PATOLOGIA

CAILOR BILIARE
Dr. Theodor Voiosu

I. LITIAZA VEZICULARA
EPIDEMIOLOGIE:
- FEMEI
- VARSTA: 0-20 0,1%
70 30%

COMPOZITIA BILEI NORMALE

ELECTROLITI

25-50mEq/l

BILIRUBINA

0,25-1mM/l15

PROTEINE

200 mg

AC. BILIARI

40-100mM/l110

COLESTEROL

2-5mM/l25

FOSFOLIPIDE

5-10mM/l50

Tipuri de calculi
1. Colesterolici (80%)
-

dieta, obezitate, hormoni estrogeni, genetica

2. Pigmentari negri (bilirubina si pigmenti

biliari, colesterol < 30%)
- hemoliza, ciroza

3. Pigmentari bruni sau bilurubinat de calciu

- infectii, manipularea caillor biliare (calculi
coledocieni !)

Formarea calculilor

Bila litogena (suprasaturata in colesterol)

Factori de nucleere
Perturbarea motilitatii VB / ductelor biliare
Colonizare bacteriana

LITOGENEZA

1. FORMAREA BILEI SUPRASATURATE

2. NUCLEERE (OMOGENA, NEOMOGENA)

3. CRESTEREA

MANIFESTARI POSIBILE ALE

LITIAZEI BILIARE
1.

ASIMPTOMATICA 80%

2.

COLICA BILIARA
20% SIMPTOMATICI

3.

COLECISTITA ACUTA

4.

ICTERUL MECANIC / COLANGITA

5.

PANCREATITA ACUTA BILIARA

TIPUL COMPLICATIEI
Depinde de dimensiunea calculului
Nivelul de inclavare
Factori individuali

Colica biliara
Durere localizata in hipocondrul drept sau
epigastru +/- iradiere posterioara
Durata sub 300 minute
Frecvent nocturn
Trigger mese copioase
+/- caracter ondulant

Colecistita acuta

90% de etiologie litiazica

Durere cu caracter biliar
Durata > colica biliara
Asociaza febra, frison, varsaturi, semne
de iritatie peritoneala, +/- icter
URGENTA CHIRURGICALA
Complicatii !

Ecografia abdominala diagnostic

rapid si sigur !

Diagnostic Criteria for Acute Cholecystitis, According to Tokyo Guidelines

Strasberg S. N Engl J Med 2008;358:2804-2811

Severity Grading for Acute Cholecystitis, According to Tokyo Guidelines

Strasberg S. N Engl J Med 2008;358:2804-2811

A 70-year-old man with a history of heart disease, hyperlipidemia, and diabetes mellitus
presented at the hospital with a 4-day history of increasing abdominal pain, nausea, and vomiting

Shrestha Y and Trottier S. N Engl J Med 2007;357:1238

Ileus Biliar

An 83-year-old woman was hospitalized with nausea, vomiting, and obstipation

- Fistula biliodigestiva urmata de impactarea calculului in tractul

digestiv superior si ileus mecanic secundar

Graham J and Rothwell B. N Engl J Med 2004;351:1119

TRATAMENT
1.

COLECISTECTOMIE LAPAROSCOPICA LA
PACIENTUL SIMPTOMATIC INDIFERENT DE
MANIFESTARE (colica, colecistita, pancreatita)

2. SOLUTII MINIM-INVAZIVE la pacientul instabil

(colecistostomie, stentare endoscopica, tratament
conservator)

Complicatii postoperatorii

Complicatii postoperatorii
Imediate fistule biliare
La distanta - stenoze benigne de cale biliara
Diverse nivele ale caii pot fi interesate

Terapia este endoscopica (ERCP), rar

chirurgicala

II. LITIAZA CAII BILIARE

PRINCIPALE
Epidemiologie:
calculii veziculari de 10X mai frecventi decat cei
coledocieni !

Orice tip de calcul !

Calculi formati de novo / migrati

De obicei se manifesta clinic dar sunt si cazuri asimpt.

SIMPTOME
1. TRIADA CHARCOT:
1. COLICA BILIARA
2. FEBRA
3. ICTER

2. PANCREATITA ACUTA BILIARA !

ANOMALII BIOLOGICE
1. COLESTAZA (FA, GT)
2. CITOLIZA

3. AMILAZE (PA biliara !)

4. LEUCOCITOZA

DIAGNOSTIC IMAGISTIC
1. ECHOGRAFIE 55-75%
2. CT
3. RMN (inclusiv COLANGIORMN!)
4. ECHOENDOSCOPIE
5. ERCP rol TERAPEUTIC

Colangita acuta Criteriile Tokyo

ColangioRMN - diagnostic

Ecoendoscopia rol diagnostic adjuvant

ERCP diagnostic si tratament

TRATAMENTUL LITIAZEI
COLEDOCIENE
1. SFINCTEROTOMIE
2. EXTRACTIA CALCULULUI
3. LITOTRIPSIE
4. STENTARE (cazuri dificile, pacienti la risc)

4. CHIRURGIE

III. Tumori de cai biliare

Tumori rare
Adenocarcinoame
La orice nivel (vezicula biliara, cai biliare
intra si extrahepatice)
Cel mai frecvent - colangiocarcinomul

Colangiocarcinomul
Repere generale
Boal rar (inciden 1/100.000)
3% din cancerele digestive
Diagnostic tardiv (std III/IV)
Prognostic prost (30% la 5 ani post-op!)
Blechacz b et al. Clin Liver Dis 12 (2008) 131150

Repere generale

Inciden crescut n Est (100/106)

Infecii (Clonorchis, Opistorchis)
Colangita sclerozant (5-15%)
Litiaz hepatic
B. Caroli, chiste coledociene, fibroza
hepatic, toxine

Supot Kamsa-ard et. Al Asian Pacific J Cancer Prev, 12, 2209-2213

Burak K, et al. Incidence and risk factors for cholangiocarcinoma in primary sclerosing cholangitis. Am J Gastroenterol
2004;99:5236.

Tipuri

Blechacz b et al. Clin Liver Dis 12 (2008) 131150

Cazul coal
Brbat, 60 ani
Icter indolor

Astenie, caexie
BT, BD, F. Alc.
CA 19.9

Clinica
Intrahepatic

Casexie
Astenie
Durere in hipocondru
Icter, prurit
Colangita 10%

Extrahepatic

Icter, prurit
Colangita
Scadere ponderala
Semn Courvoisier

Cazurile dificile
ColangioK in colangita sclerozanta
Stricturi biliare de etiologie incerta

DIAGNOSTIC COMPLET
=
CARTOGRAFIEREA LEZIUNII

Ecografia
Prima linie
Semne indirecte (dilatare CBIH)
Vede tumorile intrahepatice
Nu vede tumorile distale

Robledo R, Muro A, Prieto ML. Extrahepatic bile duct carcinoma: US characteristics and accuracy in demonstration of tumors.
Radiology 1996;198:869

CT

Rol limitat
Apreciere dificila a hilului
Rezultate bune privind invazia vasculara
Acuratete limitata in stadializarea TNM
Doar 60% acuratete in aprecierea
rezecabilitatii

ERCP
MALIGNITATE
Stenoza > 10 mm
shouldering
Margini neregulate

ERCP

Aprecierea buna a extensiei intraductale

Permite prelevare biopsie / citologie
Colangioscopia randament f bun in CSP
Paliatie !

Invaziva, riscuri procedurale

Randament diagnostic
Baron T. Clin Liver Dis 14 (2010) 333348
Tischendorf JJW et al. Cholangioscopic Characterization of Bile Duct Stenoses in PSC Endoscopy 2006; 38: 665669

ColangioRM

Metoda de electie
Noninvaziva, noniradianta
Stadializare / rezecabilitate
Reconstructie 3 D => planificarea
interventiei PALIATIVE
ColangioRM = MDCT plus ERCP
Khan SA, et al. Guidelines for the diagnosis and treatment of cholangiocarcinoma: consensus document. Gut 2002;51(Suppl 6):VI19
Park HS et al. Preoperative Evaluation of Bile Duct Cancer: MRI Combined with MR Cholangiopancreatography Versus MDCT with Direct
Cholangiography, AJR 2008, 190.

Ecoendoscopia
Stricturi extrahepatice
EUS FNA
Randament crescut la cei cu biopsii
negative la ERCP
Staging ganglioni
Seeding ?
Topazian M. Clin Endosc 2012;45:328-330

Next generation

US intraductala (extensie, stadializare T)

Tomografia de coerenta optica
Colangioscopia cu NBI
Miniprobe endomicroscopie confocala laser

Talreja JP et al. Dig Dis Sci. 2012 Aug 9