Biliary tract

gastroenterology 3rd year

1. Disease of the Biliary
Tract

2. 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.

3. 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.

4. Special Investigation of
the biliary Tract
•Ultrasound:
Non-invasive,painless,
Easily performed
First choice for biliary tract disease

5. Ultrasound
•Bile duct stones:
Stones in gallbladder:
High echo which cast an acoustic
shadow and which move with changes
in posture

6. Ultrasound
•Jaundice differential diagnosis:
Dilatation of the ducts
CBD: diameter > 1.0cm
•Other disease: cholecytitis, tumor ect.
•During surgery: to detect bile duct
stones

7. Radiology
•Plain abdominal radiograph:
Radio-opaque gallstones
Air in the biliary tree
•Oral cholecystography:
Biliary contrast medium
A fatty meal

8. Radiology
•Intravenous cholangiography
•Percutaneous transhepatic cholangi-
ography (PTC)
show intra and extra hepatic biliary
duct clearly
complication: bile leakage
cholangitis
hemorrhage

9. 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.

10. Radiology
•Endoscopic sphincterotomy(EST)
•Endoscopic naso-biliary drainage
(ENBD)
•Computed tomography(CT)
•Magnetic resonance cholangio-
pancreatography (MRCP)
•Cholangiopancreatography during &
operation

11. Special Investigation of
the Biliary Tract
•Hepatobiliary nuclear imaging
99m-Tc-EHIDA
•Choledochoscopy
Operation
Post opertion

12. Cholelithiasis
•Including :
gallstones
biliary duct stones

13. Cholelithiasis
In China:
• before 1981
gallstones < biliary duct stones
cholesterol stones < pigment stones
• now
gallstones > biliary duct stones
cholesterol stones > pigment stones

14. Classification of stones
•Cholesterol stones: hard,layed on
cross-section
•Pigment stones:crumble when
squashed
•Mixed stones: radio-opaque
•Black stones

15. Formation of stones
•Cholesterol stones:
cholesterol insoluble in water and
relative proportion of
cholesterol,bile salts, and
phospholipid in bile .

16. 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

17. 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

18. Clinical feature of gallstones
•20-40% patient without symptom which
is called asymptomatic gallstones
•Chronic cholecystitis
•Biliary colic
•Acute cholecystitis

19. Symptoms
•Gastrointestinal tract symptoms:
upper abdominal discomfort,
nausea,
after meals, eap. fatty meals.

20. 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.

21. 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

22. 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

23. 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.

24. Diagnosis
•History
•Physical exam
•Ultrasoud exam: high echo with an
acoustic shadow and moving with
changes in posture

25. Treatment
•The first choice is operation:
symptomatic gallstones
gallstones with complications

26. Treatment
Asymptomatic gallstones:
•oral cholecytography without showing
of gallbladder
• diameter of stones > 2.0-3.0 cm
• diabetes mellitus
• elder or cardiac and respiratory
problems
Need operation.

27. Treatment
CBD exploration:
Preoperation
•CBD stones
•Cholangitis and biliary colic repeatedly
•Pancreatitis
•Jaundice and bile duct dilatation

28. Treatmen
•Operation: the final method
•Emergency surgery
 onset in 48-72 hours
 invalidation of nonsurgical
treatment
 gangrene, perforation, pancreatitis,
or inflammation of the common bile
duct occurs