Disease of the Biliary Tract

Anatomy

Calot triangle:• The triangle bounded by the common hepatic

duct medially,the cystic duct inferiorly and the inferior surface of the liver superiorly is known as Calot triangle.

• The fact that cystic artery ,right hepatic artery & para-right hepatic duct run within the triangle makes an important area of dissection during cholecytectomy.

Anatomy

• The sphincter of Oddi: The proximal bile and pancreatic ducts

and the common channel are surrounded by circular and longitudinal smooth muscle, this muscle complex is known as the sphincter of Oddi.

Special Investigation of the biliary Tract

• Ultrasound:

Non-invasive,painless,

Easily performed

First choice for biliary tract disease

Ultrasound

• Bile duct stones:

Stones in gallbladder:

High echo which cast an acoustic shadow and which move with changes in posture

Ultrasound

• Jaundice differential diagnosis:

Dilatation of the ducts

CBD: diameter > 1.0cm

• Other disease: cholecytitis, tumor ect.

• During surgery: to detect bile duct stones

Radiology

• Plain abdominal radiograph:

Radio-opaque gallstones

Air in the biliary tree

• Oral cholecystography:

Biliary contrast medium

A fatty meal

Radiology

• Intravenous cholangiography• Percutaneous transhepatic cholangi-

ography (PTC) show intra and extra hepatic biliary

duct clearly complication: bile leakage cholangitis hemorrhage

Radiology

• Endoscopic retrograde cholangio-pancreatography(ERCP)

outline the biliary tree and pancreatic duct

inspect the ampulla of Vater

exam of the fluid of duodenum ,bile, pancreatic fluid.

Radiology

• Endoscopic sphincterotomy(EST)• Endoscopic naso-biliary drainage (ENBD) • Computed tomography(CT)• Magnetic resonance cholangio-

pancreatography (MRCP)• Cholangiopancreatography during &

operation

Special Investigation of the Biliary Tract

• Hepatobiliary nuclear imaging

99m-Tc-EHIDA

• Choledochoscopy

Operation

Post opertion

Cholelithiasis

• Including :

gallstones

biliary duct stones

Cholelithiasis

In China:• before 1981 gallstones < biliary duct stones cholesterol stones < pigment stones• now gallstones > biliary duct stones

cholesterol stones > pigment stones

Classification of stones

• Cholesterol stones: hard,layed on cross-section

• Pigment stones:crumble when squashed

• Mixed stones: radio-opaque

• Black stones

Formation of stones

• Cholesterol stones:

cholesterol insoluble in water and relative proportion of cholesterol,bile salts, and phospholipid in bile .

Formation of cholesterol stones

• Increase of cholesterol and decrease of bile salts leads to supersaturation of bile with cholesterol ,which results in the formation of liquid crystalline phase of cholesterol

Formation of cholesterol stones

• Nucleation:cholesterol will crystallize if there is a nidus on which the crystals can form.

• Nucleating factors: mucus glycoprotiens from cyst wall

and bilirubinate• Gallbladder function: the motility of the cyst wall

Clinical feature of gallstones

• 20-40% patient without symptom which is called asymptomatic gallstones

• Chronic cholecystitis

• Biliary colic

• Acute cholecystitis

Symptoms

• Gastrointestinal tract symptoms:

upper abdominal discomfort,

nausea,

after meals, eap. fatty meals.

Symptoms

Biliary colic: most commom symptom• A large or fatty meals and changing in position

when sleeping can precipitate the pain• Due to impaction of stone in the neck of the

gallbladder: the pressure increase.• Occurs in the mid or the upper-right portion of

the upper abdomen.• Severe pain starts abruptly, continuous,with

restlessness, vomitting,sweating.• Pain radiate to the right back and shoulder.

Symptoms

Mirizzi syndrome:

• Obstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmann’s pouch

• Press on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula

Sign

• Right upper area of the abdomen tenderness, rigidity,

rebound tendeness.• Gallbladder palpable• Murphy sign: inspiratory arrest during

subcostal palpation• Jaundice:common bile duct stones or Mirizzi

syndrome• Fever and chill with infection

Exam

• Jaundice (choledocholithiasis):

blood test of the liver function, elevation of the enzyme alkaline phosphate and bilirubin

• WBC count is high

• Ultrasoud: the main diagnosis exam.

• Oral cholecytography.

Diagnosis

• History

• Physical exam

• Ultrasoud exam: high echo with an acoustic shadow and moving with changes in posture

Treatment

• The first choice is operation:

symptomatic gallstones

gallstones with complications

Treatment

Asymptomatic gallstones:• oral cholecytography without showing

of gallbladder • diameter of stones > 2.0-3.0 cm• diabetes mellitus• elder or cardiac and respiratory

problemsNeed operation.

Treatment

CBD exploration:

Preoperation

• CBD stones

• Cholangitis and biliary colic repeatedly

• Pancreatitis

• Jaundice and bile duct dilatation

Treatmen

• Operation: the final method• Emergency surgery 1. onset in 48-72 hours2. invalidation of nonsurgical

treatment3. gangrene, perforation, pancreatitis,

or inflammation of the common bile duct occurs