimum of 6 hours Scanning in two positions,supine and left lateral ensures to findany missed calculus. U/S detects dilated Intrahepatic and extrahepatic ducts,cholelithiasis, cholecystitis, GB polyp, choledochal cyst etc 11. COMPUTED TOMOGRAPHY The sensitivity of CT in differentiating hepatocellularfrom obstructive jaundice and in determining the leveland cause of obstruction parallels that of ultrasound. CT is reserved for those patients in whom there isdoubt as to the cause of obstruction and in staging ofbiliary tumours. 12. RADIONUCLIDE IMAGING99mTc-HIDA is used to study the action of biliary tree.TECHNIQUE Between 2 and 10 mCi of 99mTc-HIDA is administered intravenously after a2 hr fast. Images are acquired over the next hour at 1min intervals. Subsequent images may be required at various intervals over 24 hours toevaluate excretion. The normal HIDA scan provides functional and morphologicalinformation about hepatic parenchyma in the first 10 min, the extrahepaticbiliary tree by 20 min, and excretion into the bile by 1 hrINDICATIONS Neonatal and childhood jaundice Cholesystitis Biliary obstruction and Biliary leaks 13. 99mTc-HIDA scan. Biliary obstruction. Activity on the serialimages is concentrated in the liver and none has traversed thebiliary tree into the gut. Cardiac activity is shown to decreaseas more and more of theactive agent is extracted by and concentrated in the liver. 14. INDIRECT CHOLANGIOGRAPHYORAL CHOLANGIOGRAPHY It has a limited role in anatomical and functionalassessment of gall bladder but the diagnostic accuracy indemonstrating gall stones is upto 90%. The media commonlyused is sodium ipodite (Biloptin), Calcium ipodite(Solubiloptin). 15. Small Cholesterol calculi which float in the erectposture(A) Prone (B) Erect 16. PERCUTANEOUSCHOLANGIOGRAPHY (PTC) Direct puncture of the intrahepatic ducts using a fine-gaugeChiba needle allows demonstration of biliary treewith relative safety.INDICATIONS Obstructed jaundice with or without duct dilatation. In defining biliary-enteric or biliary-cutaneous fistulas. In defining levels of bile leak. To map biliary tree as a preliminary to establish externalor internal biliary drainage with stent placement. 17. ENDOSCOPIC RETROGRADECHOLANGIOPANCREATOGRAPHY (ERCP) ERCP is a technique that combines endoscopy and fluoroscpyThrough endoscope, inject dyes into ampulla of vater and cansee the biliary tree and pancreatic duct ERCP can be used both for diagnostic and therapeuticpurposes. INDICATIONS Obstructive jaundice Gall stones with dilated bile ducts / Removal of stones Sphincter of oddi dysfunction / Sphincterotomy Bile duct tumors Dilatation of strictures 18. Risk factors involve in ERCP are: Pancreatitis Gut perforation Sphincterotomy associated bleeding. 19. OPERATIVE CHOLANGIOGRAPHYOperative cholangiography prior starting surgicalprocedure is done commonly at the time ofcholecystectomy for: Exploration of CBD Anomalous duct anatomy Developmental disorders of biliary tree.Postoperative cholangiography through a T-tube isindicated to ensure removal of all stones. 20. DEVELOPMENTAL DISORDERS OF CHILDHOOD BILIARY ATRESIA CHOLEDOCHAL CYST CAROLI,S DISEASE 21. BILIARY ATRESIA Atresia of the extrahepatic bile ducts in newborninfants of unknown etiology. Incidence is 0.8-1.0 /10,000 live births. Associated anomalies like polysplenia, situs inversus,malrotation and absent inferior vena cava occurs inupto 30% of cases. Presentation is with prolonged conjugatedhyperbilirubinaemia. u/s reveals hypoplastic gall bladder, a cystic cavity atporta and features of cirrhosis early in life. Treatment is early portoenterostomy. 22. Severe biliary atresia with obliteration of intrahepatic bileducts. Hyperplastic lymphatics allow some drainage of bile into theconstructed portoenterostomy (Kasai procedure). This is the mostcommon type and carries the worst prognosis. 23. Choledochal cyst Cystic dilatation of extrahepatic bile ducts in chilldhoodPresented by; jaundice from obstruction and cholangitis. abdominal pain from pancreatitis. Cholangiography reveals a long common pancreaticobiliarychannel.TYPESTYPE I _ Cystic or fusiformTYPE II _ DiverticulumTYPE III _ Choledochocele of intraduodenal common bile duct.TYPE IV_ Extra and intrahepatic cysts.TYPE V _ Intrahepatic dilatation. Diagnosis is mainly by u/s and cholangiography. Treatment is redical excision of cyst and hepaticojujenostomy. 24. Fusiform choledochal cyst with along common channel andassociated stricture at thepancreaticobiliary junction.CT of a large choledocal cystwith biliary obstruction 25. CAROLI,S DISEASE It is characterised by multifocal, saccular dilatation ofintrahepatic bile ducts sparing the extrahepatic ones. Biliary stasis lead to cholangitis,ductal calculi and liverabscesses. A specific sonographic apperance is central dotsign, occurs when dilated bile duct segment surroundsthe adjacent hepatic artery and portal vein. It is usually associated with congenital hepatic fibrosisand cystic disease of kidneys called AUTOSOMALRECESSIVE FIBRO POLYSTIC DISEASE. 26. Caroli's disease with characteristic strictures andsegmental intrahepatic dilated ducts. 27. ACQUIRED DISORDERS OF CHILDHOOD INSPISSATED BILE PLUG SYNDROME SPONTANEOUS PERFORATION OF BILE DUCT BILE DUCT TUMOURS CHOLILITHIASIS BILIARY STRICTURES CHOLANGIOPATHIES OF CHILDHOOD 28. Inspissated bile plug syndrome Infants may present with jaundice secondary to plugsof thickened bile or rarely obstructing calculi ,andacholic stools. Aetiological factors include prematurity, prolongedparenteral nutrition,hemolysis developmentalcholedochal anomalies etc Treatment is saline irrigation at percutaneouscholangiography or surgical intervention. 29. Cholelithiasis Cholelithiasis is being increasinglydiagnosed in childhood. Phototherapy,infection,ileal resectionhemolytic diseases contribute to this risingincident. Spontaneous resolution is often reportedin infancy, therefore conservativemanagement is advisable. 30. DISORDERS OF GALL BLADDERGALL STONES Upto 17% of adult population have gallstones. About50% of detected calculi remain asymptomatic over a10 year period.Stones may be of CHOLESTEROLPURE PIGMENTCALCIUM BILE SALTSMIXED 31. CALCULUS CHOLECYSTITIS This results when a calculus obstructing the cystic duct causeinfection of static bile and the gall bladder mucosa. Differentiated into ACUTE CHOLECYSTITISCHRONIC CHOLECYSTITISRADIOLOGICAL INVESTIGATIONSPLAIN RADIOGRAPHIt is estimated that only 15% of gallstones are radiopaque.Thedensest stones are of almost pure calcium carbonate describedas mulberry stones .They show stellate faceted appearancewith gas forming fissures(Mercedes Benz sign) 32. Calcium carbonate(mulberry)stonesMercedes Benz' stone; char