BILIARY TRACT DISEASEDr Julia EpsteinGastroenterology departmentHadassah Medical center

Biliary disease

• Gallstones • Congenital anomalies• Extrinsic compression of the bile ducts• Hepatobiliary parasitism• Noncancerous strictures

Biliary tract anatomy

Ampullary anatomy

Pancreatic duct sphincter

Biliary duct sphincter

Sphincter of Oddi

Papilla of Vater

כיס מרה

ס"מ7.5-10מבנה אגסי • ס"מ30-50תכולה ••

מרה מיוצרת←כבד ••מרה נאגרת←כיס מרה ••

•CCK• אוכל שומני←תרסריון←הפרשת+ מרה מתכווץ

ספינקטר ע"ש אודי נפרה ← מעבר מיצי •מרה לתריסריון

ספיגה מחדש לוריד הפורטלי←חזרה ••לכבד Enterohepatic Circulation :

כבד←מרה←מעי

מיצי מרה: מים, אלקטרוליטייםמכיל -

Na, K, Ca, Cl, HCO3 ,לציטין,חומצות שומן, כולסטרול

בילירובין ומלחי מרה

?מאיפה מגיע בילירובין:תפקיד

ספיגה של השומנים לאחר תהליך אמולסיפיקציה –

שפעול מיצי הלבלב –

המרה )בסיסית( סותרת את מיץ הקיבה החומצי –

.המגיע לתריסריון

מבנה מרה

• מלחי המרה ← מסיסים במים

• פוספוליפידים + הכולסטרול ← לא מסיסים במים

• הופכים למסיסים שנוצרות מיצלות

• היחס בין שלושת המרכיבים עדין

• ← כל חריגה מהיחס המסוים

• מרה רוויה + שקיעה של

• כולסטרול )יצירת אבנים(

Principal pathways of cholesterol metabolism in liver

Gallstones – Pathophysiology

• Cholesterol, ordinarily insoluble in water, comes into solution by forming vesicles with phospholipids

• If ratio of cholesterol, phospholipids, and bile salts altered, cholesterol crystals may form

• Gallstone formation involves a variety of factors:– Cholesterol supersaturation– Mucin hypersecretion by the gallbladder mucosa

creates a viscoelastic gel that fosters nucleation. – Bile stasis

Gallstone pathogenesis

Gallstones • Risk factors:• Obesity• Female gender • Parity• Maternal family history ( ABCB4 , CYP7A1)• Ethnic predilection (Hispanic, Native americans)• Increasing age• Rapid weight loss

Gallstones

• Risk factors: Ileal diseaseLipid abnormalities (high TG, low LDL)Medications (contraceptives, postmenopausal estrogens, lipid lowering agents fibric acid derivated)• TPN

5 F’s• Fair• Fat• Fertile• Female• Forty

מצבים שכיחים

• Cholelithiasis• Biliary colic• Hydrops• Empyema• Choledocholithiasis• Acute Cholecystitis• Ascending Cholangitis

Gallstones – Types

• Two main types:– Cholesterol stones (85%)– Pigment stones (15%) occur in 2 subtypes— brown and black.

• Black stones result when excess bilirubin enters the bile and polymerizes into calcium bilirubinate (chronic hemolysis)

• Brown stones are made up of calcium bilirubinate and calcium-soaps. Bacteria involved in formation via secretion of beta glucuronidase and phospholipase

Gallstones – Natural History

• 80% of patients, gallstones are clinically silent

• 20% of patients develop symptoms over 15-20 years (1-2% per year)

• 50-70% continued to have symptoms and complications

• More than 90% of complications are preceded by biliary colic

Biliary Colic

• Intermittent obstruction of the cystic duct, no inflammation of GB

• Severe epigastric/ RUQ pain growing over 15 min and remaining constant up to 3h

• Frequency of attacks varies• Normal examination• Lab tests usually normal• DS: US, EUS• Natural history: 30% have no further symptoms 50% continue symptoms in 2y

Acute Calculous Cholecystitis

• Impacted stone in the cystic duct• 75% are preceded by attacks of biliary colic• Visceral epigastric pain – mod to severe, irradiated to RUQ,

back, shoulder, chest and lasting > 6 h• Fever, Right subcostal tenderness with inspiratory arrest ( Murphy’s sign) , palpable GB• Leucocytosis, mild elevation of BIL, Amylase• 50% resolve spontaneously in 7-10 days without surgery• DS: US, EUS, CT• 10% are complicated by perforation.

Empyema / Mucocoele

• Mucocele refers to an overdistended gallbladder filled with mucoid or clear and watery content.

• Empyema refers to a gallbladder filled with pus due to acute cholecystitis

Choledocholithiasis

• Intermittent obstruction of CBD• Often symptomatic – indistinguishable from biliary

colic• Predisposed to acute cholangitis and pancreatitis• Signs : jaundice with pain. • Investigations

– Elevated BIL, transient spike in Tranaaminases / Amylase, – US, EUS, CT

• Treatment – ERCP - Endoscopic Retrograde CholangioPancreatography

Ascending Cholangitis

• Impacted stone in CBD causing bile stasis•Bacterial superinfection•Charcot’s triad : pain, jaundice, fever – 70%•Mental confusion, hypotension, RUQ tenderness• Jaundice (>80%)•Peritoneal signs (15%)•Elevated WBC, BIL, APH (blood cult usually pos)•Emergent decompression of the CBD (ERCP, PTC)

Acute biliary pancreatitis• Pancreatic duct obstruction or chemical inflammation • Signs - Variable – None to Sepsis

(Severe pain, fever, tachycardia, low BP), Jaundice, acute abdomen• Investigations

• Bloods – U&E, FBC, LFT, Amylase, CRP• Ultrasound of abdomen• MRCP• CT Pancreas

• Treatment Supportive / ERCP

Gallstone ileus

• Obstruction of the small bowel by a large gallstone–A stone ulcerates through the gallbladder into the

duodenum and causes obstruction at the terminal ileum/rt colon

• Symptoms : SBO - vomiting, abdominal pain, distension, obstructive bowel sounds

• Investigations: X-ray, US/CT - air in CBD• Treatment : Laparotomy and removal of stone from

small bowel and cholecystectomy.

Mirizzi’s Syndrome

Inflammatory phenomenon secondary to a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum

The impacted gallstone causes first external obstruction of the CBD

Eventually erodes into the bile duct evolving into a

cholecystocholedochal fistula with different degrees of communication between the GB and CBD

Mirizzi’s Syndrome

Lemmmel’s Syndrome

Duodenal diverticula syndromeSecondary to extrinsic compression by

periampullary diverticula in the absence of additional pathology (cholelithiasis, tumor)

• The hypothesized mechanisms:• Alterations of the papillary motility• Bacterial contamination• Extrinsic compression of the Main biliary tract

Lemmmel’s Syndrome

Acute Acalculous Cholecystitis

• Presence of an inflamed gallbladder in the absence of an obstructed cystic or common bile duct

• Typically occurs in the setting of a critically ill patient (eg, severe burns, multiple traumas, lengthy postoperative care, prolonged intensive care)

• Accounts for 5% of cholecystectomies• Etiology is thought to have ischemic basis, and gangrenous

gallbladder may result• Increased rate of complications and mortality• An uncommon subtype known as acute emphysematous

cholecystitis generally is caused by infection with clostridial organisms and occlusion of the cystic artery associated with atherosclerotic vascular disease and, often, diabetes.

Cholecystectomy

• Laparoscopic cholecystectomy standard of care

• Timing– Early vs interval operation

• Patient consent– Conversion to open

procedure 10%– Bleeding– Bile duct injury– Damage to other organs

Biliary disease

• Gallstones • Congenital anomalies• Extrinsic compression of the bile ducts• Hepatobiliary parasitism• Noncancerous strictures

Biliary Tract Cysts

• Choledochal cysts• Consist of cystic dilatations of the extra-

hepatic biliary tree• Uncommon abnormality and 90% diagnosed

before age 30• Infantile form presentation identical to biliary

atresia• 50% present with combination of jaundice,

abdominal pain, and an abdominal mass

Choledochal cysts

• Classified into 5 types• Can occur in the presence of pancreatico-

biliary maljunction (PBM) • Treatment for choledochal cysts is surgical

excision of the cyst with construction• Most ominous complication is malignancy

Choledochal cysts

Caroli disease

PBM

Biliary ductopenic disorders

• Paucity of interlobular bile ducts - 2 types: syndromic and non syndromic

Syndromic ( Alagille’s syn) ADD d/t JAG1 gene Intrahepatic cholestasis and biliary hypoplasiaPruritus and hepatomegalyExtrahepatic manifeatations - congenital heartdefects, eye defects, triangular face

Biliary ductopenic disorders

• interlobular ductopenia as result of inflammatory condition:

• PSC• PBC• GVHD• Liver allograft resection• Drug induced liver disease• idiopathic

Biliary disease

• Gallstones • Congenital anomalies

• Extrinsic compression of the bile ducts• Hepatobiliary parasitism• Noncancerous strictures

Extrinsic compression of the bile ducts

• Biliary tract tumor• Carcinoma of the head of pancreas• Acute and chronic pancreatitis• Lymph nodes – lymphoma or metastasis• Benign stricture of biliary ducts

Biliary Tract Tumor Cholangiocarcinoma

Cancer of the Gall Bladder

Cholangiocarcinoma

• Slow growing malignancy of biliary tract which tend to infiltrate locally and metastasize late

• 90% adenocarcinoma• 60-70% at the bifurcation ofhepatic ducts• 20-30% - in the distal CBD• 5-10% - arise within the liver (peripheral)

Biliary Tree Neoplasms

• Clinical symptoms:– Weight loss (77%)– Nausea (60%)– Anorexia (56%)– Abdominal pain (56%)– Fatigue (63%)– Pruritus (51%)

• Symptomatic patients usually have advanced disease, with spread to hilar lymph nodes before obstructive jaundice occurs

• Associated with a poor prognosis

• Fever )21%(• Malaise )19%(• Diarrheoa )19%(• Constipation )16%(• Abdominal fullness )16%(.

Risk factors

• Liver flukes (Opistorchis viverrini, Chlonorchis sinensis)

• Chemial exposition (Asbestosis)• Congenital predisposition (PBM, Choledochal

cysts)• Intrahepatic biliary stones• PSC

CholangiocarcinomaDiagnosis and Initial Workup

• Jaundice• Weight loss, anorexia, abdominal pain, fever

• US – bile duct dilatation• 3-phase CT• MRCP/MRI• ERCP with Brush biopsy• Percutaneous Cholangiography with Internal

Stent and Brush Biopsy

MRCP: Cholangiocarcinoma at the Bifurcation

Klatskin tumour - Cholangiocarcinoma of junction of right & left hepatic ducts

ERCP: Distal CBD Cancer

Surgical Removal – only 25%resectable at the time of

diagnosis• Node Dissection in Bile

Duct Excision• Roux-en-Y

Hepaticojejunostomy

Cholangiocarcinoma

Palliative therapy :•Stent•Chemotherapy +/- Radiation Therapy•Survival with surgery and chemo/radiation is 24 to 36 months•With chemotherapy / radiation alone survival is 12 to 18 months•Liver transplantation – 80% 5-y survival rate•In selected patients who complete chemo-radiation protocol

Gallbladder Cancer

• 6th decade• 1:3, Male:Female• Highest prevalence in Israel, Mexico,

Chile, Japan, and Native American women.

• Risk Factors: gallstones, porcelain gallbladder, polyps, Salmonella typhi carrier state, some drugs

Gall Bladder Cancer

• Uncommonly diagnosed preoperatively• >80% with gallstones• Clinical manifestation from abdominal pain to

unexplained weight loss and jaundice• Palpable RUQ mass• Jaundice suggests local extention with ductal

obstruction• DS: US, EUS, CT

Gall Bladder Cancer

• Discovered on pathology after a routine cholecystectomy (1-2%)

• If negative for metastasis: – Radical cholecystectomy with nodal dissection,

central hepatectomy, w or w/o bile duct excision– Excise port sites– Followed by Chemo/Radiation

• 5 year survival = 60%

Gallbladder Cancer

• Cholecystectomy should not be offered for all patients with stones for fear of cancer

• Cholecystectomy should be considered for calcified GB and for growths (adenomyoma, polyps > 15 mm)

Pancreatic cancer

• Pancreatic cancer is the most common malignant cause, followed by cancers of the gallbladder, bile duct, liver, and large intestine.

Metastasis • 1st category involves local extension into the hilum by a tumor

arising in an adjacent structure, such as the gallbladder, cholangio CA

• The 2nd - includes metastases from a distant primary site, most often from solid tumors, such as carcinoma of the breast, colon, ovaries or lymphoma, melanoma

• Mechanical cholestasis caused by the stricture, mostly of the common hepatic or common bile duct Patients have severe jaundice and associated symptoms such as

pruritis, recurrent cholangitis and malaise.

Metastasis

Biliary disease

• Gallstones • Congenital anomalies• Extrinsic compression of the bile ducts

• Hepatobiliary parasitism• Noncancerous strictures

Hepatobiliary parasitism

• Pyogenic cholangitis &hepatic abscess, ductal stones, biliary obstruction

• Clonorchis sinensis, Opisthorchis viverrini, O. felineus, Fasciola hepatica

• Ascaris lumbricoides, Echinococcus spp.

Clinical manifestation of hydatid cyst

• Most patients with hepatic uncomplicated hydatid cyst are asymptomatic

Possible symptoms and signs are: RUQ pain , epigastric pain , fever , fatigue , nausea and dyspepsia ,hepatomegaly and abdominal mass

Complications: Superinfection of hydatid cysts Rupture to adjacent structures (peritoneal spillage, cholangitis, pancreatitis, anaphylaxis) Rare – portal HTN, hepatic vein thrombosis, secondary biliary cirrhosis

Diagnosis History of exposure

Chest and abdominal X-ray

Ultrasound (diagnostic method of choice)

CT (better information about location, depth , mandatory before planning operation)

MRI (for NS, venous system and biliary complications )

Serology (positive – confirms infection, negative test does not exclude)

Gharbi’s US classification Type I - Pure fluid collection Type II - Fluid collection with a detached membrane Type III - Fluid collection with multiple septa and or daughter cysts Type IV - Hyperechoic with high internal echoes Type V - Cysts with reflecting, calcified walls

CT

ERCP

Histology

Treatment of hepatic hydatid cyst

The treatment of hepatic hydatid cysts is strongly indicated in order to prevent cyst complications

The therapeutic options are: 1. Surgical intervention – remains the

cornerstone of radical treatment 2. Percutaneous drainage 3. Drug therapy

Surgical optionsOpen surgical techniques Radical removal of pericystic membrane and parasitic

content Marsupialization (partial cysto-pericystectomy)

Contraindications: severe comorbidity Complications: biliary fistula, cyst infection, pleural

effusion, peritonitis, abscess, anaphylactic shock Laparoscopic surgery Contraindications: Deep intraparenchimal cysts > 3 cysts, with thick calcified wall Complications: intra-abdominal seeding due to

pneumoperitoneum

Paliative procedures PAIR - puncture-aspiration-injection-reaspiration Indicated for type I , II and III cysts Inoperable patients, pregnant women Multiple disseminated cysts Contraindications: IV, V types of cysts, ruptured cysts into biliary tree or peritoneum ERCP – Naso-biliary drainage – biliary endoprosthesis Combined therapy with albendazole is an effective and safe

alternative to surgery for uncomplicated hydatid cysts (Khuroo et al, 1998)

Indications for drug therapy:

WHO Guidelines 1996 Inoperable primary liver or lung echinococcosis Multiple echinococcal multiorgan and peritoneal

cystsPreoperative or pre-drainage (at least 4 days

before surgery and 1 m (ABZ) or 3 m (MBZ) after)Poor patient status

Contraindications:Large cysts that are at risk of rupture Pregnancy ,chronic liver disease or depressed BM

Biliary disease

• Gallstones • Congenital anomalies• Extrinsic compression of the bile ducts• Hepatobiliary parasitism

• Noncancerous strictures

Biliary Stricture – Non Cancerous Causes

Noncancerous causes of bile duct stricture include:•Injury to the bile ducts during surgery for gallbladder removal •Pancreatitis (inflammation of the pancreas)•Primary sclerosing cholangitis • Gallstones (benign CBD stricture, papillary stenosis

•Blunt trauma to the abdomen

Primary Sclerosing Cholangitis

• Chronic cholestatic biliary disease characterized by non-suppurative inflammation and fibrosis of the biliary ductal system

• Cause is unknown but is associated with autoimmune inflammatory diseases, such as chronic ulcerative colitis and Crohn’s colitis, and rare conditions, such as Riedel thyroiditis and retroperitoneal fibrosis

• Most patients present with fatigue and pruritus and, occasionally, jaundice

PSC

•Natural history is variable but involves progressive destruction of the bile ducts, leading to cirrhosis and liver failure

•Clinical features of cholangitis (ie, fever, right upper quadrant pain, jaundice) are uncommon unless the biliary system has been instrumented.

PSC

PSCMedical Care•Chronic progressive disease with no curative medical therapy•Goals of medical management are to treat the symptoms and to prevent or treat the known complications•Liver transplantation is the only effective therapy and is indicated in end-stage liver disease.

Surgical Care•Indications for liver transplantation include variceal bleed or portal gastropathy, intractable ascites, recurrent cholangitis, progressive muscle wasting, and hepatic encephalopathy. •Recurs in 15-20% of patients after transplantation.

Primary Biliary Cirrhosis

•Progressive cholestatic biliary disease that presents with fatigue and itching or asymptomatic elevation of the alkaline phosphatase.

• Jaundice develops with progressive destruction of bile ductules that eventually leads to liver cirrhosis and hepatic failure.

•Autoimmune illness has a familial predisposition

PBC

Antimitochondrial antibodies )AMA( are present in 95% of patients

Goals of treatment are to slow the progression rate of the disease and to alleviate the symptoms )eg, pruritus, osteoporosis, sicca syndrome(

Liver transplantation appears to be the only life-saving procedure.

ERCP

Endoscopic retrogradecholangiopancreatography (ERCP) •Endoscopic tube is placed into the patient’s mouth, through the stomach, and into the duodenal portion of the small intestine. •Contrast is introduced into the biliary tract through the endoscope, in a retrograde manner. •X-rays taken

ERCP• ספינקטרוטומיה

• הוצאת אבנים )בלון, בסקט(, ריסוק אבנים• הכנסת סטנטם

PTC הזרקת חומר ניגוד דרך עור לדרכי מרה

התוך כבדיים תחת סונר והדמיה ברנטגן

PCC

• PerCutaneous Cholecystostomy• במקרים קשים בהם ניתוח עלול לסכן את החולה –

ניקוז מרה בשיטה מלעורית

Indications For Biliary Stenting

Indications for stent insertion include:•Ampullary Stenosis•Bile duct injury•Benign or malignant biliary obstruction•Prevention of obstruction where stone

extraction is not possible at that time•Pancreatic duct strictures, stones and

sphincter of Oddi dysfunction

Stent Placement -Endoscopic Approach

• A catheter is inserted through the endoscope into the ostium of the common bile duct.

• While maintaining the endoscope position in the duodenum, a wire is inserted through the catheter into the bile duct.

• The stent delivery system is then inserted over the wire to the site of obstruction, where the stent is deployed.

Stent Placement – Endoscopic Approach

Success rate of ERCP 90-95%Complication rate of approximately 3-5%. Complications:• Pancreatitis• Bleeding• Perforation• Infection• Cardiopulmonary depression from conscious sedation.

Biliary Stent - Percutaneous transhepatic approach PTC

For biliary stent placement using a percutaneous approach:•A fine needle is inserted between the 4th and 5th rib on the patient’s right side•The puncture is through the liver•The needle is inserted into an intrahepatic duct under image guidance.

Photo on file at Medtronic

Biliary Stent - Percutaneous Approach

Success rate 95% when ducts are dilated• 5-10% rate of major complications which include:•Sepsis•Bile leak•Intraperitoneal haemorrhage, Haemobilia•Hepatic and perihepatic abscess, Pneumothorax•Skin infection and granuloma at the catheter entry site

• Contraindicated in patients with bleeding diatheses and significant ascites.