surgery_1.6 gallbladder and the hbt.docx

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Suzie, Patsu, Dayle, Gemmy Page 1 of 7

I.6 Gallbladder and the Extrahepatic Biliary SystemDr. HAZEL Z. TURINGAN, MD, FPCS, FPSGS, DPBTCVS

July 16, 2013

ANATOMY

a = right hepatic ductb = left hepatic ductc = common hepatic ducth = common bile ducti = fundus of the gallbladder

j = body of gallbladderk = infundibuluml = cystic duct

d. portal veine. hepatic arteryf. gastroduodenal artg. left gastric arterym. cystic arteryn. superior pancreaticoduodenal artery

What connects to gallbladder? Cystic ductRight hepatic duct + Left hepatic duct forms thecommon hepatic duct common bile duct goes all theway to meet pancreatic duct

Duct of Wirsung major duct Duct of Santorini small, accessory duct

Gallbladder stores bile until you need itSphincter of Oddi important in regulating flow of bile

Contracts if it does NOT need bile Relaxes if it does need bile

H + - acidifies bile; helps develop stoneCa 2+ in presence of acid no stone formationCa 2+ in presence of alkali with stone formation

GALLBLADDER

pear-shaped sac 7 to 10 cm long 30 - 50 ml capacity 300 ml obstructed

GALLBLADDER FUNCTION concentrate and store hepatic bile deliver bile into the duodenum in response to a meal

FASTING STATE 80% of the bile secreted by the liver stored in thegallbladder

gradual relaxation emptying of the gallbladder

role in maintaining a relatively low intraluminal pressure in the biliary tree

H ion transport

bile pHacidification promotes calcium solubilityPrevents precipitation as calcium salts

CYSTIC ARTERY AND THE HEPATOCYSTICTRIANGLE

Liver bed Cystic duct CHD

Relevance : this is where you find the cystic arteryNot seen in cadaversIn living bodies, covered by mesentery. Hence, youhave to be careful baka ma-ligate ang Right Hepatic

Artery

CALOT TRIANGLE Cystic artery Cystic duct CHD

Important for surgeons: CHD diameter is important (usually 4mm). You wantto know if the stone can pass the duct

CBD there must be a stone inside for it to dilate

LUNDS NODE & MASCAGNI NODE


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I.6 Gallbladder and the Extrahepatic Biliary SystemPage 2 of 7

COMMON HEPATIC DUCT 1 - 4 cm length 4 mm diameter

COMMON BILE DUCT 7 - 11 cm length 5 - 10 mm diameter

CYSTIC DUCT 2-5 mm diameter 1-6 cm length

Spiral valves of Heister Not really clinically significant undulating folds or valves in the proximal mucosa

of the cystic duct

CBD & PD UNITES 70% outside the duodenal wall and traverse theduodenal wall as a single duct

20% join within the duodenal wall and have a shortor no common duct, but open through the sameopening into the duodenum.

10% exit via separate openings into the duodenum.

SPHINCTER OF ODDI thick coat of circular smooth muscle surrounds the common bile duct at the ampulla ofVater

Controls the flow of bile, and in some casespancreatic juice, into the duodenum.

VARIATIONS IN CYSTIC DUCT

Small ducts ( of Luschka ) may drain directly from theliver into the body of the gallbladder [FAVORITEEXAM QUESTION!]

Unrecognized post cholecystectomy causesBILOMA (accumulation of bile in the peritoneal fluid)

liver produces bile excreted

bile canaliculi

500 to 1000 ml/day average diet produced withinthe liver

Vagal stimulation - bile secretion Splanchnic nerve stimulation - bile flow

Memorize the FLOW of BILE!Liver R&L hepatic duct common hepatic duct cystic duct common bile duct duodenum

DUODENUMHydrochloric acid

partly digested proteinsfatty acids

stimulate releaseSecretin

bile production

bile flow


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Liver bile flow

hepatic duct

common hepatic duct

common bile duct

Duodenum

Intact sphincter of Oddi - bile flow is directed intothe gallbladder

EFFECT OF CHOLECYSTOKININ

response to a mealgallbladder contractionsphincter of Oddi relaxation

gallbladder empties

CHOLECYSTOKININ (CCK) stimulus for galbladder emptying released endogenously from the duodenal mucosa inresponse to a meal

After a meal GB empties

30-40 mins 50 -70% of contents GB refills

60-90 minscorrelated with a reduced CCK level

acts directly on GB smooth muscle receptors stimulates gallbladder contraction relaxes

terminal bile duct sphincter of Oddi duodenum

Vasoactive intestinal polypeptide inhibitscontraction and causes gallbladder relaxation.

Somatostatin and its analogues are potentinhibitors of gallbladder contraction.

high incidence of gallstones, presumably due to theinhibition of gallbladder contraction and emptying.

Somatostatin is given when there is spastic painbecause of the stones

HBT ULTRASONOGRAPHYHBT hepatobiliary tree

>90% sensitivity & specificity Post-acoustic shadowing = stone Also notes thickness of the GB wall = inflammation

STONES acoustically dense reflect the ultrasound waves back to the ultrasonictransducer

block the passage of sound waves to the regionbehind them

they also produce an acoustic shadow

PERCUTANEOUS TRANSHEPATICCHOLANGIOGRAM AND DRAINAGE

For Obstructing Proximal CholangioCA

bile duct strictures and tumors, defines the anatomy of the biliary tree proximal to theaffected segment

ENDOSCOPIC RETROGRADECHOLANGIOGRAPHY (ERC)

& ENDOSCOPIC ULTRASOUND CBD cannulated cholangiogram using fluoroscopy

Diagnostic and treatment procedure of choice forCBD stones

ADVANTAGES OF ERC direct visualization of the ampullary region direct access to the distal CBD possibility of therapeutic

DIAGNOSTIC & THERAPEUTICPROCEDURE OF CHOICE

stones in the CBD associated with obstructive jaundice cholangitis gallstone pancreatitis

endoscopic cholangiogram (+) ductal stones

sphincterotomystone extraction

(-) CBD stones

CBD cannulation and cholangiography success rate>90%.


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ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY(ERC) & ENDOSCOPIC ULTRASOUND

DEFINITION OF TERMS Cholecyst itis

GB + inflammation Cholecysto lithiasis

GB + stone Choledocho lithiasis CBD + stone

Chole lithiasis GB / BD + stone

Cholang itis bile duct + inflammation

Cholecyst ectomy GB + removal

Cholecyst ostomy GB + tube

Choledoch ostomy CBD + tube

Choledoch otomy

CBD + incise

CHOLECYST - Gall bladderCHOLEDOCHO Common Bile DuctLITHIASIS - StoneTECTOMY RemovalOSTOMY Tube insertion

CHOLELITHIASIS Over a 20-year period, 2/3 asymptomatic patientswith gallstones remain symptom free

GALLSTONE FORMATION Major organic solutes in bile :

bilirubin bile salts phospholipids cholesterol

Cholesterol solubility depends on the relativeconcentration of: cholesterol bile salts lecithin (the main phospholipid in bile)

SUPERSATURATION cholesterol hypersecretion > reduced secretion ofphospholipid or bile salts

CHOLESTEROL

LECITHIN BILE SALTS

Cholesterol is secreted into bile as cholesterol-phospholipid vesicles

Cholesterol is held in solution by micelles, aconjugated bile salt-phospholipid-cholesterolcomplex, as well as by the cholesterol-phospholipidvesicles

PIGMENT STONES contain


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DIAGNOTICS HBT USG

MANAGEMENT Lap cholecystectomy treatment of choice Open cholecystectomy

LAPAROSCOPIC CHOLECYSTECTOMY

ACUTE CHOLECYSTITIS 90-95% 2ndry to gallstones No stones sometimes due to systemic diseases

GALLSTONE

gallbladder distentioninflammation

edema of the gallbladder wall

Take not of the thick walls of GB and edemaGALLBLADDER WALL

grossly thickened reddish with subserosal hemorrhages

PERICHOLECYSTIC fluid often is present

ACUTE ACALCULOUS CHOLESCTITIS typically occurs in patients with other acute

systemic diseases

TREATMENT LAPAROSCOPIC CHOLECYSTECTOMY

Procedure of Choice You can give antibiotics first before lap conversion rate to open cholecystectomy 10-15%

higher acute cholecystitis > chronic cholecystitis

ANTIBIOTICS + LAPAROSCOPICCHOLECYSTECTOMY 2 MONTHS LATER

Late presentation > 3-4 days of illness unfit for surgery Ginagawa ito sa mga cases na inoperable pa dahil

inflamed ba ang GB (increased morbidity). So you giveantibiotics first for the inflammation. Pag wala nanginflammation (2months later), you can operate na.

PERCUTANEOUS CHOLECYSTOSTOMY/ OPENCHOLECYSTOSTOMY UNDER LA

Unfit for surgery Poke it and drain fluid (pang-alleviate lang ng

symptoms)

CHOLEDOCHOLITHIASIS Common bile duct stones

small or large single or multiple 6 to 12% (+) GB stones

INCIDENCE increases with age 20-25% age 60 - (+) stones in GB & CBD

DIAGNOSTIC HBT USG

document GB stone size CBD (normal 5-10mm)

HIGHLY SUGGESTIVE OF CBD STONEdilated CBD (>8 mm in diameter)

(+) GB stone, jaundice biliary pain

MAGNETIC RESONANCE CHOLANGIOGRAPHY excellent anatomic detail 95% sensitivity 89% specificity detecting choledocholithiasis >5 mm

ENDOSCOPIC CHOLANGIOGRAPHY gold standard for diagnosing CBD stones

TREATMENT FOR CBD STONES Laparoscopic common bile duct exploration viathe cystic duct or with formal choledochotomyallows the stones to be retrieved in the same setting

Open common bile duct exploration choledochotomy with T-tube (for small stones tohelp them pass)


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the problem with small stones, they are easilyfriable, so not all of them are taken out

CHOLEDOCHODUODENOSTOMY OR ROUX-EN-YCHOLEDOCHOJEJUNOSTOMY

Stones impacted in the ampulla

CBD STONES COMPLICATION Cholangitis inflammation of GB Gallstone pancreatitis

CHOLANGITIS ascending bacterial infection in association withpartial or complete obstruction of the bile ducts

Hepatic bile is sterile bile in the bile ducts is kept sterile by continuousbile flow (stasis causes bacterial infection)

presence of antibacterial substances in bile, such asimmunoglobulin

Mechanical hindrance to bile flow facilitates bacterialcontamination

Most common cause of Obstruction in cholangitis Gallstones most common benign and malignant strictures parasites instrumentation of the ducts indwelling stents

Most common organisms cultured from bile

E. coli Klebsiella pneumoniae Streptococcus faecalis Enterobacter Bacteroides fragilis

PRESENTATION Charcot's triad

fever epigastric or right upper quadrant pain jaundice ( present in 2/3 of patients)

patients with Charcots triad go straight to OR!

Reynolds pentad

fever jaundice right upper quadrant pain septic shock mental status changes

DIAGNOSTIC ERC

definitive diagnostic test PTC

ERC not available PTC is indicated Both ERC and PTC

show the level & reason for the obstruction, allow culture of the bile

allow the removal of stones if present drainage of the bile ducts with drainage cathetersor stents

CT scanning and MRI show pancreatic and periampullary masses ductal dilatation

TREATMENT Initial treatment

IV antibiotics and fluid resuscitation Biliary decompression

endoscopically percutaneous transhepatic route surgically

BILIARY PANCREATITIS Obstruction of the pancreatic duct by an impactedstone

Temporary obstruction by a stone passing throughthe ampulla may lead to pancreatitis

ERC with sphincterotomy and stone extraction mayabort the episode of pancreatitis

Once the pancreatitis has subsided GB (GB stone) removed during same admission

Treatment: cholecystectomy + IOC preoperative ERC

OPERATIVE INTERVENTION

CHOLECYSTOSTOMY decompresses and drains the distended, inflamed,hydropic, or purulent gallbladder.

applicable if the patient is not fit to tolerate anabdominal operation.

Ultrasound-guided percutaneous drainage with apigtail catheter is the procedure of choice.

LAPAROSCOPIC CHOLECYSTOSTOMY Absolute contraindications

uncontrolled coagulopathy end-stage liver disease

Rarely

severe obstructive pulmonary disease CHF (EF


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I 6 G llbl dd d th E t h ti Bili S tPage 7 of 7

CHOLEDOCHAL DRAINAGE PROCEDURE pallative esp for cancer patients

CHOLEDOCHAL CYSTS

Treatment Cholecystectomy Hepaticojejunostomy

15% risk of chalangioca

GALLBLADDER CARCINOMA rare malignancy predominantly in the elderly an aggressive tumor poor prognosis overall 5-year survival rate 5% Cholelithiasis is the most important risk factor forgallbladder carcinoma

95% of patients with carcinoma of the gallbladderhave gallstone

Polypoid lesions of the gallbladder increased risk of cancer polyps >10 mm

Calcified "Porcelain" Gallbladder >20% incidence of gallbladder carcinoma cholecystectomy even if asymptomatic

Choledochal Cysts highest in gallbladder

Sclerosing cholangitis anomalous pancreaticobiliary duct junction exposure to carcinogens (azotoluene, nitrosamines) Most common GB CA: 80-90% adenocarcinomas spreads through:

a. the lymphatics (Calots node)

b. venous drainagec. direct liver parenchyma invasion

When diagnosed 25% localized to the gallbladder wall, 35% have regional nodal involvement and/or

extension into adjacent liver 40% have distant metastasis

CT scan staging identify a gallbladder mass local invasion into adjacent organs cannot identify nodal spread

In jaundiced patients: percutaneous transhepatic endoscopic cholangiogram delineate the extent of biliary tree involvement

TREATMENT : Surgery - only curative option Palliation unresectable disease at the time of diagnosis 5-year survival rate

surgery_1.6 gallbladder and the hbt.docx

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