Gallbladder and billary tract

GALL BLADDER, BILIARY SYSTEM, LIVER CIRRHOSIS

الدكتورمحمدصالح عبداللهاستشاري الجراحة العامةرئيس فرع الجراحة كلية طب نينوى

GALL BLADDER AND BILIARY TRACT

The gall bladder is pear shaped viscous organ located at visceral space of the liver at the plane dividing it to the two lobes The gall bladder divided to the; 1-fundus 2-body 3-infudibulum when it is dilated called Hartmann` pouch 4-neck The neck is connected to the cystic duct which conected to the common hepatic duct Extra hepatic biliary duct The right and left hepatid duct united to form hepatic duct at porta hepatis which join cystic duct to form common bile duct which join the pancreatic duct at ampulla of Vatter at middle part of the second part of duodenum (duodenal papilla) and they surrounded by sphinctor of Oddi


The common bile duct length is 5-10 cm. and is diameter is 8mm. 1-superduodenl 2-retroduodenal 3-intrapancreatic 4-intraduodenal Blood supply ; 1-Cystic artery is branch of right hepatic artery passes posterior to the hepatic duct 2- direct branches from liver. variation of cystic artery the most common are 1-arises from gasteroduodenal artery 2- passes anterior to the hepatic duct Vein; Directly to the liver and cystic vein to the right portal vein

Lymphatic drainage To the hilar lymph node then to the coelic lymph node. Nerve supply parasympathetic from hepatic branch of vagus ,it cause contraction of gall bladder Sympathetic from coelic plexus

Gall bladder function

1-bile reservoir 2- concentration of bile up to 10 fold due to absorption of NACL and water. 3- mucous secretion Content of bile 1-water and electrolyte 2-bile salt cholic, deoxycholic chenodeoxycholic 3- cholesterol and phospholipid 4-bile pigment bilirubin diglucuronide


Table 1 Composition of adult human hepatic bile g/l% Water 98.0Bile salts 6.5–140.7Inorganic salts 0.7 Bile pigments 0.12–1.35 0.2Fatty acids 1.6–4.1 0.15Lecithin 0.1Cholesterol 0.8–1.8 0.06Between 250–1000 ml of hepatic bile is secreted in 24 h

Gall bladder and biliary tract investigation

1- plain x-ray detect a-gall stone in 10% b-porcelain g.b. c- air in g. b. 2-abdominal u.s. is 1st choice ,it detect a- gall stone 98% b- CBD stone c- g.b. size and wall d- dilatation of biliary tract e- mass 3- oral cholecystography it was 1st choice 4-i.v. cholangiography 5- ERCP 6- MRCP


5-ERCP endoscopic reterogradecholangiopancreaticography 1-diagnostic for biliary tract disease (stone,tumour,dilatation,pancreatic tumour,biobcy) 2-therapeutic a-sphinctrectomy. Removal of CBD stone b-insertion of stent complication of ERCP pancreatitis cholangitis septicaemia 6-PTC percutaneus transhepatic cholangiography (chiba needle) -diagnostic for biliary obstruction -therapeutic for biliary drainage -prothrombin time +vit.K +antiboitic 7-C.T.scan

8- MRCP magnetic resonance cholangiopancereatography it is standard technique for visualization of the biliary tract 9-radio-isotope scanning (HIDA) 99TC for acute cholecystitis congenital biliary atersia biliary-enteric anastomosis 10-per-operative cholangiography to detect missed bile duct stone 11-operative biliary endoscopy (choledechoscopy)

Congenital abnormality of gall bladder 1-absence of gall bladder rare 2-phrygian g. b. Kinking of fundus 2-6% 3-double g.b. 1;4000 4-floating g.b. Has mesentery liable to torsion 5- absence of cystic duct 6- low insertion of cystic duct 7-accessory cholecystohepatic duct 8- cystic duct might inter R. or L.hepatic duct

Anomalies of cystic artery

1- accessory cystic artery 2-left hepatic artery arises from left gasteric artery 3-right hepatic artery arises from superior mesenteric artery 4-right hepatic artery might be pass in front or behind the C.B.D. 5- cystic artery arises from gasteroduodenal artery 6-cystic artery passes anterior to the hepati duct

Anomalies of bile duct  Biliaey atersia

inflammation of the extra hepatic biliary tract and it is cord like Incidence; 1/10000 – 1/14000 birth sex male=femaleClinical feature; 1- jaundice since birth pruritus 2-pale stool ,dark urine 3-steatorea 4-20% associated with other disease 5-liver cirrhosis

DDX 1- α-anti-trpsin deficiency 2- choledochal cyst 3- neonatal hepatitis 4- phsiological jaundice INVESTIGATION 1-s.bilirubin 2-radio-isotope study 3- laparotomy TREATMENT1-in 10% only distal part involved (roux-en-Y anastomosis)2-KASIA operation porto-enterostomy3-if 1 and 2 fail liver transplantation is indicated

Choledochale cyst

Dilatation of the common bile duct either fusiform or diverticulum or interahepatic the sex incidence is the same Clinical feature; -age before 10 year - jaundice - fever -right hypochondrial pain -cholangitis Investigation U.S. MRI Treatment ; it is premalignamt 1- Excision of the cyst and Roux-en-Y -anastomosis 2- Choledochjejunostomy other option



CAROLI`DISEASE
Congenital dilatation of intera hepatic duct it lead to bile stasis, cholangitis, stone formation Associated disease congenital hepatic fibrosis polycystic disease of liver cholangio-carcinoma Trearment; antibiotic removal of stone lobectomy

Trauma; gall bladder penterating or crush injury Clinical feature Acute abdomen Treatment; cholecystectomy If C.B.D. choledochojejunostomy Tortion of g.b. long mesentery it cause mucocele,acute abdomen Treatment; cholecystectomy

Gall stone

Incidence 10-15% of adult population in the USA has gall stone 600000 cholecystectomy/year in USA 85%of gall stone is asymptomatic 1-4% per year of asymptomatic become symptomatic

Type of gall stone

1-cholesterol -pure cholesterol is not common it is 10%, -it is large and single >2.5 cm. - radiolucent. 2-mixed - cholesterol is mixed with Ca bilirubinate, Ca phosphate -most common -multiple -0.5-2.5cm. Diameter -10% radiopaqe 3- pigmented stone it contain less than 30%cholesterol a-black - insoluble bilirubine with Ca phosphate, Ca bicarbonate -20-30% -accompany haemolysis b-brown -it related to the bile stasis and infection - is rare in g.b. it is formed in bile duct -Ca bilirubinate.Ca palmmitate and Ca stearate

Aetiology of gall stone

A-cholesterol and mixed 1-disterbed bile salt, cholesterol, phospholipid. normally bile salt/phospholipid is 25/1 .this in one hand and cholesterol concentration in other hand affect the cholesterol solubility. when bile supersaturated with cholesterol ,or bile salt decrease lead cholesterol crystal to nucleate and formation of stone this occur in malabsorption of bile salt ,liver disease, estrogen, obesity, high fatty diet 2-stasis of bile ,female hormone, vagatomy, D.M. B-pigmented stone 1- black -haemolytic anaemia -liver cirrhosis 2-brown infection E.C. produce B-glucuronidase enzyme which change soluble bilirubine to insoluble bilirubin

Clinical feature of gall stone

85% is asymptomatic ↓ 1-4%symptommatic every year Ch. Cholcystitis (biliary colic) ↓3-5% develop complication 1-acute cholecytitis→empyema→gangrene→perforation 2-mucocele 3- Ca. of gall bladder 4-choledecholithiasis→cholangitis→liver abscess →liver cirrhosis 5-gall stone pancreatitis 6-cholcystodudenal fistula 7-gall stone ileus (intestinal obstruction) stone size >2.5cm.

Chronic cholcytitis

-2/3 of gall bladder disease is presented as ch. Cholecytitis -recrrent biliary cholic due to obstruction of cystic duct by gall stone-pain radiate to back of chest and R. shoulder-dyspepsia-murphy`sign +or –-Pathology varies from minor inflamation in the mucosa to the non- functioning gall bladder with fibrosis and adherent to surrounding organInvestigation; 1-plain x-ray 2-u.s. 3- oral cholecystographyTreatment; cholecystectomy

Acute calculus cholecytitis

-Cystic duct obstruction by stone with consequence infection usually by E.C. other bacteria.- distended g.b. -inflammation in the wall – patchy necrosis- gangrene, perforation.Clinical feature; 1- 80% history of biliary colic 2-Rt hypochondrial pain, tenderness , Boas`s sign 3-palpable g.b. 4-pyrexia ,tachycardia. 5-jaundice Mrrizi syndrome 6-W.B.C. incerease DDX- 1-perforated DU 2- acute pancreatitis 3-acute appendicitis 4-pyelonephritis


DX; 1-CLINICAL FEATURE 2- US 3-leucosytosis 4-liver function test Fate of acute cholecystitis 1-resolution 2-complication 3-empyaema 4-chronic cholcystitis

Treatment; Two options 1-Conservative treatment; concervative treatment followed by cholecystectomy after 6-8 weeks due to - difficulty of surgery - 90% respond to treatment 1- nil by mouth , i.v. fluid , N/G.? 2-antibiotic 3rd generation of cephalosporin, or 2nd with metronidazole 3-analgesic 4- follow up of patient if not respond surgery is indicated a- cholecystectomy b- cholcystostomy c- percutaneous cholecystomy 2- Urgent cholecystectomy with in 2-3 days up to one weak, idea is to -ovoid complication of acute cholecystitis -one admission to hospital

Acute non calculus cholecytitis. acute inflammation of g.b. with out obstruction of cystic duct by stone It occur in 1-burn,sever trauma 2-prolong PTN 3-complication of typhoid, brucellosis. Treatment ; urgent cholecystectomy Mucocle;-obstruction of cystic duct with out infection - absorption of bile.replaced by mucous - palpable g.b. Treatment by cholecystectomy Empyema -complication of acute cholecystitis -infection of mucocle - tender ,painful gall bladder Treatment; cholecystectomy

Cholecystectomy ; is removal of gall bladder

Indication;
1-ch. Cholecystitis 2-acute cholecystitis 3-acute non calcalus cholecystitis 4-mucocele 5-empyaema 6-ca. of g.b. 7-stone in CBD 8-asymptomatic gall stone ? -in DM, - possibility of ca. in g. b., - in case of isolation from medical serves

Open cholecystectomy Lapratomy -Through Rt paramedian, midline, subcostal(Kocher) incision -Dissection of cystic artery , duct. CHD,CBD (Calot triangle) -per operative cholangiography? -ligation and incision of cystic artery and duct -removal of g.b. -drain?

Exploration of CBD 1-palpable stone in CBD 2-dilated CBD 3-jaundice,or history of jaundice 4-dilated cystic duct with small stone in g.b. T-tube kept in side the CBD for 7-10 days then chlangigaphy and if no stone remove the tube

LAPRASCOPIC CHOLECYSTECTOMY

-- Pneumoperitoneum by CO2 gas - 4-port at abdominal wall - Telescope and instrument introduced through port - g.b. is removed like open advantage 1-less post operative pain 2-early discharge from hospital 3-early return to work 4-bitter cosmetic contraindication 1- ca. of g.b. 2- bleeding tendency 3- C.V. and Respiratory failure 4- pregnancy?



Complication of cholecystectomy A-general complication B-specific complication 1-haemorrage 2-biliary leakage 3-sub-phrenic bile, or pus 4-jaundice - halothane -missed stone in CBD -injury of CBD 5-postcholecystectomy syndrome

Verses needle lap. cholcystectomy

Lap. View

choldochlithiasis -6-12% of patient with G.B. stone has stone in CBD, it is either -secondary or primary -clinical feature; 1- silent 2- gall stone pancereatitis 3- Charcot triad ( pain+jaundice+fever,rigor) 4- Reynold pentad (3+altered mental state+ shock) 5- sign of hepatocellular failure 6- itching 7- Courvoisier`law ( dilatation of GB with jaundice is sign of malignant obstruction) 0


Investigation 1-liver function test 2-biood picture 3-us 4-MRCP 5-ERCP Treatment; (remove the stone+ cholecysyectomy) preparation of patient; 1- i.v. fluid +mannitol 2- vit K 3-antiboitic Removal of stone; 1-ERCP papillotomy +removal of stone by Dormia basket followed by cholecystectomy 2- if ERCP not available surgery is indicated -exploration of CBD removal of stone +T-tube -cholecystectomy - or choledochodudenostomy if CBD is more than 2cm.+stricture at lower end of CBD -after 10 days T-tube cholangiographys ,to detect missed stone then remove stone

Stone in CBD

T-tube cholangiography stone in CBD



Stricture of bile duct; 1-congenital 2-bile injury 3-inflammtory 4-idiopathic 5-tumour TRAUMATIC stricture 1-observed during surgery do R-x-en-Y-choledocho-jejunostomy 2-not observed during surgery patient develop jaundice or bile leakage or fistula or biliary peritoitis Treatment; ERCP, stent , surgery Rx-en-y choledochojejunostomy

Primary sclerosing cholangitis; jaundice, pain, pruritis,associated with inf.bowel disease. Biliary ascariasis; - biliary colic - cholangitis and is complication Treatment; antispasmin, antihelminthic drug, ERCP, surgery if there is complication

Ca. of g.b. -rare, age >60 year -associated with 1-gall stone 0.3-3% of gall stone has ca. with it. 2- porcelian g.b. 10- 25% of porcelian g.b. has ca. Pathlogy; s.c.ca. or adenoca., or mixed. metastasis ; direct to liver -hilar l.node. -peritoneal cavity Clinical feature;-1-like ch. cholecystitis 2-jaundice 3-palpable mass Investigation; us.ct-scan ,percutneous biobsy. serum CA19-9 Treatment; surgical resection 1-g.b. 2-liver bed 3-hillar l.node Prognosis; is poor ,5% 5-year survival

jaundice

Is yellow coloration of the body tissue and fluid which is due to high bilirubin in the blood,it occur when S. bilirubin exceeds 2.0-2.5mg/dl bilirubin metabolism old RBC in the RET spleen. Bone marrow ↓ globin + heme ↓ ↓ oxidation amino acid biliverdin ↓ reduced bilirubin insoluble in water combined with albumin ↓ glucuronyl transferase in the liver bilirubin diglucuronide water soluble, excreted via biliary tract ↓ by bacterial enzyme in the intestine stercobilinogen → stercolin (color of stool) ↓ 20% reabsorbed ↓, 90%of this is reexcreted. urobilinogen appear in urine

aetiology; 1-prehepatic haemolysis of RBC indirect bilirubin increase 2- hepatic hepato cellalar disease both bilirubin increase 3-post-hepatic- obstructive jaundice –surgical jaundice

3-post-hepatic- obstructive jaundice –surgical jaundice obstruction of biliary path way direct bilirubin increase later indirect increase and it is due to a- cause in the lumen eg stone, parasite b-in the wall of bile duct -congenital atersia -inflammatory stricture-sclerosing cholangitis -tramatic -malignant stricture -hydate cyst c-out side of bile duct -ca. of head of pancreas -CBD tumor -metastasis lymph node in porta hepatis

the most common cause is

1- CBD stone 2- CA of head of pancreas

3- CBD stricture

clinical features of obstructive jaundice 1- jaundice 2- dark color urine 3- clay ,pale color stool 4-pruritis 5 -clinical feature of causative factor



investigation; 1-blood examination 2-liver function test -s . bilirubin -alkaline phosphatase -s.enzyme - prothrombine time - s. albumin - stercobilinogen 3- imaging –US, CT -MRCP -ERCP -PTC 4- Live biopsy

Treatment; is surgical pre operative prepration - good hydration normal saline - i.m. vitamine K - anti biotic surgical operation according to the cause