A 95 year-old woman presented with upper abdominal pain and jaundice; A 95 year-old woman presented with upper abdominal pain and jaundice; ultrasound demonstrated gallstones. Symptoms were short in duration, and ultrasound demonstrated gallstones. Symptoms were short in duration, and jaundice began to clear rapidly. In view of her age and improving condition, jaundice began to clear rapidly. In view of her age and improving condition, she was treated conservatively for cholecystitis. However, she then she was treated conservatively for cholecystitis. However, she then developed protracted vomiting; endoscopy demonstrated several stones in developed protracted vomiting; endoscopy demonstrated several stones in the duodenum.the duodenum.

What is the most likely cause this type of complication?What is the most likely cause this type of complication?

a. Malignancy extending into duodenuma. Malignancy extending into duodenumb. Perforation of gallbladderb. Perforation of gallbladderc. Caroli’s syndromec. Caroli’s syndromed. Metastasis from another primary tumord. Metastasis from another primary tumor

Diseases of the Gallbladder Diseases of the Gallbladder and Biliary Tractand Biliary Tract

Driss Raissi, MDDriss Raissi, MDNew York State UniversityNew York State UniversityDownstate Lecture SeriesDownstate Lecture Series

Normal Biliary PhysiologyNormal Biliary Physiology

Liver produces 500-1500 mL of bile/dayLiver produces 500-1500 mL of bile/dayMajor physiologic role of biliary tract and Major physiologic role of biliary tract and GB is to concentrate bile and conduct it in GB is to concentrate bile and conduct it in well-timed aliquots to the intestine.well-timed aliquots to the intestine.In the intestine:In the intestine: bile acids participate in normal fat digestionbile acids participate in normal fat digestion Cholesterol and other Cholesterol and other

endogenous/exogenous cmpds in bile endogenous/exogenous cmpds in bile excreted in feces.excreted in feces.

Biliary PhysiologyBiliary PhysiologyComplex fluid secreted by hepatocytesComplex fluid secreted by hepatocytes

Passes through hepatic bile ducts into common hepatic ductPasses through hepatic bile ducts into common hepatic duct

Tonic contraction of sphincter of Oddi during fasting diverts ~1/2 of Tonic contraction of sphincter of Oddi during fasting diverts ~1/2 of bile through the cystic duct into the GB – stored and concentrated.bile through the cystic duct into the GB – stored and concentrated.

CCKCCK – released after food ingestion – released after food ingestion GB contracts, sphincter of Oddi relaxesGB contracts, sphincter of Oddi relaxes Allows delivery of timed bolus of bile into intestine.Allows delivery of timed bolus of bile into intestine.

Bile acids – Bile acids – detergent moleculesdetergent molecules Have both fat and water soluble moietiesHave both fat and water soluble moieties Convey phospholipids and cholesterol from liver to intestine Convey phospholipids and cholesterol from liver to intestine Cholesterol undergoes fecal excretionCholesterol undergoes fecal excretion

Enterohepatic circulationEnterohepatic circulationBile acids Bile acids solubilize dietary solubilize dietary fat and promote fat and promote its digestion and its digestion and absorptionabsorption

Enterohepatic Enterohepatic circulation:circulation:

Bile acids Bile acids efficiently efficiently reabsorbed by SI reabsorbed by SI mucosa (terminal mucosa (terminal ileum) ileum) recycled to liver recycled to liver for re-excretionfor re-excretion

CholelithiasisCholelithiasis

Normal GallbladderNormal Gallbladder

Velvety green mucosaVelvety green mucosa

Thin wallThin wall

Tall columnar cells lining Tall columnar cells lining mucosal folds (right)mucosal folds (right)

Submucosa and Submucosa and muscularis at the left. muscularis at the left.

CholelithiasisCholelithiasis

Gallstones:Gallstones: MCC biliary tract MCC biliary tract

disease in US (20-disease in US (20-35% by age 75)35% by age 75)

2 types:2 types:CholesterolCholesterol (75%) (75%)PigmentPigment

Calcium bilirubinate Calcium bilirubinate and other calcium and other calcium saltssalts

Cholesterol StonesCholesterol StonesCholesterol:Cholesterol:

Insoluble in waterInsoluble in water

Normally carried in bile solubilized by bile acids and Normally carried in bile solubilized by bile acids and phospholipidsphospholipids

In most individuals, bile contains > cholesterol than can be In most individuals, bile contains > cholesterol than can be maintained in stable solutionmaintained in stable solution

““supersaturated” with cholesterol supersaturated” with cholesterol microscopic cholesterol crystals microscopic cholesterol crystals formformInterplay of Interplay of nucleation nucleation (mucus, stasis) and “anti-nucleating” (mucus, stasis) and “anti-nucleating” (apolipoprotein A-I) factors determine whether cholesterol gall (apolipoprotein A-I) factors determine whether cholesterol gall stones formstones formGradual deposition of cholesterol layers Gradual deposition of cholesterol layers

macroscopic cholesterol stonesmacroscopic cholesterol stones

Cholesterol StonesCholesterol StonesGallbladder: Gallbladder:

key to stone formation key to stone formation

Area of bile stasis Area of bile stasis slow crystal growth slow crystal growth

Provides mucus or other material to act as a nidus for initiating Provides mucus or other material to act as a nidus for initiating cholesterol crystal.cholesterol crystal.

Mexican Americans and several American Indian tribes, Mexican Americans and several American Indian tribes, particularly the Pima Indians in the Southwestparticularly the Pima Indians in the Southwest

high prevalence rates of cholesterol gallstoneshigh prevalence rates of cholesterol gallstones↓↓bile acid secretion is believed to be the common denominator in bile acid secretion is believed to be the common denominator in these ethnic groupsthese ethnic groups

Pigment stonesPigment stones

Pathophysiology less well understoodPathophysiology less well understood production of bilirubin conjugates (hemolytic production of bilirubin conjugates (hemolytic

states)states) biliary Cabiliary Ca2+2+ and CO and CO33

2-2-

CirrhosisCirrhosis Bacterial deconjugation of bilirubin to less Bacterial deconjugation of bilirubin to less

soluble formsoluble form

Predisposing FactorsPredisposing FactorsFactors that increase biliary cholesterol saturation:Factors that increase biliary cholesterol saturation:

EstrogensEstrogens MultiparityMultiparity OCP’sOCP’s ObesityObesity Rapid weight lossRapid weight loss Terminal ileal disease (decreases bile acid pool)Terminal ileal disease (decreases bile acid pool)

Factors that increase bile stasis:Factors that increase bile stasis: Bile duct stricturesBile duct strictures Parenteral hyperalimentationParenteral hyperalimentation FastingFasting Choledochal cystsCholedochal cysts Pregnancy – (GB hypomotility)Pregnancy – (GB hypomotility)

Clinical ManifestationsClinical Manifestations

Most are asymptomaticMost are asymptomaticDuct obstruction - Duct obstruction - underlying cause of all manifestationsunderlying cause of all manifestations

Cystic duct obstructionCystic duct obstruction distends GB distends GB biliary pain biliary pain Superimposed inflamm/ifxSuperimposed inflamm/ifx acute cholecystitisacute cholecystitis

Common duct obstructionCommon duct obstruction pain, jaundice, ifx(cholangitis), pancreatitis, and/or pain, jaundice, ifx(cholangitis), pancreatitis, and/or hepatic damage 2hepatic damage 2° to biliary cirrhosis° to biliary cirrhosis

Asymptomatic GallstonesAsymptomatic Gallstones

60-80% patients with gallstones in US60-80% patients with gallstones in US Over 20-year period:Over 20-year period:

18% of these develop biliary pain18% of these develop biliary pain3% require cholecystectomy3% require cholecystectomy

Prophylactic cholecystectomy considered in 3 Prophylactic cholecystectomy considered in 3 high-risk groups:high-risk groups: 1. 1. Diabetics – Diabetics – 10-15% greater mortality10-15% greater mortality 2. 2. Calcified (porcelain) GB – Calcified (porcelain) GB – Associated w/CA of GBAssociated w/CA of GB 3. 3. Sickle cell anemia – Sickle cell anemia –

hepatic crisis difficult to differentiate vs. acute cholecystitishepatic crisis difficult to differentiate vs. acute cholecystitis

Porcelain GallbladderPorcelain Gallbladder

Treatment of Asx GallstonesTreatment of Asx GallstonesChenodeoxycholic acid or Ursodeoxycholic acidChenodeoxycholic acid or Ursodeoxycholic acid

Dissolution of cholesterol stonesDissolution of cholesterol stones

Expectant management Expectant management then cholecystectomy if then cholecystectomy if symptomatic disease develops = more cost effectivesymptomatic disease develops = more cost effective

Alternatives:Alternatives: Dissove cholesterol stones:Dissove cholesterol stones:

Instill Instill Methyl-tert-butyl-ether Methyl-tert-butyl-ether or or ethyl propionateethyl propionate into GB into GB Fragment stones:Fragment stones:

extracorporeal shock wave lithotripsyextracorporeal shock wave lithotripsy

Extracorporeal Shockwave Extracorporeal Shockwave LithotripsyLithotripsy

Chronic Cholecystitis and Biliary PainChronic Cholecystitis and Biliary Pain

Nonacute sx. caused by presence of gallstonesNonacute sx. caused by presence of gallstonesBiliary Pain (misnamed biliary colic)Biliary Pain (misnamed biliary colic)GB from symptomatic patients may be grossly normal GB from symptomatic patients may be grossly normal Mild histologic inflammation with fibrosis and thickening often from Mild histologic inflammation with fibrosis and thickening often from previous attacks of acute cholecystitis.previous attacks of acute cholecystitis.

SymptomsSymptoms:: From contraction of GB during transient obstruction of cystic duct by From contraction of GB during transient obstruction of cystic duct by

gallstones.gallstones. Steady ache in epigastrium or RUQ Steady ache in epigastrium or RUQ

comes on quickly comes on quickly plateau over a few minutes plateau over a few minutes subsides gradually over subsides gradually over 30 min-several hours30 min-several hoursReferred pain at tip of scapula or right shoulderReferred pain at tip of scapula or right shoulderN/V can accompany. (no fever, leukocytosis, or palpable mass)N/V can accompany. (no fever, leukocytosis, or palpable mass)Attacks occur at variable intervals (days – years)Attacks occur at variable intervals (days – years)Nonspecific symptoms: Nonspecific symptoms:

Dyspepsia, fatty food intolerance, bloating and flatulence, heartburn, belchingDyspepsia, fatty food intolerance, bloating and flatulence, heartburn, belching

DiagnosisDiagnosis

UltrasonographyUltrasonography Sensitivity and specificity >95%Sensitivity and specificity >95%

Oral cholecystograpyOral cholecystograpy 90% sensitivity, 75% specificity90% sensitivity, 75% specificity Reserved for ensuring cystic duct patency in pts Reserved for ensuring cystic duct patency in pts

whom dissolution therapy or extracorporeal shock whom dissolution therapy or extracorporeal shock wave lithotripsy is plannedwave lithotripsy is planned

TreatmentTreatmentLaparoscopic cholecystectomyLaparoscopic cholecystectomy

Treatment of choice for recurrent biliary painTreatment of choice for recurrent biliary pain May need preoperative endoscopic or radiologic examination of May need preoperative endoscopic or radiologic examination of

CBD for concomitant choledocholithiasisCBD for concomitant choledocholithiasis

Open cholecystectomyOpen cholecystectomy Mortality rate <0.5%Mortality rate <0.5% Might be required if difficulties during procedure i.e. adhesions, Might be required if difficulties during procedure i.e. adhesions,

obesityobesity

NSAIDSNSAIDS Several reorts and trials suggest that use during biliary pain Several reorts and trials suggest that use during biliary pain

provides adequate pain relief and provides adequate pain relief and ↓ progression to acute ↓ progression to acute cholecystitischolecystitis

Acute CholecystitisAcute Cholecystitis

Acute Cholecystitis Acute Cholecystitis

Acute right subcostal pain and tenderness Acute right subcostal pain and tenderness from obstruction of from obstruction of cystic ductcystic duct Distension, inflammation, and 2Distension, inflammation, and 2° ifx of GB° ifx of GB

Acalculous cholecystitis (5%)Acalculous cholecystitis (5%) Triad - Prolonged fasting, immobility, Triad - Prolonged fasting, immobility,

hemodynamic instabilityhemodynamic instability Critically ill patients (burns, trauma, sepsis)Critically ill patients (burns, trauma, sepsis) Parenteral hyperalimentationParenteral hyperalimentation

Acute CholecystitisAcute Cholecystitis

Epigastric or RUQ painEpigastric or RUQ pain Gradually Gradually in severity and localizes to GB area in severity and localizes to GB area Unlike biliary pain, does not spontaneously resolveUnlike biliary pain, does not spontaneously resolve Low grade fever, anorexia, n/v, right subcostal Low grade fever, anorexia, n/v, right subcostal

tendernesstenderness (+)Murphy’s sign(+)Murphy’s sign

subhepatic tenderness and inspiratory arrest subhepatic tenderness and inspiratory arrest during deep breathduring deep breath

Tender enlarged gallbladder (1/3)Tender enlarged gallbladder (1/3) Mild jaundice (20%) – concomitant CBD stones or BD Mild jaundice (20%) – concomitant CBD stones or BD

edemaedema

Murphy’s SignMurphy’s Sign

Complications Complications Onset of fever, shaking chills, Onset of fever, shaking chills, leukocytosis, leukocytosis, abdominal pain or abdominal pain or tenderness, or persistent severe symptoms =tenderness, or persistent severe symptoms =

progression of disease and development of complicationsprogression of disease and development of complications

Emphysematous cholecystitis Emphysematous cholecystitis Diabetics with bacterial gas present in GB lumen and wallDiabetics with bacterial gas present in GB lumen and wall

Empyema of gallbladderEmpyema of gallbladder GangreneGangrene PerforationPerforation Mirizzi’s syndromeMirizzi’s syndrome

Profound jaundice in which extrinsic CBD compression occurs from Profound jaundice in which extrinsic CBD compression occurs from impacted stone in GB neckimpacted stone in GB neck

EmphysematousEmphysematousCholecystitisCholecystitis

Diagnosis Acute CholecystitisDiagnosis Acute Cholecystitis

Radionuclide scanning after Radionuclide scanning after administration of administration of 99m99mTc-DISIDA or HIDATc-DISIDA or HIDA Most accurate test to confirm cystic duct Most accurate test to confirm cystic duct

obstructionobstruction If GB fills with isotope If GB fills with isotope

acute cholecystitis unlikelyacute cholecystitis unlikely If bile duct visualized but gallbladder not If bile duct visualized but gallbladder not

Clinical diagnosis strongly supportedClinical diagnosis strongly supported

IImages taken shortly after mages taken shortly after injection of the radiolabeled injection of the radiolabeled tracer. tracer. Gallbladder (black spot) fills as Gallbladder (black spot) fills as radioactive material is secreted radioactive material is secreted into bile and floods in. into bile and floods in.

Images after gallbladder filled.Images after gallbladder filled.Emptying stimulated by an injection of CCKEmptying stimulated by an injection of CCKEnlarging black streak representing the Enlarging black streak representing the CBD appears below the gallbladder. CBD appears below the gallbladder. As streak becomes visible, black spot As streak becomes visible, black spot representing the GB representing the GB ↓ ↓ in size and almost in size and almost disappears as bile is squeezed into the disappears as bile is squeezed into the small intestine. small intestine.

Diagnosis Acute CholecystitisDiagnosis Acute Cholecystitis

Ultrasonagraphy:Ultrasonagraphy: Gallstones (or sludge in acalculous) along Gallstones (or sludge in acalculous) along

with localized tenderness over the GB, with localized tenderness over the GB, pericholecystic fluid, and GB wall thickeningpericholecystic fluid, and GB wall thickening

strong supportive evidence for acute cholecystitisstrong supportive evidence for acute cholecystitis

Oral cholecystograms = no clinical use Oral cholecystograms = no clinical use Unreliable in acutely ill patientUnreliable in acutely ill patient

Management of Acute CholecystitisManagement of Acute Cholecystitis

Patients may improve over 1-7 days with Patients may improve over 1-7 days with expectant managementexpectant management

NG suction for profound vomiting, and/or abdominal distensionNG suction for profound vomiting, and/or abdominal distension IV fluids, ABX, and analgesicsIV fluids, ABX, and analgesics

CholecystectomyCholecystectomy Because of high risk of recurrent acute cholecystitisBecause of high risk of recurrent acute cholecystitis Within first 24-48 hours after acute episodeWithin first 24-48 hours after acute episode Emergency surgery if advanced disease and complications, usually Emergency surgery if advanced disease and complications, usually

associated with infection and sepsis.associated with infection and sepsis.

Cholecystostomy Cholecystostomy (operative or percutaneous)(operative or percutaneous) Alternative to cholecystectomy in patients with high operative riskAlternative to cholecystectomy in patients with high operative risk

PrognosisPrognosis

Mortality of acute cholecystitis = 5-10%Mortality of acute cholecystitis = 5-10% Almost entirely confined to patients >60 with Almost entirely confined to patients >60 with

serious associated diseases and those with serious associated diseases and those with supparative complicationssupparative complications

ComplicationsComplications InfectionInfection Cholecystoenteric fistula Cholecystoenteric fistula results in results in

gallstone ileus.gallstone ileus.

Choledocholithiasis Choledocholithiasis and Cholangitisand Cholangitis

Choledocholithiasis & Acute CholangitisCholedocholithiasis & Acute Cholangitis

~15% of pts with gallstones have CBD ~15% of pts with gallstones have CBD stones (choledocholithiasis)stones (choledocholithiasis)CD stones usually originate from GBCD stones usually originate from GBLess commonly Less commonly stones form stones form de novode novo in the biliary tree in the biliary tree

International incidence rate higher b/c International incidence rate higher b/c primary CBD stones caused by parasitesprimary CBD stones caused by parasites

Asians Asians Ascaris lumbricoidesAscaris lumbricoides and and Clonorchis sinensisClonorchis sinensis

Biliary tract lithiasis most often Biliary tract lithiasis most often begins with a calculus (stone) in the begins with a calculus (stone) in the gallbladder. gallbladder.

A small enough calculus (or part of A small enough calculus (or part of a calculus) may become impacted a calculus) may become impacted in the in the neckneck of the gallbladder or of the gallbladder or cystic ductcystic duct acute cholecystitisacute cholecystitis..

The stone may travel further down The stone may travel further down into the into the common bile ductcommon bile duct, and , and impaction in this duct impaction in this duct (choledocholithiasis)(choledocholithiasis) may produce may produce obstruction with jaundice.obstruction with jaundice.

The stone may travel further down The stone may travel further down and, near the ampulla, obstruct the and, near the ampulla, obstruct the pancreatic duct, leading to pancreatic duct, leading to acute acute pancreatitispancreatitis. .

The stone may pass through the The stone may pass through the ampulla and out into the duodenum.ampulla and out into the duodenum.

Symptoms and SignsSymptoms and SignsBiliary colicBiliary colic From rapid From rapid in CBD pressure due to obstructed bile in CBD pressure due to obstructed bile

flowflow

Charcot’s Triad = classic cholangitisCharcot’s Triad = classic cholangitis 1. RUQ pain – 1. RUQ pain – frequently recurring, severe, persists for several hoursfrequently recurring, severe, persists for several hours 2. Chills and Fever - 2. Chills and Fever - associated with severe colicassociated with severe colic 3. Jaundice - 3. Jaundice - associated with abdominal painassociated with abdominal pain

HepatomegalyHepatomegaly – – in calculous biliary obstructionin calculous biliary obstruction

Tenderness Tenderness – – RUQ and epigastriumRUQ and epigastrium

PainPain = = MC presenting symptomMC presenting symptom colicky in nature, moderate in severity, and located in the RUQcolicky in nature, moderate in severity, and located in the RUQ intermittent, transient, and recurrent and may be associated with nausea and vomiting. intermittent, transient, and recurrent and may be associated with nausea and vomiting.

JaundiceJaundice CBD becomes obstructed and conjugated bilirubin enters the bloodstream. CBD becomes obstructed and conjugated bilirubin enters the bloodstream. History of clay-colored stools and tea-colored urine is obtained from such patients in History of clay-colored stools and tea-colored urine is obtained from such patients in

approximately 50%approximately 50% The jaundice can be episodic.The jaundice can be episodic.

FeverFever Indication of cholangitisIndication of cholangitis Charcot triad: Charcot triad: fever, jaundice, and RUQ pain strongly favors the diagnosis. fever, jaundice, and RUQ pain strongly favors the diagnosis.

PancreatitisPancreatitis Gallstones are responsible for 50% of all casesGallstones are responsible for 50% of all cases Conversely, 4-8% of patients with gallstones develop pancreatitis. Conversely, 4-8% of patients with gallstones develop pancreatitis. Pancreatitis can be precipitated if CBD obstruction occurs at the level of the ampulla of Pancreatitis can be precipitated if CBD obstruction occurs at the level of the ampulla of

Vater. Vater.

Presentation of CholedocholithiasisPresentation of Choledocholithiasis

Primary CBD StonesPrimary CBD StonesCaused by conditions leading to Caused by conditions leading to bile stasisbile stasis and and chronic bactibiliachronic bactibilia..

Up to 90% of patients with brown pigment CBD stones have (+) bile culture Up to 90% of patients with brown pigment CBD stones have (+) bile culture results results Usually brown pigment stones. Brown stones differ from black pigment stones Usually brown pigment stones. Brown stones differ from black pigment stones by having a higher content of cholesterol. Brown stones are soft and earthy in by having a higher content of cholesterol. Brown stones are soft and earthy in consistency and take the shape of the duct.consistency and take the shape of the duct.

In Western populations, biliary stasis is secondary to factors such as:In Western populations, biliary stasis is secondary to factors such as: sphincter of Oddi dysfunction, benign biliary strictures, sclerosing cholangitis, and sphincter of Oddi dysfunction, benign biliary strictures, sclerosing cholangitis, and

cystic dilatation of the bile ducts.cystic dilatation of the bile ducts.

In Asian populations, In Asian populations, A lumbricoidesA lumbricoides and and C sinensis C sinensis promote stasis:promote stasis: Either blocking the biliary ducts or by damaging the duct wallsEither blocking the biliary ducts or by damaging the duct walls Results in stricture formation. Results in stricture formation. Bactibilia is also common in these instances, probably secondary to episodic portal Bactibilia is also common in these instances, probably secondary to episodic portal

bacteremia. bacteremia.

Secondary CBD StonesSecondary CBD Stones

Arise from the gallbladder Arise from the gallbladder migrate to the migrate to the CBDCBDHave a typical spectrum of cholesterol Have a typical spectrum of cholesterol stones and black pigment stones. stones and black pigment stones. Bacteria can be cultured from the surface of Bacteria can be cultured from the surface of cholesterol and pigment stones but not from cholesterol and pigment stones but not from the core, suggesting that bacteria do not the core, suggesting that bacteria do not play a role in their formation.play a role in their formation.

Laboratory DiagnosisLaboratory Diagnosis WBCWBC nonspecific. nonspecific. Serum and urine bilirubinSerum and urine bilirubin - indicate obstruction of the CBD - indicate obstruction of the CBD

the higher the bilirubin level, the greater the predictive value. the higher the bilirubin level, the greater the predictive value. CBD stones are present in approximately 60% of patients with serum bilirubin CBD stones are present in approximately 60% of patients with serum bilirubin

levels greater than 3 mg/dL.levels greater than 3 mg/dL. Serum amylase and lipaseSerum amylase and lipase

acute pancreatitis complicating choledocholithiasis.acute pancreatitis complicating choledocholithiasis. Alkaline phosphatase and gamma-glutamyl transpeptidaseAlkaline phosphatase and gamma-glutamyl transpeptidase

obstructive choledocholithiasisobstructive choledocholithiasis good predictive value for the presence of CBD stones.good predictive value for the presence of CBD stones.

Prothrombin timeProthrombin time In prolonged CBD obstruction, secondary to depletion of vitamin K (the In prolonged CBD obstruction, secondary to depletion of vitamin K (the

absorption of which is bile-dependent).absorption of which is bile-dependent). Liver transaminasesLiver transaminases

choledocholithiasis complicated by cholangitis, pancreatitis, or both.choledocholithiasis complicated by cholangitis, pancreatitis, or both.Blood cultureBlood culture

positive in 30-60% of patients with cholangitis.positive in 30-60% of patients with cholangitis.

Preoperative DiagnosisPreoperative DiagnosisTransabdominal ultrasonographyTransabdominal ultrasonography

It is usually the first modality used in the diagnosis of patients with biliary-related symptoms. It is usually the first modality used in the diagnosis of patients with biliary-related symptoms. Ultrasonography findings are accurate in the diagnosis of gallbladder stones, but CBD stones are missed Ultrasonography findings are accurate in the diagnosis of gallbladder stones, but CBD stones are missed

frequently (sensitivity 15-40%). frequently (sensitivity 15-40%). On the other hand, CBD dilatation is identified accurately, with up to 90% accuracy. On the other hand, CBD dilatation is identified accurately, with up to 90% accuracy.

Endoscopic ultrasonography Endoscopic ultrasonography Introduction of a high-frequency (7.5-12 MHz) ultrasonic probe advanced into the duodenum Introduction of a high-frequency (7.5-12 MHz) ultrasonic probe advanced into the duodenum

under endoscopic guidance. A water-filled balloon is used to provide an acoustic window. under endoscopic guidance. A water-filled balloon is used to provide an acoustic window. Sensitivity and specificity of CBD stone detection are reported in range of 85-100%. Sensitivity and specificity of CBD stone detection are reported in range of 85-100%. Invasive, $$$, need experienced enoscopist/ultrasonographerInvasive, $$$, need experienced enoscopist/ultrasonographer

Computed tomography scan Computed tomography scan very accurate in the detection of biliary tree obstruction and ductal dilatationvery accurate in the detection of biliary tree obstruction and ductal dilatation sensitivity of 75-90% in the detection of CBD stones = essential in evaluation of jaundice. sensitivity of 75-90% in the detection of CBD stones = essential in evaluation of jaundice. Capable of defining the level of the obstruction and provides information about the Capable of defining the level of the obstruction and provides information about the

surrounding structures, especially the pancreassurrounding structures, especially the pancreas..

MRCP MRCP noninvasive tool with 97% accuracy, 92% sensitivity, and 100% specificity. noninvasive tool with 97% accuracy, 92% sensitivity, and 100% specificity. $$$, inconvenience, and limitations (eg, obesity, presence of metal objects, eg, $$$, inconvenience, and limitations (eg, obesity, presence of metal objects, eg,

pacemakers)pacemakers)

Endoscopic Ultrasound (EUS)Endoscopic Ultrasound (EUS)

MRCPMRCP

CholangiographyCholangiography

Criterion standard for the detection of CBD stonesCriterion standard for the detection of CBD stones Endoscopic Retrograde Cholangiopancreatography (ERCP)Endoscopic Retrograde Cholangiopancreatography (ERCP)

The CBD is cannulated through the ampulla, contrast injected, and The CBD is cannulated through the ampulla, contrast injected, and films are obtained. films are obtained. Experience of the endoscopist is best predictor of success, (90-95% Experience of the endoscopist is best predictor of success, (90-95% in expert hands)in expert hands)Complications = hyperamylasemia and cholangitis. Complications = hyperamylasemia and cholangitis.

Percutaneous Transhepatic Cholangiography (PTC)Percutaneous Transhepatic Cholangiography (PTC) may be the modality of choice in patients in whom ERCP is difficult may be the modality of choice in patients in whom ERCP is difficult

(eg, previous gastric surgery)(eg, previous gastric surgery)percutaneously and transhepatically into an intrahepatic duct, and percutaneously and transhepatically into an intrahepatic duct, and cholangiography is performed. cholangiography is performed.

ComplicationsComplications

Biliary Cirrhosis:Biliary Cirrhosis: CBD obstruction >30 days CBD obstruction >30 days liver damage liver damage

cirrhosiscirrhosis

Hypoprothrombinemia:Hypoprothrombinemia: Pts may bleed excessively d/t Pts may bleed excessively d/t PTPT Responds to 10mg parenteral vitamin K or Responds to 10mg parenteral vitamin K or

water soluble oral vitamin K within 24-36h.water soluble oral vitamin K within 24-36h.

Treatment of CholedocholithiasisTreatment of Choledocholithiasis

CBD stone in pt with cholelithiasis and CBD stone in pt with cholelithiasis and cholecystitis:cholecystitis:

endoscopic papillotomy and stone extraction followed by endoscopic papillotomy and stone extraction followed by laparoscopic cholecystectomy.laparoscopic cholecystectomy.

ERCPERCP before cholecystectomy in patients with: before cholecystectomy in patients with: Gallstones and jaundice (serum bili >2 mg/dL)Gallstones and jaundice (serum bili >2 mg/dL) Dilated CBD (>7mm)Dilated CBD (>7mm) Stones in bile duct seen on ultrasound or CTStones in bile duct seen on ultrasound or CT

Primary Biliary CirrhosisPrimary Biliary Cirrhosis

Primary Biliary CirrhosisPrimary Biliary CirrhosisChronic disease of liver with autoimmune destruction of intrahepatic bile Chronic disease of liver with autoimmune destruction of intrahepatic bile ducts and cholestasisducts and cholestasis

Insidious onsetInsidious onset Often detected by chance finding of Often detected by chance finding of Alkaline PhosphataseAlkaline Phosphatase

Women aged 40-60Women aged 40-60

Disease is progressive and complicated by:Disease is progressive and complicated by: Steatorrhea, xanthomas, xanthelasma, osteoporosis, osteomalacia, and portal Steatorrhea, xanthomas, xanthelasma, osteoporosis, osteomalacia, and portal

hypertensionhypertension

Associated with SjAssociated with Sjögren’s syndrome, scleroderma, hypothyroidism, and ögren’s syndrome, scleroderma, hypothyroidism, and celiac diseaseceliac disease

Infection with Infection with Chlamydia pneumoniaeChlamydia pneumoniae may be trigger or causative agent may be trigger or causative agent

Xanthoma in PBCXanthoma in PBC

Clinical FindingsClinical FindingsMany asymptomatic for yearsMany asymptomatic for years

Fatigue and pruritisFatigue and pruritis

Hepatomegaly with progressionHepatomegaly with progression

Xanthomatous lesionsXanthomatous lesions In skin and tendons and around eyelidsIn skin and tendons and around eyelids

Jaundice and signs of portal HTN (late)Jaundice and signs of portal HTN (late)

Risk of osteoporosis increased Risk of osteoporosis increased

Laboratory findings in PBCLaboratory findings in PBC

Signs of cholestasisSigns of cholestasis AlkPhos, AlkPhos, cholesterol (HDL), later cholesterol (HDL), later bilirubinbilirubin

Anti-mitochondrial Antibodies (95%)Anti-mitochondrial Antibodies (95%) Directed against PDH in mitochondriaDirected against PDH in mitochondria

Serum IgMSerum IgM

Diagnosis of PBCDiagnosis of PBC

Based on cholestatic liver chemistries and anti-Based on cholestatic liver chemistries and anti-mitochondrial antibodies in serum combined with mitochondrial antibodies in serum combined with characteristic histology in liver biopsycharacteristic histology in liver biopsy

Liver biopsyLiver biopsy Permits histologic stagingPermits histologic staging

Stage I: Portal inflammation with granulomasStage I: Portal inflammation with granulomasStage II: Bile duct proliferationStage II: Bile duct proliferationStage III: Interlobular fibrous septaStage III: Interlobular fibrous septaStage IV: CirrhosisStage IV: Cirrhosis

Biliary FibrosisBiliary Fibrosis

Portal area with marked ductular proliferation and minimal inflammation in a case of chronic biliary obstruction.Portal area with marked ductular proliferation and minimal inflammation in a case of chronic biliary obstruction.

Treatment of PBCTreatment of PBCUrsodeoxycholic Acid Ursodeoxycholic Acid

Preferred medical treatmentPreferred medical treatment slows progression, improves long-term survival, slows progression, improves long-term survival, ↓risk of esophageal varices↓risk of esophageal varices

Symptomatic TreatmentSymptomatic Treatment Cholestyramine or Colestipol - for pruritisCholestyramine or Colestipol - for pruritis

Can aggravate steatorrha leading to vitamin A,D,K deficiencyCan aggravate steatorrha leading to vitamin A,D,K deficiency Rifampin inconsistently beneficialRifampin inconsistently beneficial Opiod antagonistsOpiod antagonists

Naloxone, naltrexone – show promise for treating pruritisNaloxone, naltrexone – show promise for treating pruritis 5-HT5-HT33 antagonists antagonists

Ondansetron Ondansetron Calcium supplementationCalcium supplementation

Helps prevent osteomalciaHelps prevent osteomalcia

Colchicine and MethotrexateColchicine and Methotrexate Some benefit improving symptoms and serum levels of APSome benefit improving symptoms and serum levels of AP

Liver transplantLiver transplant Treatment of choice for advanced diseaseTreatment of choice for advanced disease

Prognosis of PBCPrognosis of PBCWithout transplant, survival = 7-10 years once symptoms Without transplant, survival = 7-10 years once symptoms developdevelopAdverse prognostic indicators:Adverse prognostic indicators:

Older ageOlder age High serum bilirubinHigh serum bilirubin EdemaEdema Low serum albuminLow serum albumin Prolonged PTProlonged PT Variceal hemorrhageVariceal hemorrhage

The Mayo risk score:The Mayo risk score:R = 0.871 loge (bilirubin in mg/dL) + (–2.53) loge (albumin in g/dL) + 0.039 age in years + 2.38 R = 0.871 loge (bilirubin in mg/dL) + (–2.53) loge (albumin in g/dL) + 0.039 age in years + 2.38 loge(prothrombin time in seconds) + 0.859 (edema score of 0, 0.5, or 1)loge(prothrombin time in seconds) + 0.859 (edema score of 0, 0.5, or 1)

Primary Sclerosing Primary Sclerosing CholangitisCholangitis

Primary Sclerosing CholangitisPrimary Sclerosing CholangitisUncommon disease characterized by diffuse inflammation of biliary tract Uncommon disease characterized by diffuse inflammation of biliary tract leading to leading to fibrosis and strictures of biliary system.fibrosis and strictures of biliary system.

Most common in men age 20-40 and closely associated with ulcerative colitis Most common in men age 20-40 and closely associated with ulcerative colitis (present in ~2/3 of pts with PSC)(present in ~2/3 of pts with PSC)

Only 1-4% of patients with UC develop PSC.Only 1-4% of patients with UC develop PSC. Like UC, smoking is associated with a Like UC, smoking is associated with a ↓risk of PSC↓risk of PSC

Associated with HLA-B8 and DR3 or DR4Associated with HLA-B8 and DR3 or DR4

ANCA (70%), with fluorescent staining characteristics and target antigens distinct ANCA (70%), with fluorescent staining characteristics and target antigens distinct from those in Wegener’s from those in Wegener’s

In AIDS, PSC may result from infections caused by In AIDS, PSC may result from infections caused by CMV, cryptosporidium, or microsporum.CMV, cryptosporidium, or microsporum.

PSC is usually progressive, leading to cirrhosis, portal hypertension, and liver failure.PSC is usually progressive, leading to cirrhosis, portal hypertension, and liver failure.

Symptoms and SignsSymptoms and Signs

Progressive obstructive jaundiceProgressive obstructive jaundice Frequently associated with malaise, pruritus, Frequently associated with malaise, pruritus,

anorexia, and indigestion.anorexia, and indigestion.

Complications of chronic cholestasisComplications of chronic cholestasis Osteoporosis Osteoporosis Malabsorption of fat soluble vitaminsMalabsorption of fat soluble vitamins

Laboratory Diagnosis of PSCLaboratory Diagnosis of PSCAP or GGT – MC abnormalityAP or GGT – MC abnormality

Serum transaminases can be normal or Serum transaminases can be normal or

serum bilirubinserum bilirubin in advanced PSCin advanced PSC

Hepatic synthetic tests (albumin, PT, etc)Hepatic synthetic tests (albumin, PT, etc) abnormal in advanced PSCabnormal in advanced PSC

Serum cholylglycine (bile salt)Serum cholylglycine (bile salt) out of proportion to the elevation of serum bilirubin. out of proportion to the elevation of serum bilirubin.

p-ANCAsp-ANCAs inin 60-82% of patients with PSC. (Frequency in UC is similar.) 60-82% of patients with PSC. (Frequency in UC is similar.)

CA 19-9 CA 19-9 level greater than 100 U/mL has 75% sensitivity and 80% specificity in identifying PSC level greater than 100 U/mL has 75% sensitivity and 80% specificity in identifying PSC

patients with cholangiocarcinoma. patients with cholangiocarcinoma.

Imaging Diagnosis of PSCImaging Diagnosis of PSC

ERCP ERCP Cholangiography remains criterion standardCholangiography remains criterion standard

Cholangiography remains the criterion standard for Cholangiography remains the criterion standard for establishing the diagnosis of PSC.establishing the diagnosis of PSC.irregularly distributed, multifocal irregularly distributed, multifocal strictures and dilatationsstrictures and dilatations of of the intrahepatic and extrahepatic bile ducts = the intrahepatic and extrahepatic bile ducts = beadingbeading

MRCPMRCP Noninvasive, but less sensitive (90%) than Noninvasive, but less sensitive (90%) than

ERCP(97%) for visualizing intrahepatic ductsERCP(97%) for visualizing intrahepatic ducts

Imaging of PSCImaging of PSCThe radiographic pattern of PSC is that The radiographic pattern of PSC is that of strictures of varying lengths in the of strictures of varying lengths in the intrahepatic and extrahepatic ducts. intrahepatic and extrahepatic ducts.

There may intervening areas of There may intervening areas of minimal dilatation of the ducts with a minimal dilatation of the ducts with a resulting "beaded" appearance.resulting "beaded" appearance.

Usually there are multiple areas of Usually there are multiple areas of involvement. In this case almost all of involvement. In this case almost all of the visualized ducts are abnormal in the visualized ducts are abnormal in contourcontour. .

ERCPERCP

ERCP image shows ERCP image shows multifocal strictures multifocal strictures and irregularity of the and irregularity of the right intrahepatic bile right intrahepatic bile ducts. ducts.

Treatment of PSCTreatment of PSCNo effective medical therapies existNo effective medical therapies exist

CiprofloxacinCiprofloxacinEpisodes of acute bacterial cholangitisEpisodes of acute bacterial cholangitis

Ursodeoxycholic acid (UDCA) Ursodeoxycholic acid (UDCA) improves symptoms and LFTs in adult patients with PSC. improves symptoms and LFTs in adult patients with PSC.

ERCPERCP Balloon dilation of localized strictures. Repeated procedures improves survival.Balloon dilation of localized strictures. Repeated procedures improves survival. If major stricture – short term stent relieves symptoms and improves LFTsIf major stricture – short term stent relieves symptoms and improves LFTs

Surgical resectionSurgical resection In patients without cirrhosis, resection of dominant bile duct stricture In patients without cirrhosis, resection of dominant bile duct stricture

may improve survival vs. ERCP because of may improve survival vs. ERCP because of ↓risk cholangiocarcinoma.↓risk cholangiocarcinoma.

Prognosis of PSCPrognosis of PSCAverages 10 years once symptoms appearAverages 10 years once symptoms appearAdverse prognostic markers:Adverse prognostic markers:

Older ageOlder age Higher serum bilirubin and ASTHigher serum bilirubin and AST Lower albumin levelsLower albumin levels History of variceal bleedingHistory of variceal bleeding

Complications:Complications: Cholangiocarcinoma (10-15%) of adults with PSC. Cholangiocarcinoma (10-15%) of adults with PSC. Colon CA/dysplasia Colon CA/dysplasia

In patients with ulcerative colitis, PSC is independent risk factorIn patients with ulcerative colitis, PSC is independent risk factorStrict adherence to colonoscopic surveillance program avisedStrict adherence to colonoscopic surveillance program avised

Neoplasms in the Neoplasms in the Biliary TractBiliary Tract

Carcinomas of Biliary TractCarcinomas of Biliary TractManifestationsManifestations

weight loss (77%)weight loss (77%)nausea (60%)nausea (60%)anorexia (56%)anorexia (56%)abdominal pain (56%)abdominal pain (56%)fatigue (63%)fatigue (63%)pruritus (51%)pruritus (51%)fever (21%)fever (21%)malaise (19%) malaise (19%) diarrhea (19%)diarrhea (19%)constipation (16%)constipation (16%)abdominal fullness (16%)abdominal fullness (16%)

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

It is associated with a It is associated with a poor prognosis. poor prognosis.

Carcinoma of the GallbladderCarcinoma of the GallbladderUncommon malignancy – 2.5/100,000Uncommon malignancy – 2.5/100,000

Most common of biliary tract cancers (54%)Most common of biliary tract cancers (54%)

>90% are adenocarcinomas>90% are adenocarcinomas

In Native Americans, GB carcinoma is the most commonly seen GI In Native Americans, GB carcinoma is the most commonly seen GI malignancy malignancy

Male:Female = 1:3Male:Female = 1:3

Overall mean survival rate = 6 months, 5-year survival rate is 5%Overall mean survival rate = 6 months, 5-year survival rate is 5%

At diagnosis, most of the GB is replaced or destroyed by the cancerAt diagnosis, most of the GB is replaced or destroyed by the cancer

Risk Factors for GB CancerRisk Factors for GB Cancer Cholelithiasis Cholelithiasis

often large and symptomatic stones presentoften large and symptomatic stones present Chronic infection of gallbladderChronic infection of gallbladder

Salmonella TyphiSalmonella Typhi Genetic FactorsGenetic Factors GB polyps >1cm in diameterGB polyps >1cm in diameter Mucosal calcification of GB (Porcelain GB)Mucosal calcification of GB (Porcelain GB)

carcinoma in 25% carcinoma in 25% Anomalous pancreaticobiliary ductal junctionAnomalous pancreaticobiliary ductal junction Congenital biliary cystsCongenital biliary cysts Environmental carcinogensEnvironmental carcinogens

Anabolic SteroidsAnabolic SteroidsNo hablo

ingles!

Baseball be very good to

me

I'm not a crazy person.

I'm not stupid.

Symptoms and SignsSymptoms and SignsJaundiceJaundice

skin or icteric scleraeskin or icteric sclerae

Early Early Pain in RUQ with radiation into back Pain in RUQ with radiation into back

Anorexia, weight loss, fever and chillsAnorexia, weight loss, fever and chills (cholangitis), supraclavicular LN (cholangitis), supraclavicular LN

Courvoisier’s Law Courvoisier’s Law Palpable GB with obstructive jaundice signifies malignant diseasePalpable GB with obstructive jaundice signifies malignant disease This generalization accurate only 50% of timeThis generalization accurate only 50% of time

HepatomegalyHepatomegaly Usually present and associated with liver tendernessUsually present and associated with liver tenderness

Ascites Ascites Can occur with peritoneal implantsCan occur with peritoneal implants

Hematemesis or melenaHematemesis or melena From erosion of tumor into blood vessel (hemobilia)From erosion of tumor into blood vessel (hemobilia)

Carcinoma of GallbladderCarcinoma of GallbladderLocation:Location: fundus (60%), body (30%), neck (10%) fundus (60%), body (30%), neck (10%)

Notoriously insidiousNotoriously insidious Diagnosis made incidently at surgeryDiagnosis made incidently at surgery

SpreadSpread Early lymphatic spread Early lymphatic spread retroperitoneal, right celiac, retroperitoneal, right celiac,

and pancreaticoduodenal nodes. and pancreaticoduodenal nodes. Direct invasion of the liver, extrahepatic biliary ducts, Direct invasion of the liver, extrahepatic biliary ducts,

and duodenum and colon (less common) occurs. and duodenum and colon (less common) occurs. Intraperitoneal seeding may occur.Intraperitoneal seeding may occur.

TNM StagingTNM StagingTisTis = Carcinoma in situ = Carcinoma in situ

T1a T1a = GB wall: invades lamina propria= GB wall: invades lamina propriaT1b T1b == GB wall: invades muscle layerGB wall: invades muscle layer

T2T2 = Perimuscular connective tissue = Perimuscular connective tissue

T3T3 = Perforates serosa or directly invades = Perforates serosa or directly invades liver or adjacent organ liver or adjacent organ

T4T4 = Invades main portal vein or hepatic artery = Invades main portal vein or hepatic artery or multiple organsor multiple organs

N1a N1a = Hepatoduodenal ligament nodes= Hepatoduodenal ligament nodesN1bN1b = Other regional lymph nodes = Other regional lymph nodes

M0M0 = No distant metastases = No distant metastasesM1= Distant metastasesM1= Distant metastases

Stage 0Stage 0: Tis: Tis N0 N0 M0 M0

Stage I: Stage I: T1 T1 N0 N0 M0 M0

Stage II:Stage II: T2 T2 N0 N0 M0 M0

Stage III: Stage III: T1-2T1-2 N1 N1 M0 M0 T3 N0-1 M0T3 N0-1 M0

Stage IVAStage IVA: T4: T4 N0-1 N0-1 M0 M0

Stage IVB: Stage IVB: T1-4 N2T1-4 N2 M0 M0 T1-4 N0-2 M1T1-4 N0-2 M1

Carcinoma of Bile Ducts Carcinoma of Bile Ducts (Cholangiocarcinoma)(Cholangiocarcinoma)

Tumor that arises from the intrahepatic or extrahepatic biliary epitheliumTumor that arises from the intrahepatic or extrahepatic biliary epithelium

3% of all cancer deaths in the US3% of all cancer deaths in the US

> 90% are adenocarcinomas, remainder are squamous cell CA> 90% are adenocarcinomas, remainder are squamous cell CA

3 Geographic Locations:3 Geographic Locations: Intrahepatic Intrahepatic

Least commonLeast common Extrahepatic Extrahepatic (ie, perihilar)(ie, perihilar)

Perihilar (Klatskin tumors) = Most commonPerihilar (Klatskin tumors) = Most common At bifurcation of R and L hepatic ductsAt bifurcation of R and L hepatic ducts

Distal extrahepaticDistal extrahepaticUpper border of pancreas Upper border of pancreas ampulla ampulla

The etiology of most bile duct cancers remains undetermined. The etiology of most bile duct cancers remains undetermined.

Possible EtiologiesPossible EtiologiesInfectionsInfections

In SE Asia, chronic infx with liver flukesIn SE Asia, chronic infx with liver flukesClonorchis sinensis,Clonorchis sinensis, Opisthorchis viverriniOpisthorchis viverrini and and Fasciola HepaticaFasciola Hepatica

Inflammatory bowel diseaseInflammatory bowel disease CCC generally develops in patients with long-standing ulcerative colitis CCC generally develops in patients with long-standing ulcerative colitis

and PSC.and PSC.

Chemical exposuresChemical exposures primarily among workers in the aircraft, rubber, and wood finishing primarily among workers in the aircraft, rubber, and wood finishing

industries.industries. ThorotrastThorotrast

Congenital diseases of the biliary treeCongenital diseases of the biliary tree choledochal cysts and Caroli diseasecholedochal cysts and Caroli disease

Pathophysiology of CCCPathophysiology of CCCLong-standing inflammation as with PSC, Long-standing inflammation as with PSC, chronic parasitic infection suggested to play a chronic parasitic infection suggested to play a role by inducing hyperplasia role by inducing hyperplasia cellular cellular proliferation proliferation malignant transformation. malignant transformation.

Grow slowly and infiltrate walls of the ducts, Grow slowly and infiltrate walls of the ducts, dissecting along tissue planesdissecting along tissue planes

Local extension:Local extension: liver, porta hepatis, regional LN of the celiac and liver, porta hepatis, regional LN of the celiac and

pancreaticoduodenal chains. pancreaticoduodenal chains.

Symptoms and SignsSymptoms and SignsProgressive jaundiceProgressive jaundice

MC manifestation of bile duct cancer MC manifestation of bile duct cancer The obstruction and subsequent cholestasis tends to occur early if the tumor is The obstruction and subsequent cholestasis tends to occur early if the tumor is

located in the common bile duct or common hepatic duct.located in the common bile duct or common hepatic duct. Jaundice often occurs later in perihilar or intrahepatic tumors and is often a Jaundice often occurs later in perihilar or intrahepatic tumors and is often a

marker of advanced disease. marker of advanced disease. The excess of conjugated bilirubin is associated with bilirubinuria and clay The excess of conjugated bilirubin is associated with bilirubinuria and clay

colored stools.colored stools.

PruritusPruritus usually is preceded by jaundice, but itching may be the initial symptom of CCC. usually is preceded by jaundice, but itching may be the initial symptom of CCC. related to circulating bile acids.related to circulating bile acids.

Weight lossWeight loss

Abdominal painAbdominal pain common in advanced disease and often is described as a dull ache in the RUQcommon in advanced disease and often is described as a dull ache in the RUQ

Courvoisier’s SignCourvoisier’s Sign

If CCC located distal If CCC located distal to the cystic duct to the cystic duct takeoff takeoff the patient may have a the patient may have a

palpable gallbladder, palpable gallbladder, (Courvoisier sign)(Courvoisier sign)

Laboratory ExaminationLaboratory ExaminationBiliary NeoplasmsBiliary Neoplasms

Conjugated BilirubinConjugated Bilirubin Total serum bilirubin from 5-30mg/dLTotal serum bilirubin from 5-30mg/dL

Alkaline Phosphatase and GGTAlkaline Phosphatase and GGT

Serum CholesterolSerum Cholesterol

ASTAST normal or mildly elevatednormal or mildly elevated

CA 19-9CA 19-9 If elevated – may help distinguish CCC from benign biliary If elevated – may help distinguish CCC from benign biliary

stricturestricture

Imaging in Biliary NeoplasmsImaging in Biliary NeoplasmsUltrasonagraphy and CT:Ultrasonagraphy and CT:

Show GB mass in GB CarcinomaShow GB mass in GB Carcinoma Intrahepatic masses or biliary duct dilationIntrahepatic masses or biliary duct dilation CT also shows involved regional LNCT also shows involved regional LN

MRI with MRCPMRI with MRCP Visualization of biliary treeVisualization of biliary tree Detection of vascular invasionDetection of vascular invasion

Positron Emission Tomography (PET)Positron Emission Tomography (PET) Can detect CCC as small as 1cmCan detect CCC as small as 1cm

The most helpful diagnostic studies before surgery are The most helpful diagnostic studies before surgery are either PTC or ERCP with biopsy and cytologyeither PTC or ERCP with biopsy and cytology

Treatment of Biliary NeoplasmsTreatment of Biliary NeoplasmsCurative Surgery (Gallbladder CA)Curative Surgery (Gallbladder CA)

May be attempted in young and fit pts if tumor is well localized.May be attempted in young and fit pts if tumor is well localized. 5 year survival for localized (stage 1, T1a, N0, M0) is as high as 80% with laparoscopic 5 year survival for localized (stage 1, T1a, N0, M0) is as high as 80% with laparoscopic

cholecystectomycholecystectomy Only 15% if muscular invasion (T1b)Only 15% if muscular invasion (T1b) If tumor unresectable at laparotomyIf tumor unresectable at laparotomy

Cholecystoduodenostomy or T-tube drainage of CBDCholecystoduodenostomy or T-tube drainage of CBD

Curative Surgery (CCC)Curative Surgery (CCC) Curable in <10%Curable in <10% Palliation - place self-expandable metal stent via ERCP or PTCPalliation - place self-expandable metal stent via ERCP or PTC

Photodynamic therapyPhotodynamic therapy – palliative – palliative

RadiotherapyRadiotherapy Relieve pain and contributes to biliary decomressionRelieve pain and contributes to biliary decomression

ChemotherapyChemotherapy with gemcitabine – limited response with gemcitabine – limited response

In general, prognosis is poor, with few patients surviving >12 months after surgeryIn general, prognosis is poor, with few patients surviving >12 months after surgery

A 95 year-old woman presented with upper abdominal pain and jaundice; A 95 year-old woman presented with upper abdominal pain and jaundice; ultrasound demonstrated gallstones. Symptoms were short in duration, and ultrasound demonstrated gallstones. Symptoms were short in duration, and jaundice began to clear rapidly. In view of her age and improving condition, jaundice began to clear rapidly. In view of her age and improving condition, she was treated conservatively for cholecystitis. However, she then she was treated conservatively for cholecystitis. However, she then developed protracted vomiting; endoscopy demonstrated several stones in developed protracted vomiting; endoscopy demonstrated several stones in the duodenum.the duodenum.

What is the most likely cause this type of complication?What is the most likely cause this type of complication?

a. Malignancy extending into duodenuma. Malignancy extending into duodenumb. Perforation of gallbladderb. Perforation of gallbladderc. Caroli’s syndromec. Caroli’s syndromed. Metastasis from another primary tumord. Metastasis from another primary tumor

AnswerAnswer

B. This stone could not be removed B. This stone could not be removed endoscopically. Surgery confirmed the endoscopically. Surgery confirmed the suspicion that the gallbladder had suspicion that the gallbladder had perforated into the duodenum, releasing perforated into the duodenum, releasing the stones into the duodenal lumen. the stones into the duodenal lumen. Measurement of the largest stone after Measurement of the largest stone after surgical removal revealed it to be over 5 surgical removal revealed it to be over 5 cm in length (right).cm in length (right).