Download - Biliary tract
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Disease of the Biliary Tract
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Anatomy
Calot 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 & para-right hepatic duct run within the triangle makes an important area of dissection during cholecytectomy.
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Anatomy
• The sphincter of Oddi: 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.
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Special Investigation of the biliary Tract
• Ultrasound:
Non-invasive,painless,
Easily performed
First choice for biliary tract disease
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Ultrasound
• Bile duct stones:
Stones in gallbladder:
High echo which cast an acoustic shadow and which move with changes in posture
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Ultrasound
• Jaundice differential diagnosis:
Dilatation of the ducts
CBD: diameter > 1.0cm
• Other disease: cholecytitis, tumor ect.
• During surgery: to detect bile duct stones
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Radiology
• Plain abdominal radiograph:
Radio-opaque gallstones
Air in the biliary tree
• Oral cholecystography:
Biliary contrast medium
A fatty meal
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Radiology
• Intravenous cholangiography• Percutaneous transhepatic cholangi-
ography (PTC) show intra and extra hepatic biliary
duct clearly complication: bile leakage cholangitis hemorrhage
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Radiology
• Endoscopic retrograde cholangio-pancreatography(ERCP)
outline the biliary tree and pancreatic duct
inspect the ampulla of Vater
exam of the fluid of duodenum ,bile, pancreatic fluid.
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Radiology
• Endoscopic sphincterotomy(EST)• Endoscopic naso-biliary drainage (ENBD) • Computed tomography(CT)• Magnetic resonance cholangio-
pancreatography (MRCP)• Cholangiopancreatography during &
operation
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Special Investigation of the Biliary Tract
• Hepatobiliary nuclear imaging
99m-Tc-EHIDA
• Choledochoscopy
Operation
Post opertion
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Cholelithiasis
• Including :
gallstones
biliary duct stones
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Cholelithiasis
In China:• before 1981 gallstones < biliary duct stones cholesterol stones < pigment stones• now gallstones > biliary duct stones
cholesterol stones > pigment stones
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Classification of stones
• Cholesterol stones: hard,layed on cross-section
• Pigment stones:crumble when squashed
• Mixed stones: radio-opaque
• Black stones
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Formation of stones
• Cholesterol stones:
cholesterol insoluble in water and relative proportion of cholesterol,bile salts, and phospholipid in bile .
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Formation of cholesterol stones
• Increase of cholesterol and decrease of bile salts leads to supersaturation of bile with cholesterol ,which results in the formation of liquid crystalline phase of cholesterol
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Formation of cholesterol stones
• Nucleation:cholesterol will crystallize if there is a nidus on which the crystals can form.
• Nucleating factors: mucus glycoprotiens from cyst wall
and bilirubinate• Gallbladder function: the motility of the cyst wall
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Clinical feature of gallstones
• 20-40% patient without symptom which is called asymptomatic gallstones
• Chronic cholecystitis
• Biliary colic
• Acute cholecystitis
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Symptoms
• Gastrointestinal tract symptoms:
upper abdominal discomfort,
nausea,
after meals, eap. fatty meals.
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Symptoms
Biliary colic: most commom symptom• A large or fatty meals and changing in position
when sleeping can precipitate the pain• Due to impaction of stone in the neck of the
gallbladder: the pressure increase.• Occurs in the mid or the upper-right portion of
the upper abdomen.• Severe pain starts abruptly, continuous,with
restlessness, vomitting,sweating.• Pain radiate to the right back and shoulder.
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Symptoms
Mirizzi syndrome:
• Obstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmann’s pouch
• Press on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula
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Sign
• Right upper area of the abdomen tenderness, rigidity,
rebound tendeness.• Gallbladder palpable• Murphy sign: inspiratory arrest during
subcostal palpation• Jaundice:common bile duct stones or Mirizzi
syndrome• Fever and chill with infection
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Exam
• Jaundice (choledocholithiasis):
blood test of the liver function, elevation of the enzyme alkaline phosphate and bilirubin
• WBC count is high
• Ultrasoud: the main diagnosis exam.
• Oral cholecytography.
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Diagnosis
• History
• Physical exam
• Ultrasoud exam: high echo with an acoustic shadow and moving with changes in posture
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Treatment
• The first choice is operation:
symptomatic gallstones
gallstones with complications
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Treatment
Asymptomatic gallstones:• oral cholecytography without showing
of gallbladder • diameter of stones > 2.0-3.0 cm• diabetes mellitus• elder or cardiac and respiratory
problemsNeed operation.
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Treatment
CBD exploration:
Preoperation
• CBD stones
• Cholangitis and biliary colic repeatedly
• Pancreatitis
• Jaundice and bile duct dilatation
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Treatmen
• Operation: the final method• Emergency surgery 1. onset in 48-72 hours2. invalidation of nonsurgical
treatment3. gangrene, perforation, pancreatitis,
or inflammation of the common bile duct occurs