biliary demo
TRANSCRIPT
THE BILIARY TREE AND BILIARY THE BILIARY TREE AND BILIARY TRACT DISEASESTRACT DISEASES
Presented By:Presented By:Rhile M. Arcenio, M.D.Rhile M. Arcenio, M.D.
OUTLINEOUTLINE
ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGY DuctsDucts Gall BladderGall Bladder PancreasPancreas
COMMON BILIARY TRACT COMMON BILIARY TRACT DISEASESDISEASES
Cholelithiasis ( Gall stones)Cholelithiasis ( Gall stones) Acute CholecystitisAcute Cholecystitis Acute CholangitisAcute Cholangitis
ANATOMY: The DuctsANATOMY: The Ducts
THE DUCTS:THE DUCTS:
1.1. Right Hepatic Right Hepatic Duct (RHD)Duct (RHD)
2.2. Left Hepatic Left Hepatic Duct (LHD)Duct (LHD)
3.3. Common Common Hepatic Duct Hepatic Duct (CHD)(CHD)
4.4. Common Bile Common Bile Duct (CBD)Duct (CBD)
THE DUCTS:THE DUCTS:
The Hepatic Ducts:The Hepatic Ducts:- R and L Hepatic R and L Hepatic
ducts emerge from ducts emerge from the liver via the the liver via the Porta HepatisPorta Hepatis
- R and L unite to R and L unite to form the form the Common Common Hepatic DuctHepatic Duct
- The Common The Common Hepatic Duct Hepatic Duct
- descends and is descends and is joined on the R side joined on the R side by the cystic duct by the cystic duct from the gall from the gall bladder to form the bladder to form the Common Bile Common Bile DuctDuct
The Common The Common Bile DuctBile Duct 3 inches long3 inches long Pierces the Pierces the
duodenum and duodenum and joined by the joined by the main pancreatic main pancreatic ductduct
Opens into the Opens into the Ampulla of Ampulla of VaterVater
ANATOMY: The Gall ANATOMY: The Gall BladderBladder
Pear shaped sac Pear shaped sac lying on the lying on the visceral side of visceral side of the liverthe liver
Approx 8 cm longApprox 8 cm long
FUNCTIONS:FUNCTIONS: Reservoir for Reservoir for
bile~ 50 mLbile~ 50 mL Concentrates bileConcentrates bile
3 MAIN ANATOMIC 3 MAIN ANATOMIC PARTS:PARTS:
1.1. NeckNeck
2.2. Corpus/ BodyCorpus/ Body
3.3. FundusFundus
Blood Supply:Blood Supply: Cystic ArteryCystic Artery
Drainage:Drainage: Cystic VeinCystic Vein
Nerve Supply:Nerve Supply: Celiac PlexusCeliac Plexus
THE CYSTIC THE CYSTIC DUCTDUCT 1.5 cm 1.5 cm Connects the Connects the
neck of the GB to neck of the GB to the Common the Common Hepatic Duct to Hepatic Duct to form the form the Common Bile Common Bile DuctDuct
THE PANCREAS:THE PANCREAS: Exocrine- produce Exocrine- produce
secretions with secretions with enzymes that are enzymes that are capable of capable of hydrolyzing fats, hydrolyzing fats, proteins and proteins and carbohydratescarbohydrates
Endocrine- ( Islet of Endocrine- ( Islet of Langerhans) Langerhans) produce Insulin & produce Insulin & GlucagonGlucagon
HEADHEAD Disc shapedDisc shaped Lies in the Lies in the
concavity of the concavity of the duodenumduodenum
Part of the head Part of the head extends to the extends to the leftleft UNCINATE UNCINATE PROCESSPROCESS
NECKNECK Connects the Connects the
head to the bodyhead to the body BODYBODY
Runs upward and Runs upward and to the L across to the L across the midlinethe midline
TAILTAIL
SUMMARY:SUMMARY:
GALL BLADDERGALL BLADDER An 8cm sac stuck to the An 8cm sac stuck to the
undersurface of the liver. undersurface of the liver. Store and concentrate the bileStore and concentrate the bile Deliver Bile into the gut Deliver Bile into the gut Mixes with the food and aids in Mixes with the food and aids in
the absorption of fats and certain the absorption of fats and certain vitaminsvitamins
BILIARY TRACT BILIARY TRACT PROCEDURESPROCEDURES
22ndnd most common procedure most common procedure next to Appendectomynext to Appendectomy
CHOLELITHIASIS:CHOLELITHIASIS:
Also known as Gall StonesAlso known as Gall Stones Formed when bile acids are Formed when bile acids are
overwhelmed by increased overwhelmed by increased cholesterolcholesterol
RISK FACTORS: (5 F’s)RISK FACTORS: (5 F’s) FemaleFemale FatFat FertileFertile Forty Forty FlatulentFlatulent
CHOLELITHIASISCHOLELITHIASIS
TYPES OF GALL TYPES OF GALL STONES:STONES:
Cholesterol StonesCholesterol Stones RadioluscentRadioluscent Grossly yellow in Grossly yellow in
colorcolor Mixed StonesMixed Stones
Has both cholesterol Has both cholesterol and pigment and pigment componentscomponents
Most common typeMost common type Pigment StonesPigment Stones
Seen in patients with Seen in patients with alcoholic cirrhosis, alcoholic cirrhosis, advanced age and advanced age and biliary infectionbiliary infection
CHOLELITHIASISCHOLELITHIASIS
Diagnostics:Diagnostics: Abdominal Ultrasound- detect Abdominal Ultrasound- detect
gallstones within the bladdergallstones within the bladder Radionuclide Biliary Scan- most Radionuclide Biliary Scan- most
sensitivesensitive Abdominal Radiograph is of little Abdominal Radiograph is of little
valuevalue
CHOLELITHIASISCHOLELITHIASIS
Treatment:Treatment: Cholecystectomy- definitive and Cholecystectomy- definitive and
curativecurative may be done on an elective basismay be done on an elective basis
ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS
Inflammation of the gall bladder Inflammation of the gall bladder secondary to prolonged blockage of secondary to prolonged blockage of the cystic ductthe cystic duct
Most commonly due to an impacted Most commonly due to an impacted gall stonegall stone
Crampy epigastric or RUQ pain, Crampy epigastric or RUQ pain, postprandialpostprandial
Fever, Nausea and VomitingFever, Nausea and Vomiting (+) Murphy’s sign- RUQ tendernes on (+) Murphy’s sign- RUQ tendernes on
inspirationinspiration Jaundice if it impacts the CBDJaundice if it impacts the CBD
ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS
TREATMENT:TREATMENT: IV AntibioticsIV Antibiotics Early Cholecystectomy ( within 72 Early Cholecystectomy ( within 72
hrs of onset of symptoms)hrs of onset of symptoms) For patients with significant medical For patients with significant medical
problems , delay cholecystectomy problems , delay cholecystectomy until acute inflammation resolvesuntil acute inflammation resolves
ACUTE CHOLANGITIS:ACUTE CHOLANGITIS:
Acute bacterial infection of the Acute bacterial infection of the biliary tree usually secondary to biliary tree usually secondary to obstructionobstruction
Fever, jaundice & RUQ pain Fever, jaundice & RUQ pain
( Charcot’s Triad)( Charcot’s Triad) Reynaud’s Pentad ( Charcot’s Reynaud’s Pentad ( Charcot’s
triad + shock+ altered mental triad + shock+ altered mental status)status)
ACUTE CHOLANGITISACUTE CHOLANGITIS
DIAGNOSTICS:DIAGNOSTICS: LeukocytosisLeukocytosis Elevated bilirubinElevated bilirubin Elevated Alkaline PhosphataseElevated Alkaline Phosphatase Culture to rule out sepsisCulture to rule out sepsis ERCP ( biliary drainage) ERCP ( biliary drainage)
ACUTE CHOLANGITISACUTE CHOLANGITIS
TREATMENT:TREATMENT: Serious & Life threateningSerious & Life threatening Requires ICU admissionRequires ICU admission Aggressive IV antibiotic Aggressive IV antibiotic
treatmenttreatment Patients with Acute Suppurative Patients with Acute Suppurative
Cholangitis require emergent bile Cholangitis require emergent bile duct decompressionduct decompression
SUMMARYSUMMARY
Biliary Tract Procedures are the 2Biliary Tract Procedures are the 2ndnd most most common surgical procedure next to common surgical procedure next to AppendectomyAppendectomy
Most Common Cause- gall stone formationMost Common Cause- gall stone formation 3 types of Gall stones3 types of Gall stones
CholesterolCholesterol MixedMixed PigmentPigment
Stones that lodge and obstruct into the CBD will Stones that lodge and obstruct into the CBD will cause jaundice and bile stasis which may super cause jaundice and bile stasis which may super infect and cause Cholecystitis/ Cholangitisinfect and cause Cholecystitis/ Cholangitis
Best Diagnosed by Radionucleotide Biliary Scan,Best Diagnosed by Radionucleotide Biliary Scan, Ultrasound remains the diagnostic procedure of Ultrasound remains the diagnostic procedure of
choice choice
Treatment – Cholecystectomy Treatment – Cholecystectomy For patients with significant For patients with significant
medical illness, delay medical illness, delay cholecystectomy until cholecystectomy until inflammation resolvesinflammation resolves
THANK YOUTHANK YOU