Gallbladder and extrahepatic biliary system

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common problems with the gall bladder and the bile ducts

Transcript of Gallbladder and extrahepatic biliary system


2. ANATOMY The Gallbladder: Pear-shaped sac. 30-50 ml. Located in the fossa on the inferior surface of the liver 4 anatomic areas. Blood supply: cystic artery ( triangle of calot). Venous drainage: small veins enter directly to the liver. Lymphatic: nodes at the neck of the GB. 3. ANATOMY The Gallbladder: Pear-shaped sac. 30-50 ml. Located in the fossa on the inferior surface of the liver 4 anatomic areas. Blood supply: cystic artery ( triangle of calot). Venous drainage: small veins enter directly to the liver. Lymphatic: nodes at the neck of the GB. 4. The Bile ducts: The extra hepatic components. Common bile duct portions. Blood supply: gastroduodenal and R hepatic arteries. 5. Anomalies: The classic description applies only in one third of the patients G.B: abnormal portions, intrahepatic, rudimentary, or duplicated. Bile ducts: duct of Luschka, accessory right hepatic duct. Arteries: In 50 % of population Right hepatic artery from SMA (20%) 2 right hepatic arteries (5%) Cystic artery can arise from left hepatic, common hepatic, gastroduodenal, or SMA(10%). 6. PHYSIOLOGY Bile Formation and composition: Produced by the liver ( 500-1000 ml/day). Production is stimulated by vagus, food particles in the duodenum, and secretin. Composed of water, electrolytes, bile salts, bile pigments, protein, lipids. Cholesterol -> primary bile acids -> ( conjugation + Na) -> bile salts -> small intestine : *80% absorbed in terminal ileum. *deconjugated (secondary bile acids) -> absorbed in colon 95% of the bile acid pools is reabsorbed (enterohepatic circulation) 7. G.B Function: Store and concentrate bile. Secrete glycoprotein and hydrogen ion. Contraction stimulated by CCK and vagus nerve and inhibited by sympathetic stimulation, VIP, and somatostatin Sphincter of oddi: Regulates bile flow, prevents back flow, and diverts bile into G.B. Basal resting pressure of 13 mm Hg above duodenal pressure. CCK causes relaxation 8. DIAGNOSTIC STUDIES Blood Tests: WBC LFT N.B in pt with biliary colic blood tests will be typically be normal. Ultrasonography: Operator dependant. Stones (>90% s&s) -> acoustic shadow, move Thickened wall. Evaluate extra hepatic biliary tree. Can evaluate tumor invasion and flow in the portal pain. 9. Oral Cholecystograhy. HIDA: Radionuclide is injected IV Detected in liver within 10 min. GB, ducts, and duodenum are visualized within 60 min. Acute cholecystitis -> nonvisulaized G.B. (95% s&s). To evaluate biliary leak. CT: The major application is to define the biliary tree and near by structure. Test of choice to evaluate for malignancy. 10. PTC: To evaluate the intrahepatic biliary system Useful in pt with duct strictures and tumors. Risk of bleeding, cholangitis, and bile leak. MRI: MRCP is used to delineate the anatomy of the bile and pancreatic ducts. ERCP: Require pt sedation. Direct visualization of the ampullary region and direct access to the distal CBD. Can be used for therapeutic intervention. Used mainly to evaluate complicated duct stones. Complications include pancreatitis and cholangistis. 11. GALLSTONE DISEASE INTRODUCTION: Prevalence 11-36%. Risk factors: 1. Obesity 2. Pregnancy 3. Crohns disease. 4. Terminal ileum resection. 5. Gastric surgery. 6. Hereditary spherocytosis, sickle cell disease, thalassemia. 7. Female. 8. 1st degree relative. 12. Natural History: Most pt remain asymptomatic 3% become symptomatic per year (biliary colic) 3-5% develop complications per year; acute cholecystitis, choledocholithiasis, cholangitis, pancreatitis, cholecystocholedochal fistula, and cholecystoenteric fistula. Prophylactic cholecystectomy may indicated for elderly pts with DM, individual who will be isolated from medical care for extended period of time, and in population with increased risk of cancer. Porcelain G.B. is an absolute indication for cholecystectomy. 13. Gallstones formation: Form as a result of settling out of solution. Can be classified into: 1- cholesterol stones *80% of gallstones. * Secondary to supersaturation of bile with cholesterol due to cholesterol hypersecretion. *10% -> pure, and present as single large stone with smooth surface. *most contain bile pigments and Ca, and are usually multiple, variable size *color range from whitish yellow and green to black. *most are radiolucent. 2-pigment stones: *black are usually small, brittle and speculated. Formed secondary to supersaturation with Ca bilirubinate . *brown stones are usually less than 1 cm, soft, and mushy. Usually formed secondary to bacterial infection due to bile stasis. 14. SYMPTOMATIC GALLSTONES CHRONIC CHOLECYSTITIS: About two thirds of patients with gallstone disease present with chronic cholecystitis . Aschoff-Rokitansky sinuses. Clinical presentation: *The patient suffers discrete attacks of pain and N/V between which they feel well. *RUQ tenderness. *Atypical presentation. Hydrops: due to an impacted stone in the cystic duct. Diagnosis: clinical presentation + US Management: dietary modification and elective cholecystectomy. 15. ACUTE CHOLECYSTITIS: Causes: 1- stones 90-95% 2-acalculous 3-tumor. Clinical manifestation: *80% give a history compatible with chronic cholecystitis. *RUQ or epigastric pain that may radiate to the right upper part of the back or the interscapular area. *fever, complains of anorexia, nausea, and vomiting. *RUQ tenderness and Murphy's sign. Diagnosis: *WBC: 12-15, LFT *US *HIDA *CT 16. Treatment: *intravenous fluids, antibiotics (G ve and anaerobes), and analgesia. *Cholecystectomy; early Vs delayed. * unfit for surgery; a percutaneous cholecystostomy or an open cholecystostomy under local analgesia can be performed. 17. CHOLEDOCHOLITHIASIS: Common bile duct stones; primary or secondary. Clinical manifestation: May be silent or can present with biliary colic, cholangitis, gallstone pancreatitis, or obstructive jaundice. Diagnosis: US, MRC, ERCP Treatment: *ERCP followed by lap chole *Intra operative cholangiogram and lap CBD ex *Open CBD ex and T-tube placement 18. CHOLANGITIS: Is an ascending bacterial infection in association with partial or complete obstruction of the bile ducts. (Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis, and Bacteroides fragilis) Clinical presentation: Charcot's triad and Reynolds pentad . Diagnosis: *Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases . *US *ERCP , PTC *CT, MRI Treatment: *intravenous antibiotics and fluid resuscitation *the obstructed bile duct must be drained as soon as the patient has been stabilized 19. BILIARY PANCREATITIS: Severe: ERCP with sphincterotomy and stone extraction, Once the pancreatitis has subsided, the gallbladder should be removed during the same admission Mild: cholecystectomy and an intraoperative cholangiogram or a preoperative ERC. Cholangiohepatitis: recurrent pyogenic cholangitis 20. OPERATIVE INTERVENTION FOR GALLSTONE DISEASE Cholecystostomy: Decompresses and drains the distended, inflamed, hydropic, or purulent gallbladder. It is applicable if the patient is not fit to tolerate an abdominal operation Ultrasound guided percutaneous drainage with a pigtail catheter is the procedure of choice. Laparoscopic Cholecystectomy: The treatment of choice for symptomatic gallstones. Absolute contraindications: uncontrolled coagulopathy, end stage liver disease. Complication: bile duct injury 21. Open Cholecystectomy Intra Operative Cholangiogram or Ultrasound: Routine intraoperative cholangiography; detect stones , outlining the anatomy and detect injury. Selective intraoperative cholangiogram : abnormal LFT, pancreatitis, jaundice, a large duct and small stones, a dilated duct on preoperative ultrasonography, and if preoperative endoscopic cholangiography for the above reasons was unsuccessful. 22. Choledochal Exploration: To manage CBD stones Laparoscopic choledochal exploration: can be carried as part of lap chole *Irrigation and flushing toward the duodenum *Stones can be retrieved through balloon catheter, wire basket , flexible choledochoscope , or choledochotomy followed be T-tube. Choledochal Drainage Procedures: When the stones cannot be cleared and/or when the duct is very dilated. Choledochoduodenostomy, choledochojejunostomy, hepaticojejunostomy Transduodenal Sphincterotomy: Replaced by endoscopic sphincterectomy. May be feasible when an open procedure is carried out. 23. OTHER BENIGN DISEASES AND LESIONS Acalculous Cholecystitis: Typically develops in critically ill patients in the intensive care unit Unknown cause. Clinical feature: similar to acute cholecystitis in alert pt while in sedated pt can be suspected with fever, WBC, T bili, and ALP. US, CT, HIDA Cholecystotmy. 24. Biliary Cysts: Congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree. Five types : Type I, fusiform or cystic dilations of the extrahepatic biliary tree(the most common type), Type II, saccular diverticulum of an extrahepatic bile duct, Type III, bile duct dilatations within the duodenal wall (choledochoceles), Types IVa and IVb, multiple cysts, Type V, intrahepatic biliary cysts. Adults commonly present with jaundice or cholangitis. Less than one half of patients present with the classic clinical triad of abdominal pain, jaundice, and a mass US, CT, ERCP, MRC Types I, II, and IV -> excision of the extrahepatic biliary tree, including cholecystectomy, with a Roux-en-Y hepaticojejunostomy. 25. Sclerosing Cholangitis: Inflammatory strictures involving the intrahepatic and extrahepatic biliary tree. Can result in secondary biliary cirrhosis. Associated with ulcerative colitis, Riedel's thyroiditis, and retroperitoneal fibrosis. Risk for developing cholangiocarcinoma 10-20% The usual presentation is inte