biliary tract disease -...
TRANSCRIPT
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Biliary Tract DiseaseHPB Division, Surgery Department of
RamathibodiParamin Muangkaew MD.
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Anatomy
Intrahepatic bile duct
IHD
Primary
Secondary
Extrahepatic bile duct
Rt & Lt HD
CHD
Cystic duct
GB
CBD
Proximal
Distal
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Anatomy (Intrahepatic)
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Physiology
800-1000mL
Entero-Hepatic circulation
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Investigation in biliary tract disease
Blood chemistry
LFT
Imaging
Plain film
Ultrasound
CT scan
Cholnagiogram
MRCP
ERCP
IOC
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Investigation : Plain X-ray
15-40% of GS radiopaque
Plain films are important
to exclude other disease
PUP
bowel obstruction with
dilated loops of bowel
right lower lobe pneumonia
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Abdominal ultrasound
Ultrasound is initial investigation who suspected disease of biliary tree
Investigation of choice for GS specificity (>98%) and sensitivity (>95%)
Limitation in distal CBD, pancreas, obesity, pain
Posterior acoustic shadow
Investigation : US
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Obstructive jaundice Direct evidence of
obstruction
Cause of obstruction with proximal bile duct dilatation
Indirect evidence of obstruction
Bile duct dilatation (CBD >8mm, IHD>4mm)
GS with bile duct dilatation
Investigation : US
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CT or MRI
CT are inferior to U/S in diagnosing GS
Sensitivity of detect GS only about 55%
Diagnosis of choice in patient with suspected HPB neoplasm
Investigation : CT or MRI
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Cholangiogram
Radiograph of the bile ducts made after the ingestion or injection of media
Gold standard for detect intra-bile duct lesion
MRCP (Magnetic resonance cholangiopancreatography)
ERCP (Endoscopic retrograde cholangiopancreatography)
IOC (Intraoperative cholangiography)
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Reconstruction bile duct anatomy by magnetic resonance machine
Cholangiogram : MRCP
- Non invasive - Can’t Rx procedure
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Cholangiogram : ERCP
-Invasive
-Complication (5%)
• Perforation
• Bleeding
• Pancreatitis
• Cholangitis
-Visualize ampulla
-Do Rx procedure
• Biopsy
• Stent
• Remove stone
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Useful in operative field ,when need to visualized bile duct
Via cystic duct
Cholangiogram : IOC
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Benign disease
Benign
GS , GS with sequelae
Acalculous cholecystitis
CBD stone , CBD stone with sequelae
IHD stone
Choledochal cyst
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Biliary tract diseases
Acalculouscholecystitis
CBDS GS
Asymptomatic AC
Emphysematous Empyema Chronic
Fistula CA GB Mirizzi
Perforation
Sympatomatic
IHDSCholedochal
cyst
GS ileus
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Gallstone
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Gallstone
Inability to maintain certain biliary solutes, primarily cholesterol and calcium salts, in a solubilized state.
Gallstones are classified by their
Cholesterol
Mixed (70%)
Pure (10%)
Pigment stones (20%)
black
brown
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Gallstone
Asymptomatic
Symptomatic
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gall bladder
Chronic calculous cholecystitis
Cholecystoenteric fistula GS ileus
Mirizzi’s syndrome
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Asymptomatic
Check up
1% - 2% develop symptoms or complications related to their gallstones per year
Over a 20-year period, 2/3 of asymptomatic patients with gallstones remain symptom-free
Rx : Expectant
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Symptomatic gallstone (SGS)
Biliary colic
Steady pain (not colic) Epigastrium or RUQ
Usually lasts 1 to 5 hours , but subsides by 24 hours
50% association with meal
Radiate to right shoulder or scapula
No peritoneal findings
No SIRS
CCK
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Symptomatic gallstone (SGS)
Natural
10 - 20% develop symptoms or complications related to their gallstones per year
Treatment
Elective cholecystectomy (LC)
Avoid dietary fats and large meals while awaiting surgery
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Surgery in asymptomatic GS
Indication (Absolute)
Risk of CA GB
Porcelian GB
GS >3cm
GB polyp > 1cm
Indication (Relative)
Can’t assessed to hospital
Splenectomy in hemolytic disease
Hereditary spherocytetosis
Sickle cell anemia
Thalassemia
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Gallstone
Asymptomatic
Symptomatic
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gall bladder
Chronic calculous cholecystitis
Cholecystoenteric fistula GS ileus
Mirizzi’s syndrome
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Acute cholecystitis
Mechanism Obstruction of cystic duct by gallstone (80%) Calculous cholecystitis
No cholelithiasis in 20% (acalculous) Acalculous cholecystitis
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Sign & Symptom
Peritoneal sign
-Murphy’s
-Guarding
-Mass
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Investigation
CBC
Leukocytosis (PMN or band)
LFT
Transminases or sligthly increase
ALP
Bilirubin
Ultrasound
GB distenstion
GB wall thickening
Pericholecystic fluid
Gallstone
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Ultrasound
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Treatment of AC
Stabilized patient
IV rehydration, Correct metabolic disorder
ATB IV: Ceftriaxone + Metronidazole
Early cholecystectomy(LC) within 48-72 hr
GB drainage(Cholecystostomy)
Interval cholecystectomy
(next 6 to 10 weeks)
Gold standard Not recommend
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LC. VS OC.
LC
แผลเล็กกว่า
ปวดแผลน้อยกว่า
Ambulate ได้เร็วกว่า
นอนรพ. น้อยกว่า
ค่าใช้จ่ายแพงกว่า
OC
แผลใหญ่กว่า
ปวดแผลมากกว่า
Ambulate ได้ช้ากว่า
นอนรพ. นานกว่า
ค่าใช้จ่ายถูกกว่า
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Gallstone
Asymptomatic
Symptomatic
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gall bladder
Chronic calculous cholecystitis
Cholecystoenteric fistula GS ileus
Mirizzi’s syndrome
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Gangrenous cholecystitis Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gallbladder
Chronic cholecystitis
Cholecystoenteric fistula GS ileus
Mirrizi’s syndrome
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Empyema gallbladder
Abscess in GB
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gallbladder
Chronic cholecystitis
Cholecystoenteric fistula GS ileus
Mirrizi’s syndrome
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Emphysematous cholecystitis
Gas-forming organisms bacterial infection
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gallbladder
Chronic cholecystitis
Cholecystoenteric fistula GS ileus
Mirrizi’s syndrome
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Clinical
Gangrenous cholecystitis
Empyema gallbladder
Emphysematous gallbladder
Peritoneal sign
-Murphy’s
-Guarding
-Mass
Severe
Hypotension
Disturbance of conciousness
Sepsis
Compromised host
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Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gallbladder
Chronic cholecystitis
Cholecystoenteric fistula GS ileus
Mirrizi’s syndrome
Chronic Calculous Cholecystitis
Ongoing inflammation or recurrent episodes of inflammation
U/S : Contracted , thick-walled GB
Treatment as SGS Elective LC
Chronic calculous cholecystitis
Gallbladder carcinoma Cholecystoenteric fistula
Mirrizi’s syndrome
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Cholecystoenteric fistula
The most common sites for fistulas are the duodenum (80%) and the hepatic flexure of the colon (20%)
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gallbladder
Chronic cholecystitis
Cholecystoenteric fistula GS ileus
Mirrizi’s syndrome
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Gallstone ileus
Gallstone ileus = Misnomer
Passage of a stone biliary-enteric fistula leading to a mechanical bowel obstruction
Most common point of obstruction = Ileocecal valve
Bouveret’s syndrome = passage of stone biliary-enteric fistula leading toduodenal obstruction
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Clinical
Cardinal sign of small bowel obstruction or gastric outlet obstruction
Obstipation
N/V
Abdominal pain
Abdominal distension
HX of biliary colic
Investigation?
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Rigler triad
Aerobilia (Pneumobilia)
Intestinal obstruction
Abnormal ectopic of GS
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Merizzi’s syndrome
Obstruction of CHD secondary to an impacted GS in cystic duct
Sequelae or complication
Acute cholecystitis
Gangrenous cholecystitis
Gallbladder perforation
Empyema gallbladder
Emphysematous gallbladder
Chronic cholecystitis
Cholecystoenteric fistula GS ileus
Mirrizi’s syndrome
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Clinical
Obstructive jaundice
History of biliary colic
U/S
Impact GS at cystic duct
IHD dilatation
CBD not dilatation
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Benign disease
Benign
GS , GS with sequelae
Acalculous cholecystitis
CBD stone , CBD stone with sequelae
IHD stone
Choledochal cyst
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Acute Acalculous Cholecystitis
5-10% of all patients with acute cholecystitis
Occur in
elderly and critically ill patient
burns
long-term parenteral nutrition
major operations such Ex. AAA repair , cardiopulmonary bypass
Gallbladder stasis and ischemia have been implicated as causative factors
Radiologic findings are also similar except for the absence of gallstones
Treatment was same as calculous cholecystitis
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Acute Acalculous Cholecystitis
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Benign disease
Benign
GS , GS with sequelae
Acalculous cholecystitis
CBD stone , CBD stone with sequelae
IHD stone
Choledochal cyst
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Asympatomatic Pancreatitis Obstruction
Partial
Biliary colic
Complete
Obstructive Jx
Cholangitis
Biliary tract diseases
Acalculouscholecystitis
CBDS GS IHDSCholedochal
cyst
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Choledocholithiasis
(CBD Stone)
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Choledocholithiasis
Secondary CBD stone (80%)
GS migrate to CBD
Primary common bile duct stones(20%)
Originate within the biliary tract
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CBD stone
Asymptomatic
Symptomatic
Complication
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LFT
ALP
Bilirubin
Transminases or slightly increase
1/3 of CBD stone are normal LFT
Investigation
Obstructive Jxpattern
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Investigation
Ultrasonography
Commonly the first test
GS or CBD stone
A dilated CBD (>8 mm in diameter) , IHD
Limited at distal CBD MRCP
Sensitivity 95%, Specificity 89%
ERCP
Sensitivity 91%, Specificity 100%
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Treatment (2CBD stone)
Minimally invasive in two operation
ERCP Discharge Admit for elective LC
Minimally invasive in single operation
LC ERCP or ERCP LC
LC Lap CBDE
High risk for conversion , Need surgical experience
Shortest hospital stay and cost-effectiveess
Opened technique in single operation
OC + CBDE (CBD exploration)
Other
Percutaneous transhepatic stone removal LC
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Minimally invasive in two operation
ERCP Discharge Admit for elective LC
Minimally invasive in single operation
LC ERCP or ERCP LC
LC Lap CBDE
High risk for conversion , Need surgical experience
Shortest hospital stay
Opened technique in single operation
OC + CBDE (CBD explorartion)
Other
Percutaneous transhepatic stone removal LC
Treatment (2CBD stone)
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Sequelae of CBD stone
Cholangitis
GS pancreatitis
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Cholangitis
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Acute Cholangitis
Ascending bacterial infection in association with partial or complete bile duct obstruction
Benign
Malignant
Most common organism
E. Coli
Klebsiella
Streptoccus faecalis
Bacteroides fragilis
Bile is kept sterile by contineousof bile flow and antibacterial substance in bile
Increased bile duct pressure
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Clinical
Charcot’s triad (present 2/3 of patient)
Fever
Epigastrium or RUQ pain
Jaundice
Reynold’s pentad (Toxic or suppurativecholangitis)
Fever
Epigastrium or RUQ pain
Jaundice
Shock
Mental status change
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LFT
ALP
Bilirubin
Transminases or slightly increase
1/3 of CBD stone are normal LFT
Investigation
Obstructive Jxpattern
CBC
Leukocytosis
Ultrasound
Direct or indirect evidence of bile duct obstruction
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Treatment
IV ATB (Ceftriaxone + Metronidazole)
Fluid resusitation
Treatment cause of obstruction as soon as possible
Patient who not response to ATB(15%) or Toxic cholangitis
ERCP , PTBD, T-tube
Emergency biliary drainage
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Treatment
Cholangitis
Non-toxic
IV ATB
Biliary drainage ASAP
Toxic
Emergency biliary drainage
+
IV ATB
PTBD ERCP Surgery
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Benign disease
Benign
GS , GS with sequelae
Acalculous cholecystitis
CBD stone , CBD stone with sequelae
Choledochal cyst
IHD stone
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Malignant condition
Cholangiocarcinoma (CCA)
Periampullary CA
Gallbladder carcinoma
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CCA
Arising from biliary epithelium
Risk factor
Sclerosing cholangitis
Choledochal cyst
Ulcerative colitis
Hepatolithiasis
Liver fluke
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Classification
Anatomically
Intrahepatic
Perihilar or hilar (Klaskin’s
tumor)
Most common (2/3 of all patient)
Distal common bile duct
Morphology
Nodular (Most common)
Scirrhous
Diffusely infiltrating
Papillary
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Intrahepatic CCA
CT : Heterogenous delay enhancing with proximal IHD dilatation
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Perihilar or hilar
(Klaskin’s tumor)
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Perihilar or hilar (Klaskin’s tumor)
Bismuth-Corlette classification
I = Confined in CHD, Not involved confluence
II = Involved confluenceBut not invade secondary IHD
IIIa = Invade to Rt secondary IHD
IIIb = Invade to Lt secondary IHD
IV = Invade to Bilat secondary IHD
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Clinical
Obstructive jaundice More than 90% of patients with perihilar or distal tumors
Patients with intrahepatic cholangiocarcinoma are rarely jaundiced
Less common presenting clinical features pruritus, fever, mild abdominal pain, fatigue, anorexia,
and weight loss.
.
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Diagnosis
Tumor Marker
CA19-9 : If >129 U/mL Sensitivity79%, Specificity 98%
CEA : > 5 U/mL
But can be seen in cholangitis, other GI & GYN malignancy
The initial test are usually ultrasound CT
Cytology or biopsy were unreliable
Patient with potential resectable should be offered surgical exploration based on
radiographic finding and clinical suspicion
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Diagnosis Perihilar, Distal CBD
Imaging : CT
+- bile cyto, +- brush cyto, +- Transampullar biopsy
(sensitivity in detecting a malignancy is low, and a benign result should be considered unreliable)
Intrahepatic
Imaging : CT scan
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Treatment : Curative
Intrahepatic
Treat as hepatoma
Resection if possible
Perihilar
TypeI,II,III = Hilar resection with hepatectomy
(Bile duct excision + Portal lymphadenectomy + Cholecystectomy)
Type IV = Palliative
Distal CBD Whipple operation
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Treatment : Curative Intrahepatic
Treat as hepatoma
Resection if possible
Perihilar
TypeI,II,III = Hilar resection with hepatectomy
(Bile duct excision + Portal lymphadenectomy + Cholecystectomy)
Type IV = Palliative
Distal CBD Whipple operation
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Treatment : Curative Intrahepatic
Treat as hepatoma
Resection if possible
Perihilar
TypeI,II,III = Hilar resection with hepatectomy
(Bile duct excision + Portal lymphadenectomy + Cholecystectomy)
Type IV = Palliative
Distal CBD Whipple operation
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Distal CBD
Whipple operation (Pancreaticoduodenectomy)
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Treatment : Palliative
Biliary drainage
External : PTBD
Internal : ERCP with biliary stent
Chemo, RT
No benefit
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Palliative : PTBD
Percutaneous Transhepatic
Biliary Drainage
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Palliative : Stent
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Malignant condition
Cholangiocarcinoma (CCA)
Periampullary CA
Gallbladder carcinoma
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Periampullary CA
1.Distal CCA
2.CA head of pancreas
3.Ampullary CA
4. CA duodenum
Treatment
Whipple’s operation
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Courvoisier ‘s law
If in present of jaundice the GB is palpable, the jaundice is unlikely to be due to stone
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Courvoisier ‘s law
If in present of jaundice the GB is palpable, the jaundice is unlikely to be due to stone
If obstructive jaundice from CBD stone (2˚CBD stone) it’s not usually complete obstruction and GB is usually thickened and fibrotic and
Remember, 50% of dilated GB can’t be palpated on PE