Disease of the Liver and Biliary TractGeneral Surgery Departmentdr Sigid Djuniawan, SpB LIVER HEPATIC TRAUMA

PENETRATING, BLUNT

Liver injury scale

Clinical : hypovolemic shock (hypotension, decreased urinary output, low cvp)

Imaging : Ct scan, FAST

Treatment : surgery

Complication : sepsis subhepatic (20%), hemobilia, stress ulcersLiver cancer Hepatoma

Incidens : male= female, > 50 yo

Etiology : HVB chronic and HVC, aflatoxin,

Type : hepatoma, cholangiocarcinoma, hepatocholangioma (mixed)

Clinical : right upper quadran pain, reffered pain in shoulder, weight loss, jaundice (1/3 cases) Clinical : hepatomegaly, arterial bruit, intermittent fever, ascites or gastriintestinal bleeding.

Laboratory : elevated bilirubin serum, increased alkaline fosfatase but serum bilirubin is normal (25%)

Imaging : CT scan, MRI, angiography

Liver biopsy (percutaneus core biopsy)

Tumor marker > 200 ng/ml

Treatment : partial hepatectomy, liver transplantation, ethanol injection, radiofrequency ablation.

HEPATIC ABCESS Et : bacterial, parasitic, fungal

90% right lobe= solitary, 10% left lobe = solitary

Cilinical : fever (high 40-41), jaundice unusual in solitary abcess, right upper quadrant pain and chills, malaise, fatique

Lab : leukocyte > 15.000, anemia, normal serum bilirubin

Imaging : atelectase in x rays, bof (air fluid level), usg and ct scan Treatment : antibiotics Aminoglcosides, clindamycin, metronidazole, ampicillin), percutaneus catheter, lobectomy

METABOLISME BILIRUBIN

Biliary Tract Biliary tract:Intra-hepatic bile ductExtra-hepatic bile duct GallbladderOddi sphincterFrom bile canaliculi to the ampulla of Vater

Intra-hepatic Bile Duct Bile canaliculi Segmental bile duct Lobal bile duct Hepatic part of left and right hepatic duct

Extra-hepatic Bile Duct Left and right hepatic duct The common hepatic ductDiameter :0.4-0.6 cm 2-4cm length Common bile ductDiameter:0.6-0.8cm length:7-9cm Gallbladder: the body,the fundus The neck Cyst duct

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.

VARIATIONS IN CYSTIC AND HEPATIC DUCTS

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 performedFirst 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 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 mediumA fatty meal Intravenous cholangiography Percutaneous transhepatic cholangi-ography (PTC)Show intra and extra hepatic biliary duct clearlyComplication : Bile leakage Cholangitis Hemorrhage 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. 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 imaging99m-Tc-EHIDA Choledochoscopy OperationPost operation Cholelithiasis Including :gallstones biliary duct stones In China : Before 1981 gallstones < biliary duct stonescholesterol stones < pigment stones Nowgallstones > 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

Localization of 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

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 Formation of stones Pigment stones: Form of calcium bilirubinate Bilirubin conjugated with glucuronide glucuronidase produced by E. coli. can split the molecule Unconjugated bilirubin precipitates as salt. Gallstones (Cholecystolithiasis) Risk factor : Women are three times more likely than men to develop stones Obesity Pregnancy Dietary factors:high energy,low in fibre Fasting Biliary infection Parasitic infestation Diabetes mellitus Gastric surgery TPN Cirrhosis of liver Chronic haemolytic anaemia 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. 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. Mirizzi syndrome: Obstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmanns pouch Press on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula Cholecystitis, cholangitis, and obstructive jaundice. Cholangiography: narrow of the bile duct at the porta hepatis Anatomy variation:cyst duct runs parallel to the hepatic duct Mucocele of the gallbladder: A stone impacts in the cystic duct without bacterial infection Bile is reabsorbed The epithelium continues to secrete mucous,which is called white bile

The gallbladder becomes distended Easily palpable, maybe visible. Infection does occur, an empyema may develop rapidly. Others: Stones migrate through the cystic duct into the common bile duct: infection, jaundice. Impaction of a small stone at the ampulla of Vater and occlusion of the pancreatic duct causes pancreatitis Cholecystoduodenal fistulaIntestinal obstruction Gallbladder carcinoma 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 (ductal dilatation), oral cholecystography (filling defect), BOF ( 10% radioopaque, pancreas calcification, porcelaine gall bladder)

Biliary tract : non ikteric : perioperatif cholangiography, ERCP)

Icteric : USG, ERCP, PTC) Treatment The first choice is operation : symptomatic gallstones/ asymptomatic gallstones acute/ chronic cholecystitis w or without gallstone

gallblader torsion

traumatic rupture

bilier peritonitis

carcinoma

retained stone

Profilactic cholecystectomy :

Stone > 2 cm

Gallblader calcification 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 CBD exploration :Preoperation CBD stones Cholangitis and biliary colic repeatedly Pancreatitis Jaundice and bile duct dilatation

CBD explorationDuring operation Cholangiography indicate CBD stone and bile duct dilatation Palpable stones, ascarid, tumor CBD diameter >1.0cm Gallstone migrate into CBD Pancreatitis Draw out purulent or haematoid bile or bile with sandy stones Laparoscopic cholecystectomy(LC) First performed in 1987 Removal of the gallbladder is guided by a laparoscope A short hospital stay, a quick recuperation, and a very small incision Contraindication Carcinoma CBD stones and biliary stenosis Severe abdominal infection Operation history Pregnancy Cardiac and respiratory problems Bleeding tendency

Minilaparotomy Minimally Invasive Open Cholecystectomy The incision is much smaller than with open cholecystectomy The operation has all the advantages of laparoscopy Non-Surgical Therapy Unwilling to undergo surgery Who have serious medical problems that increase the risks of surgery Cannot be used for patients who have acute gallbladder inflammation Oral Dissolution Therapy Contact Dissolution Therapy Extracorporeal Shock Wave Lithotripsy(ESWL) Bile duct stones Including : primary bile duct stones secondary bile duct stones Site:intrahepatic bile duct stones extrahepatic bile duct stones Extrahepatic bile duct stones Pathology : Biliary tract obstruction : Uncompletely, bile duct dilatation Infection: duct wall edma, congestion purulent bile ( blood ( sepsis bile duct wall ulcer fistula between bile duct and hepatic artery & portal vein Clinical manifestation Cholangitis May be silent Obstructive jaundiceAscending cholangitis Acute pancreatitis Charcot triad: epigastric pain febril (swinging pyrexia) jaundice Charcot triad Abdominal pain:Epigastric or right upper quadrant of the abdomenRadiate to the right back and shoulder vomiting, nausea High fever and chill :Obstruction infection pressure in duct increase bacteria flows into blood sepsis ( temperature: 39-40 Jaundice: intermittence, fluctuantThe severe of the jaundice depends on the duration of the obstruction.Complete impactation of a stone cause severe progressive jaundice.Intolerable itching Physical exam Tenderness of epigastric and upper area of the abdomen peritoneal irritation sign Gallbladder may be palpable Lab test WBC count is high Elevation of the enzyme alkaline phosphate and bilirubin Bilirubin in urea is high Urobillinogen in urea is low Urobillinogen in feces is low Imaging technique Ultrosound :stones in bile duct

bile duct dilatation PTC ERCP Diagnosis Charcot triad Lab test and imaging exam Differential diagnosis Renal colic Intestinal colic Carcinoma of the Vater ampulla Carcinoma of the head of pancreas Treatment Operation is the main therapy Principles:Try to removal all stonesRelief bile duct stenosis and obstructionThe obstructive duct must be drained adequately Operation methodsCholedocholithotomy and T-tube drainage Indication :Simple CBD stones without stenosis if gallstones or cholecystitis coexist, cholecystectomy Cholangiography during operation if stones left, choledochoscopy should be used: forcepsballoon catheter a basket T-tube cholangiogram is obtained 2 weeks after operation:if the duct is clear, T-tube is clamped without any symptoms and pulled out 2-3days later .if stones is left, choledochoscopy is performed 7 weeks after operation through T-tube fistula canal. Operation methodsCholedochojejunostomy Indication: CBD dilatation >2.5cmwith stenosis and obstructionSandy-like stones, not easy to clear Choledochoduodenostomy Cholecystectomy Endoscopic sphincterotomy(EST)Indication: stones impacted at ampulla benign stenosis of the end of CBDContraindication: pancreatitis, bleeding tendency, diverticulum of duodenum, Billroth II type gastrectomy Sphincteroplasty Peri-operation management:Control infection: antibiotics correct electrolyte and acid-alkali balance vitamin K, nutrition, etc. Treatment of residual stones Choledochoscopy Contact Dissolution Therapy Intrahepatic bile duct stones (hepatolithiasis) Pigment stones mainly Left more than right Coexist with extra hepatic bile duct stones commonly Etiology Infection Cholestasis Biliary Ascariasis Pathology Stenosis :intra hepatic bile duct Cholangitis Biliary carcinoma Clinical manifestation Feature of extra hepatic bile duct stones (when coexist) Asymptomatic or discomfort of liver area and chest back Obstruction: infection, fever,chill, acute obstructive suppurative cholangitis(AOSC) Abscess bronchobiliary fistula Bile liver cirrhosis hypertension of portal vein Carcinoma of biliary tract:Frequency attack of cholangitis, progressive jaundice, abdominal pain, fever hard to control, age > 50 become thin. Physical exam Liver swelling asymmetrical Tenderness at liver area Percussion tenderness over hepatic region Others: infection and complication Diagnosis History Imaging exam:ultrasoud PTC: Treatment Integration therapy Operation:the main method Principle: extract all stonesrelief stenosis and obstruction: key point removal intrahepatic infective focusrecovery the bile drainage prevent recrudescence Operation High positioned Cholangiolithotomy : Choledochoscopy Internal drainage: Roux-en Y cholangiojejunostomy Removal intrahepatic infective focuslocal cirrhosis: left lateral lobe and right posterior lobe Treatment of residual stones Choledochoscopy Contact Dissolution Therapy Extracorporeal Shock Wave Lithotripsy(ESWL) Biliary infection Cholecystitis Cholangitis Acute Subacute Chronic Choleliathiasis Biliary infection Acute cholecystitis Chemical and(or) bacterial inflammation Divided in to two categories:acute calculous cholecystitis (ACC) 95%acute acalculous cholecystitis (AAC) 5% Etiology : Obstruction of cyst duct :80% by an impacted gallstone others:torsion or stenosis of cyst duct, ascarid Bacterial inflammation Trauma(previous surgery),chemical stimulus Pathology Acute simple cholecystitis Acute purulent cholecystitis Acute gangrenous cholecystitis Perforation of gallbladder: peritonitis Cholangitis and pancreatitis Acute calculous cholecystitisNosogenesis Cyst duct obstruction by gallstones the result is chemical inflammation of the cyst wall Secondary bacterial infection retrogression through cyst duct by blood or lymph Others Clinical manifestation More common in women History of gallbladder disease Typical onset: biliary colic Patients tend to move around to seek relief from the pain it is prolonged and lasts hours or days Nausea, vomiting, and low-grade fever Severe case: High fever and chill: indicate empyema or perforation of gallbladder and cholangitis, diffusive peritonitis Jaundice : 1025% of all cases. PancreatitisSign Epigastric or right upper quadrant tenderness, guarding may be found Murphy sign (an inspiratory pause on palpation of the right upper quadrant) Gallbladder may be palpable. Mass in the right upper quadrant Diffusive peritonitis Tachycardia Elderly patients:Absence of typical physical signs the incidence of complication is higher Uncommon in children Lab test WBC countLeukocytosis with left shift Normal WBC Count does not rule out cholecystitis Liver Function Tests (LFTs) Serum Bilirubin elevated Serum Alkaline Phosphatase elevated Serum Aminotransferases normal Pancreatic Studies Amylase elevated Imaging exam Ultrasound: Enlargement of the gallbladder Gallbladder wall thickness > 3 mm Sonographic Murphy's Sign Halo sign (gallbladder wall with a sonolucent double-lined halo) Pericholecystic fluid or abscess Gallstones Hepatobiliary scan Normal visualization of gallbladder in 30 minutes 95% accuracy;100% sensitivity Nonvisualization of gallbladder at 60 minutes and normal visualization of intestine (cyst duct obstruction) Diagnosis Typical clinical manifestation Lab test Imaging exam Easy to diagnosis Differential diagnosis Acute pancreatitis Acute appendicitis Perforation of peptic ulcer Hepatic abscess Perforation of colon carcinoma Hepatitis Pneumonia and pleurisy (right) Treatment Nonsurgical treatment:Fasting a low fat diet when food is tolerated after the acute attack. Intravenous fluid Nasogastric suction Antibiotics Pain control 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 Operation Cholecystectomy:most cases Cholecystostomy:High risk casesLocal severe edema, conglutination Partial cholecystectomy Acute acalculous cholecystitis Etiology : Uncertain After severe trauma, operation,and burns Severe illness cases TPN for a long time Be related to gallbladder distension and bile stasis Pathology Same to acute calculous cholecystitis High rate of necrosis and perforation of gallbladder Clinical manifestation More common in men Same to acute calculous cholecystitis Easy to make an error diagnosis Ultrasound is the most useful investigation Gallbladder is palpable Treatment Once the diagnosis is made,an immediate operation is necessaryMethod: Cholecystectomy Cholecystostomy: Acute obstructive suppurative cholangitis(AOSC) Acute cholangitis of severe type(ACST) Etiology :Complete obstruction of bile ductpurulent infectionObstructive factor: Bile duct stones 76-88% Biliary Ascariasis 22-26% Biliary tract stenosis 8.7-11% Tumor of ampulla Primary sclerosing cholangitis Cholangiojejunostomy T-tube cholangiography or PTC Pathology Complete bile duct obstructionintra or extra hepatic bile duct Purulent infection: bile duct Bacteria: Escherichia coli, streptococcus faecalis, Klebsiella, pseudomonas

Anaerobic bacteria Clinical manifestation History of biliary disease and biliary operation Starts abruptly and progressively Reynolds' pentad:fever and chills jaundice abdominal pain mental status changes septic shock Reynolds' pentad Initial: intermittent chill and fever severe: continuous high fever Abdominal pain:appearance in extra hepatic bile duct obstruction right upper quadrant (RUQ) pain Jaundice: most casesAbsence in one lateral intrahepatic obstruction Mild in uncompleted obstruction e.g. cholangiojejunostomy itching Mental status changes:indifferent, lethargy unconsciousness, coma Septic shock:restless, phrenitis Sign Temperature: 39-40C and even higher Pulse: quick and weaken, >120b/m Blood pressure: low Jaundice and cyanosis Tenderness : Epigastric or right upper quadrant tenderness Mental status changes Peritonitis Percussion tenderness over hepatic region Palpable gallbladder Mild hepatomegaly Lab test WBC count is high, >20X109/L severe patients may be leukopenic PLT count is low, (10-20)X109/L Prothrombin time is long Liver function:Alkaline phosphatase and Bilirubin is elevated Renal function and electrolytes Blood cultures: Between 20-30% of blood cultures are positive. Many exhibit polymicrobial infections Amylase and/or lipase: Involvement of the lower CBD may cause elevated amylase and pancreatitis. Biliary cultures Imaging Studies Ultrasound: Used most commonly to make the diagnosis of biliary dilation Differentiate intrahepatic from extrahepatic obstruction and image dilated ducts CT scan Adjunctive or replace ultrasound Dilated intrahepatic and extrahepatic ducts and inflammation of the biliary tree are imaged Biliary scintigraphy Obstruction of the CBD causes nonvisualization of the small intestine Assess function, and positive results may appear before the ducts are enlarged sonographically Diagnosis Reynolds' pentad Lab test Imaging exam T>39 P>120R/M WBC> 20X109/L,PLT is low Treatment Principle : Emergency decompression to relieve bile duct obstruction and drainage Control infection: Broad-spectrum antibiotics Nonsurgical management : Complementary to surgical or endoscopic treatments Broad-spectrum antibiotics Fluid infusion Electrolyte imbalances corrected Others Biliary decompression : Nonoperatively by either a transhepatic or endoscopic route Surgical procedure Nonoperative decompression Endoscopy: Endoscopic sphincterotomy (EST)Endoscopic nasobiliary drainage(ENBD) Percutaneous transhepatic cholangiography and drainage(PTCD) If failure ( operation Surgical decompression To save life Simple and helpful Choledochotomy decompression and T-tube drainageCholecystostomy Tumor of biliary tract Including gallbladder tumor and bile duct tumor Benign tumors is rarely Nearly two-thirds of carcinoma arise in the gallbladder, while the remainder (cholangiocarcinoma) originate from the bile ducts and periampullary region. Gallbladder carcinoma The most common biliary tract tumor and the fifth most common GI tract cancer Women are more commonly afflicted than men The median age at presentation of gallbladder cancer is 59.6 years Etiology and risk factors The risk of developing gallbladder cancer is higher in patients with choleli-thiasis Chronic cholecystitis: calcified gallbladder Gallbladder adenomas Pathology Most located in body and fundus of gallbladder Over 80% of gallbladder neoplasms are adenocarcinomas and the remaining 15% are squamous cell or mixed tumors Spread locally by lymphatic, vascular, or intraneural, or intraductal invasion STAGE

Signs and Symptoms Early disease, asymptomatic. Late disease right upper quadrant pain, nausea, vomiting, fatty food intolerance, anorexia, jaundice, and weight loss. Physical findings may include Tenderness An abdominal mass Hepatomegaly Jaundice Fever Ascites Lab test and imaging exam Serum exam: CEA, CA19-9,CA-125 Ultrasound:gallbladder wall thickening a complex mass filling the gallbladder CT scan : more helpful in assessing adenopathy and spread of disease into the liver, porta hepatis, or adjacent structures Jaundice is the most frequent symptom nonfluctuating Abdominal pain Weight loss Pruritus Fever An abdominal mass:gallbladder Vomiting, nausea Cholangitis Treatment Operation Simple cholecystectomy: Nevin I stage Radical operation: Nevin II,III,IV stageResection should include the gallbladder bed (segments IVb and V) and a porta hepatis lymphadenectomy Palliative operation: later stage with jaundice. To relieve symptoms. Carcinoma of Bile Duct Etiology and risk factors Ulcerative colitis is a clear risk factor for bile duct tumors Primary sclerosing cholangitis, congenital anomalies of the pancreaticobiliary tree Parasitic infections Stones Pathology 50 to 75% of cancers are located in the upper third of the extrahepatic biliary tract Papillary types, nodular types, sclerosing type More than 90% of bile duct tumors are adenocarcinomas Most bile duct tumors grow slowly, spreading frequently by local extension and rarely by the hematogenous route Lab test and imaging exam Total bilirubin elevation Similarly, Alkaline phosphatase Ultrasound may function as a good screening test, but it rarely suggests a diagnosis in this disease. PTC ERCP,MRCP Treatment Operation is the main therapy method Proximal tumors: tumors local excision, Cholangiojejunostomy Mid-ductal: early stage, Cholangiojejunostomy Distal tumors: pancreaticoduodenectomy Palliative operation(therapy)