Disease of the biliary tract

Gallbladder: body, fundus, neck

Anatomy review

Level of the Stones:

Biliary tract
Intra-hepatic bile duct
Extra-hepatic bile duct
Gallbladder
Oddi sphincter
*right and left hepatic duct- a part of it
is in the intra-hepatic duct and some
are in the extra-hepatic duct
From 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 duct
Diameter: 0.4-0.6 cm ;length:24 cm
Common bile duct
Diameter: 0.6-0.8cm ; length: 79cm
Gallbladder: the body, the
fundus, the neck
Cyst duct

Gallbladder-dyspeptic
symptoms
Cyst duct-acute cholecystitis
Common bile (not fully
obstructed) -dyspepesia or
abdominal pain

The level of the symptoms depend

where the stone is located
*Common bile duct theory: the
pancreatic duct and the common bile
duct joins together to form single
opening
Carlot 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 and para-right
hepatic duct run within the
triangle makes an important
area of dissection during
cholecystectomy.
Anatomy
The sphincter of Oddi:
o 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.

*a sphincter dysfunction can cause an

additional pin to the patient

o
o

Special investigation of the biliary

tract
Ultrasound
Non-invasive, painless, easily
performed
First choice for biliary tract
disease
Bile duct stones:
Stones in gallbladder:
High echo which cast an
acoustic shadow and which
move with changes in posture
Jaundice differential diagnosis:
Dialation of the ducts distl
part
CBD: diameter>1.0cm
Other disease: cholecystitis,
tumor etc.
During surgery: to detect bile
duct stones

*sensitivity-the disease is there you

can see it
*specificity-the disease is not there,
cannot be seen
Radiology
o Plain abdominal
radiograph:
Radio-opaque
gallstones
Air in the biliary
tree
o Oral cholecystography:
Biliary contrast
medium
A fatty meal- to
contract the bile
duct

o
o
o
o

o
o

Intravenous
cholangiography
Percutaneous
transhepatic
cholangiography (PTC)
Show intra and
extra hepatic
biliary duct clearly
Complication:
bile leakage
o Chola
ngitis
o Hemo
rrhag
e
Endoscopic retrograde
cholangiopancreatograph
y
Outline the biliary
tree and pancreatic
duct
Inspect the biliary
tree and pancreatic
duct
Inspect the
ampulla of vater
Exam of fluid of
duodenum, bile,
pancreatic fluid
Endoscopic
sphincterotomy (EST)
Endoscopic naso-biliary
drainage (ENBD)
Computed tomography
(CT)
Magnetic resonance
cholangiopancreatograph
y (MRCP)
Cholangiopancreatograph
y during operation
Percutaneous
transhepatic
cholangiography

Cholelithiasis

Including: gallstones and biliary duct

stones
In China:
Before 1981
Gallstones < biliary duct stones
Cholesterol stones < pigment
stones
Now
Gallstones >biliary duct stones
Cholesterol stones > pigment
stones

Classification of stones
1. Cholesterol stones: yellow
stones, hard, layed on crosssection, usully caused by
infections
2. Pigment stones: crumble when
squashed
3. Mixed stones: radio-opaque
4. Black stones
*left hepatic duct=more
pigment stones

Formation of cholesterol stones:

Cholesterol insoluble in water and
relative proportion of cholesterol, bile
saltes, and phospholipid in bile.
Increase of cholesterol and decrease
of bile saltes 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
glycoproteins from cyst wall and
bilirubinate
Alteration of the gallbladder
function: the motility of the cyst wall
Formation of stones
Extraheptic duct: contains either
primary pigment stones or cholesterol
stones
Intrahepatic stone: primary pigment
stones
Pigment stones:- due to infection
form of calcium bilirubunate
bilirubin conjugated with
glucuronide B-glucoronidase

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 fiber
Fasting
Biliary infection
Parasitic infestation
Deaibetes mellitus
TPN
Gastric surgery
Cirrhosis of liver
Chronic haemolyticanaemia

Due to impaction of stone in the

neck of the gallbladder: the
pressure increase.
Occurs in the mid or the upperright portion of the upper
abdomen
Severe pain starts abrubtly,
continuous, with restlessness,
vomiting, 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 ducts
leads to
cholecystocholedochal
fistula
-cholecystitis, cholangitis,
and obstructive jaundice
-cholangiography: narrow
of the bile duct at the
portahepatis
-anatomy variation: cyst
duct runs parallel to the
hepatic duct

Clinical feature of gallstones

20-40% patient without
symptom which is called
asymptomatic gallstones
Chronic cholecystitis
Biliary colic
Acute cholecystitis
Symptoms
Biliary colic: most common symptom
A large or fatty meals and
changing in position when
sleeping can precipitate the
pain

Mucoceole of the
gallbladder:
-a stone impacts in the
cystic duct without
bacterial infection
-bile reabsorbed
-the epithelium continues
to secrete mucous, which
is called white bile

 Stones migrate though 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
o
o
o

Painjaundicefever=
charcots triad, obstruction of
common bile duct
Feverpainjaundice= viral
hepatitis/ infection
Jaundicefeverpain=
pancreatic cancer

Sign
Right upper area of the
abdomen tenderness, rigidity,
rebound tenderness
Gallbladder palpable
Murphy sign: inspiratory arrest
during subcostal palpation
Jaundice: common bile duct
stones or Mirizzi syndrome
Fever and chill with infection
Treatment
The first choice is operation:
-symptomatic gallstones
-gallstones with complications

Pancreatitis

Severe epigastric abdominal

pain- abrupt onset (may radiate
to back)
Nausea & vomiting
Weakness
Tachycardia
+/- Fever, +/- hypotension or
shock
Grey turner sign-flank
discoloration due to
retroperitoneal bleed in pt. with
pancrearic necrosis (rare)
Cullens sign- periumbillical
discoloration (rare)

Ranson Criteria
Pathophysiology- insult leads to
leakge of pancreatic enzymes into
pancreatic and peripancreatic tissue
leading to acute inflammatory reaction

Admission
o
o
o
o
o

Etiologies
o
o
o
o
o
o
o
o
o
o
o

Idiopathic
Gallstones(or other
obstructive lesions
EtOH
Trauma
Steroids
Mumps(& other viruses
CMV, EBV)
Autoimmune (SLE,
polyarthritis nodosa)
Scorpion sting
Hyper Ca, TG
ERCP (5-10% of points
undergoing procedure)
Drugs (thiazides,
sulfonamides, ACE-I,
NSAIDs, azathioprine)

EtOH and gallstones account for

60-70% of cases
Signs and Symptoms

Age > 55
WBC > 16, 000
Glucose > 200
LDH > 350
AST >250

During first 48 hrs

o
o
o
o
o

Hematocrit drop >10%

Serum calcium <8
Base deficit > 4.0
Increase in BUN > 5
Fluid sequestration > 6L

5% mortality risk with <2 signs

15-20% mortality risk with 3-4 signs
40% mortality risk with 5-6 signs
99% mortality risk with >7 signs
Therapy
Remove offending agent (if
possible)
Supportive
#1- NPO (until pain free)

-NG suction for patients

with ileus or emesis
- TPN may be needed
#2 aggressive volume
repletion with IVF
o Keep an eye on fluid
balance/ sequestration
and electrolyte
disturbances
>1cm = dilation of the bile duct
Alcohol/gallstone= leading cause of
pancreatitis
Gray turner sign= seen in the flanks
Cullen sign= seen in the periumbillical
area

Somatostatin= is the only gastric

peptide that has an inhibitory effect
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