The Biliary System

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The Biliary System. Mr E. Leung. Content. Surgical Anatomy Physiology Investigations for biliary tree Common Pathology. Surgical Anatomy. Surgical Anatomy - Gallbladder. Pear shaped 7 – 13 cm in length, Volume ~ 50ml Cystic duct 1 – 3cm Spiral valves of Heister - PowerPoint PPT Presentation

Transcript of The Biliary System

  • The Biliary SystemMr E. Leung

  • Content

    Surgical Anatomy


    Investigations for biliary tree

    Common Pathology


  • Surgical Anatomy - GallbladderPear shaped

    7 13 cm in length, Volume ~ 50ml

    Cystic duct 1 3cmSpiral valves of Heister

    Fundus, body, neck and Hartmanns pouch

  • Surgical Anatomy - Gallbladder

    Lies between quadrate lobe and right lobes

    Covered in peritoneum except the GB fossa

  • Surgical Anatomy - Gallbladder1st + 2nd part of duodenum lies behind

    T-colon lies inferiorly

    Common Bile Duct (CBD) 7cm long7mm wide pressure of 7mmHg

  • Surgical Anatomy Calots Triangle

  • Surgical Anatomy Common Bile DuctCBD = CHD + cystic duct

    Supraduodenal part free edge of lesser sac2.5cm long

    Retroduodenal part

    Infraduodenal part

    Intraduodenal part

  • Surgical Anatomy Major and minor papillaCBD enters duodenum posteromedially

    Joins pancreatic duct = Ampulla of Vater(10cm from pylorus)

    Accessory pancreatic duct joins duodenum via minor papilla

  • Endoscopic view of Ampulla of Vater, also known as Major duodenal papilla

  • Surgical Anatomy Sphincter of OddiCircular muscle of duodenum wraps around the confluence of the pancreatic duct and CBD

    Forms a sphincter and prevents reflux of duodenal contents

  • Surgical Anatomy nerve supplyT7-9 sympathetic and parasympathetic vagus

    Afferent fibres (including pain) => coeliac plexus => greater splanchnic nerves => dorsal ganglia

    Preganglionic efferent fibres => coeliac plexus => postganglionic fibres run along the hepatic artery

    Vagus stimulation = GB to contract, Oddi to relax


  • Physiology Bile saltsBile = 97% water, 2% bile salts, 1% pigments

    Bile acids are synthesised in the liver from cholesterol

    Primary bile acids = chenodeoxycholic + cholic acidConjugated with Taurine + Glycine = water soluble bile salts

    Secondary bile salts = gut bacterial metabolism (deoxycholic and lithocholic acid)

  • Physiology function of gallbladder + bileConcentrates and stores bile (upto 10x)

    Mucin secretion

    Bile + small globlets of fat = micelles

    Allows digestion by lipases

  • Physiology The enterohepatic circulationSecretin and CCK, secreted by duodenum

    low pH or high fat content

    CCK => GB to contract and Oddi to relax

    Secretin => bile production and pancreatic juice release


  • InvestigationsLargely radiological

    Blood tests: inflammatory markers, GGT, LFTs, Clotting, Amylase

    Radiology:AXR, USS, cholangiography (oral, iv or intraductal)CT, MRCP, radionuclide scans (HIDA or PIPIDA)

  • Radiological investigationsPlain AXR


  • Radiological investigationsCholangiography

    CT better at assessing the pancreas

    MRCP best resolution in assessing the biliary tree

    Tc-labelled scan functional study


  • Congenital abnormalitiesAtresia type I, II and III or Gallbladder1 in 30,000

    Double or intra-hepatic gallbladder

    Phrygian cap

    Choledochal cysts

  • Acquired pathology Gallstone diseaseVery common The 4 FsF:M = 3:1West > East

    Pure cholesterol stone 5%Mixed stone (70%) Lecithin, cholesterol and saltsPure pigment stones 25%

    90% of time is radiolucent

  • Causes of Gallstone formationChanges in bile composition, multifactorialSupersaturation Precipitation

    Metabolic e.g. diet, cirrhosis

    Infective e.g. reflux of bile

    Biliary stagnation e.g. pregnancy

  • Complications of gallstones

  • Complications of gallstonesBiliary colicAnalgesia then cholecystectomyCholecystitisMucoceolePerforationAbx then cholecystectomy

    GS ileusSurgery

    CholangitisAbx and ERCP, then cholecystectomy


  • Other benign gallbladder conditionsStrawberry GB lipid/cholesterol infiltration to mucosa

    Adenomyomatosis - Mucosal diverticula

    Acalculus cholecystitis 5%Precipitated by illness, surgery or trauma

    Benign polyp

  • Symptoms of gallstone disease

    Most gallstones are asymptomatic

  • Symptoms of gallstone diseaseBiliary colicIntermittent colicky RUQ painPost-prandial vomitingRight shoulder pain

    CholecystitisConstant sharp RUQ painFever and vomiting (not post-prandial)

  • Symptoms of gallstone diseaseCholangitisJaundiced (urine, faeces, itch)Rigors Colicky RUQ pain

    PancreatitisContinuous sharp pain alleviated by leaning forwardOther symptoms for complications of pancreatitis

  • Differential diagnoses

    PUD / Gastritis / GORD


    Liver pathology