Hepato-billiary system
The gall bladder & bile ducts
The gall bladder is a pear shaped organ 7.5 to 12.5 cm long,
capacity-50ml
Cystic duct -2.5cm, Common hepatic duct -2.5cm
Common bile duct-7.5cm
Cystic artery -branch of right hepatic artery
Functions of gall bladder
1. reservior of bile
2. concentration of bile-5-10 times
3. secretion of mucus -20 ml/day
Investigation of the biliary tract disease
1. Ultrasonography of HBS & Pancreas- shows any
stone(90%) in gall bladder or CBD
Size, shape, thickness of gall bladder
Dilatation of biliary tree
Carcinoma head of pancreas, Cholangiocarcinoma
2. plain x-ray abdomen- gall stone radio-opaque 10%
cases
3. CT scan-Ca gall bladder or bile ducts, its extent
and metastasis, Ca of head of pancreas
4. Radioisotope scanning-HIDA scan-function-to
visualise biliary tree & GB
5. ERCP Endoscopic retrograde colangio
pancreatography - Bile ducts visualised after inj water soluable contrast. Anatomy ,stones, biliary
strictures.
6. PTC - percutaneous transhepatic cholangiography anatomy,biliary strictures
7. ( MRCP-Magnetic resonance cholangiopancreatography-Biliary tree anatomy &stones cross sectional &
projection images contrast 'DYE) not required.
8. peroperative cholangiography - any pathology in CBD
9. post operative T tube cholangiography-Any blockage or narrowing of CBD.
10. Endoscopic ultrasound - anatomy&stones
https://t.me/medical_theorist
congenital abnormalities of gall bladder and bile ducts
1. Absence of gall bladder
2. The phrygian cap
3. Floating gall bladder
4. Double gall bladder
5. Absence of cystic duct
6. low insertion of cystic duct
7. An accessory cholecystohepatic duct
GALL STONES (CHOLELITHIASIS )Gall stones most common biliary pathology..10-15% of adult population
USA.They are asymptomatic more than 80%cases. Approximately 1-2% of asymptomatic patients develop symptoms
per year..
TYPES OF GALL STONES
CHOLESTEROL STONE -consists almost entirely of cholesterol & often solitary.
MIXED STONE- Most common. consists of cholesterol, calcium phosphate, calcium carbonate, calcium bilirubinate,
calcium palmitate and protiens. They are multiple, often faceted.
PIGMENT STONE- (brown/black) Composed of calcium bilirubinate, calcium palmitate, calcium stearate, less than
30%cholesterol .They are small multiple, hard coral like/soft, sludge
Mixed stone 90%
Pigment stone 5%
Cholesterol stone 6%
INCIDENCE OF GALL STONES
In USA& Europe 80% are
cholesterol or mixed stones. In
Asia 80% pigment stones
5F–
• Female
• fatty
• fertile multiparty
•
flatulence
• fifty
is the classical sufferer from
symptomatic gall stones. But
cholelithiasis occurs in both sexes.
AETIOLOGY OF GALL STONE
CHOLESTEROL AND MIXED STONES
1)METABOLIC - Bile containing cholesterol stone has excess of cholesterol relative to bile salts& phospholipids.
(Lithogenic Bile)
Bile cholesterol increase in High fatty diet, obesity,oral Contraceptive pill clofibrate therapy--drug of
hyperlipoprotenemia
Bile salts reduced by estrogen therapy, ileal disease,resection or bypass ileum cholestvramine therapy
2)INFECTION- often bile from patients of gall stone is sterile, but organisms have been cultured from the
centers of gall stone. - E cooli., Salmonella typhi
3)BILE STASIS--Gall bladder contractility is reduced by pestrogen, in pregnancy, after truncal vagotomy, long
term perenteral nutrition.
Lithesis stone
https://t.me/medical_theorist
PIGMENT STONES
Causes Seen in patients with hemolysis in which bilirubin production is increased example –
1. Hereditary spherocytosis,
2. sickle cell anemia,
3. Thalassemia
4. Malaria, mechanical destruction of RBC
5. Bile duct strictures.
COMPLICATIONS &EFFECTS OF
GALLSTONES
A)IN THE GALL BLADDER
• Biliary colic
• Acute cholecystitis
• *Chronic cholecystitis
• *Empyema of gall bladder
• *Mucocele of the gall bladder
• Gangrene & perforation Gall
bladder
• Carcinoma of the gall bladder
B)IN THE COMMON BILE DUCTS
• Biliary obstruction(Obstructive jaundice)
• *Acute Cholangitis
• *Acute pancreatitis
C)IN THE INTESTINE
• Intestinal obstruction (gallstone ileus)---through cholecystoduodenal Fistula
ACUTE CHOLECYSTITIS ( Due toCHOLELITHIASIS
CLINICAL PRESENTATION
1. Biliary colic typically present 10-25% patients.Severe right upper abdominal or epigastric pain, may last for
few minutes to several hours., frequently starts at night& waking the patients. Pain may be
colicky(intermittent) but more often dull& Constant(steady). Pain may radiate may reffered to scapular
region or on the tip of the right shoulder suggests diaphragmatic irritation, pain inceease after taking
fatty food
2. Nausea & vomiting may accompany pain.
3. Dyspepsia,flatulence, food intolerance particularly to fat and some alteration in bowel frequency.
/indigestion may associated with gall stone disease.
4. Biliary colic is caused by transient gallstone obstruction to the Neck of GB OR Cystic duct. Majority of
cases this process limited bi the stone slipping back into the gall bladder. Contents escaping by way of the
cystic duct.
5. When symtoms do not resolve but progress to continued pain with fever &leucocytosis diagnosis is Acute
cholecyctitis.
ON EXAMINATION - Temp-38-38.5"C Tachycardia
ACUTE PHASE1)Right upper quadrant tenderness
2) Murphy,s sign positive.(Acute cholecystitis)
3) A mass may be palpable as omentum wall off on inflamed gall bladder.
4)If resolution do not occur Empyema gall bladder results.The wall may become necrotic and perforate.
localized peritonitis ----pus -----peritoneal cavity-----septic peritonitis.
https://t.me/medical_theorist
ACALCULUS CHOLECYSTITIS
20% Cases of Acute cholecystitis occur in absence of cholelithiasis.Most cases occur in patients hospitalized with
some other illness.common in l)trauma ,2)burn,
Patient receiving 3)total per enteral nutrition.some cases due to 4)cystic duct obstruction by malignant tumour.
Rarely due to cystic duct obstruction or primary bacterial infection 5) by E.coli,clostadia,salmonella typhi.
small vessel occlusion occurs early ,and unless treatment Is given promptly ,the disease progress rapidly to
gangrenous cholecystitis and septic complication in that case death rate Is high.
TREATMENT
Most authors suggest--it is safe to observe patients with Asymptomatic gallstone.
CHOLECYSTECTOMY performed for those patients who develop symptoms or complications.
Prophylactic cholecystectomy should be considered in Diabetic patients, those with congenital haemolytic anaemia,
those undergo bariatric surgery for morbid obesity, as these groups are at increase risk of complications from gall
stones.
Patients with biliary colic or cholecystitis-cholecystectomy is the treatment of choice.
Timing of surgery in acute cholecystitis controversial
*Many units favour early intervention(within 1-2days of Onset of attack). performed as early as possible/next
available
O.T list(1---2 days)
Or patients allowed to go home & return
*Others suggests a delayed approach Interval
Cholecystectomy (6-8 weeks) is preferable.
Acute Cholecystitis subside with conservative Treatment.
1. Nil per mouth ( NPO) &intravenous fluid administration.
2. Administration of iv analgesics/ anti spasmodic./iv PPI
3. Administration of antibiotics.-iv broad spectrum antibiotics.
4. Subsequent management- when temp, pulse, & other physical signs shows inflammation is subsiding oral
fluids are started followed by regular diet.
Cholecystectomy Laparoscopic/open later after 6-8 weeks for elective operation.
Conservative treatment must be abandoned if the pain and tenderness increase(?Empyema GB), Cholecystectomy
should be performed.
If patient has serious comorbid conditions a percutaneous cholecystostomy can be performed under ultrasound
control which will rapidly relieve symptoms. A subsequent Cholecystectomy is usually required.
MUCOCELE OF GALL BLADDER
When neck of the gall bladder becomes Obstructed by a stone (hartsmann pouch) but the contents remains
sterile.The bile
Is absorbed and replace by mucous (GOBLET CELL) secreted by the gall bladder epithelium.
The gall bladder Become distended & palpable. NON TENDER
Mucocele also occurs in those cases of malignancy which occlude the cystic duct- Cholangiocarcinoma.
R× CHOLECYSTECTOMY
EMPYEMA GALL BLADDER
points
mucocele empyema
Empyema gall bladder may be
fever
present
1. a sequel of acute cholecystitis or
jaundice
2. the result of mucocele become infected.
Tender gall
present
CLINICAL FEATURE
Palpable gall palpable
palpable
1. same as Acute Cholecystitis
2. Palpable, Tender GB,pt will toxic, high fever
3. Treatment- *cholecystectomy *cholecystostomy &later cholecystectomy
https://t.me/medical_theorist
ca head pancreas
present
palpable
What are the causes of Palpable Gall Bladder??
Mucocele GB
Empyema GB
Ca Head of Pancreas
Ca GB
CAUSES OF OBSTRUCTIVE/SURGICAL JAUNDICE Aka Surgical jaundice
Within the lumen of Common bile duct
1. stone
2. Round worm
In the wall of Common bile duct
1. malignant stricture--cholangiocarcinoma
2. Sclerosing cholangitis
Outside wall of Common bile duct
1. Carcinoma head of pancreas
2. peri ampullary carcinoma
3. Pancreatic pseudocyst, chronic pancreatitis, duodenal diverculitis, metastatic cancer.--rarely
CHOLEDOCHOLITHIASIS
Approximately 15% of patients with stones in the gall bladder are associated with stone in the bile ducts.
Stone in the common bile duct are usually accompanied by other stones in the gall bladder but in 5% cases gall
bladder is empty.
Origin of common bile duct stone
1)Most cholesterol stone develops within the gall Bladder and enter the common bile duct.
2)Pigment stones more often develop de novo common bile duct stone-60% cholesterol stone 40% pigment stone
CLINICAL FINDINGS (choledocholithiasis/obstructive jaundice
Symptoms - - May be Aymptomatic
1. Pain in the right subcostal region or epigastrium
2. Referred pain to right scapular region
3. Intermittent chills, fever
4. Jaundice (fluctuating )& sudden onset.
5. itching more on the extrimities
6. passage of dark /high coloured urine.
7. pale, offensive stool that floats on water.
Signs1. patient may be icteric, toxic , with high fever & chill
2. tenderness in the right hypochondrium / epigastrium
3. gall bladder -not palpable
COURVOISIER'S LAW
A nontender Palpable gall bladder in jaundiced patients suggests malignant obstruction of the common bile duct,
not due to stone in the common bile duct.
Malignant obstuction is due to carcinoma Head of pancreas periampullary carcinoma, or cholangiocarcinoma
CHARCOT'S TRIAD
Pain+ jaundice + fever --due to cholangitis
https://t.me/medical_theorist
CALLOT'S TRIANGLE
Superoirly - inferior surface of liver
Medially --- Common Hepatic duct
Inferiolaterally-Cystic duct
Content--- Cystic artery & Lymph node.
INVESTIGATIONS OF JAUNDICED PATIENTS
1.
CBC -TC, DC, Hb % ESR
2.
FBS, Blood urea,Serum creatinine
3.
Liver Function Tests-serum bilirubin
AST, (aspertate amino transferase)/SGOT, ALT, (Alanine
aminotransferase) /SGPT
Alkaline phosphatase,
Prothrombin time,
HBsAg
4.
Urine -urobilinogen -absent, bilirubin -present (obs jaun)
5.
Stool----pale, stercobilinogen-absent, bilirubin- present(obs jaun)
6.
Chest X-Ray, ECG
7.
USG of HBS &Pancreas
8.
ERCP
9.
PTC
10.
MRCP
11.
CT SCAN
RISK OF SURGERY IN A PATIENT WITH OBSTRUCTIVE JAUNDICE
1. Bleeding- due to deficiency of Vit K dependent coagulation factors. - II,VII,IX,X
2. Infection
3. Hepatic failure
4. Renal failure.(hepatorenal syndrome)
TREATMENT(Choledocholithiasis)
A)initial management of jaundice patient/Preparation of Obstructive Jaundice before Surgery
i)
patient may be ill.-Full supportive measures are required with rehydration ,i.v. 10% Dextrose increase
hepatic glycogen storage. improvement of patient general condition.
ii)
correction of clotting abnormalities -Injection of Vit -K 3-5 days helps in the formation of clotting
factors II,VIl IX ,X.
iii)
treatment with appropriate broad spectrum antibiotic.
iv)
I.V Mannitol-( Osmotic diuretic) before& during operation to maintain adequate kidney perfusion.
v)
Correction of Anemia & correction of electrolyte imbalance.
B)Relief of obstruction by1)Minimally invasive techniques (BY ERCP)
** Endoscopic papillotomy with a sphincterotomy, removal of stones using a Dormia busket.
* If stone removal is not possible-placement of a stent.
*if this fail-percutaneous transhepatic cholangiography perfomed to provide drainage and subsequent percutaneous
choledochoscopy,
*laparoscopic choledocholithotomy
2) open choledocholithotomy
+ Cholecystectomy
https://t.me/medical_theorist
3) Laperoscopic choledocholithotomy
Transduodenal sphinterotomy
4)Choledochoduodenostomy
INDICATIONS OF CHOLEDOCHOTOMY
(Opening of CBD)/T -Tube should given
1. presence of stone in common bile duct
Preoperative
• USG
• ERCP
Peroperative
• palpation
• cholangiography
2. Jaundice, a history of jaundice or cholangitis
3. A dilated common bile duct > 10 mm dia
4. Abnormal liver function tests, particularly raised alkaline phosphatase. & Prothrombin time
Why you introduce a T tube in the CBD before repair Of CBD?
After removal of stone from CBD ,due to inflammation & oedema Distal part of CB become blocked. So bile flow to
the second part of duodenum is hampered & bile accumulate in the CBD causing distension & rupture of
repair/sutured area.
so if I put a T tube in CBD, bile is drained through this T tube & collected outside .
here will be no pressure of bile over the sutured area in CBD
Management of T tube
Bile collceted in the outside bottle in the post operative days.
After 7th postoperative days the oedema/ blockage the CBD decrease so bile flow started from liver to duodenum.
then I started clumping of T tube from 8th POD.for2 Hours & observe the patient an abdominal pain Jaundice fever
If patient condition normal I will increase the time of T tube clumping as follows 8th POD for 4 hours, 9th POD for
8 hours 10th POD 12 hours, 11 th POD for 24hours
If patient condition normal , I will do a Post Operative T tube Cholangiogram on 12 th POD.If that x ray normal„
I will remove the Ttube on 13 th POD by slow & sustain traction on the bedside.
https://t.me/medical_theorist