• No results found

SURGERY_1.6 Gallbladder and the HBT.docx

N/A
N/A
Protected

Academic year: 2021

Share "SURGERY_1.6 Gallbladder and the HBT.docx"

Copied!
7
0
0

Loading.... (view fulltext now)

Full text

(1)

I.6 – Gallbladder and the Extrahepatic Biliary System

Dr. HAZEL Z. TURINGAN, MD, FPCS, FPSGS, DPBTCVS, DMCC

July 16, 2013

ANATOMY

a = right hepatic duct b = left hepatic duct c = common hepatic duct h = common bile duct i = fundus of the gallbladder j = body of gallbladder k = infundibulum l = cystic duct d. portal vein e. hepatic artery f. gastroduodenal art g. left gastric artery m. cystic artery

n. superior pancreaticoduodenal artery

What connects to gallbladder? Cystic duct Right hepatic duct + Left hepatic duct forms the common hepatic duct common bile duct goes all the way to meet pancreatic duct

 Duct of Wirsung – major duct

 Duct of Santorini – small, accessory duct

Gallbladder – stores bile until you need it

Sphincter 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 stone

Ca2+ in presence of acid – no stone formation

Ca2+ 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 the gallbladder

 gradual relaxation

 emptying of the gallbladder

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

H ion transport ↓ ↓bile pH

acidification promotes calcium solubility Prevents precipitation as calcium salts CYSTIC ARTERY AND THE HEPATOCYSTIC

TRIANGLE  Liver bed

 Cystic duct  CHD

Relevance : this is where you find the cystic artery Not seen in cadavers

In living bodies, covered by mesentery. Hence, you have 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 want

to know if the stone can pass the duct

CBD – there must be a stone inside for it to dilate LUND’S NODE & MASCAGNI NODE

(2)

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 the duodenal wall as a single duct

20% join within the duodenal wall and have a short or no common duct, but open through the same opening 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 of Vater

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

VARIATIONS IN CYSTIC DUCT

Small ducts (of Luschka) may drain directly from the liver into the body of the gallbladder [FAVORITE

EXAM QUESTION!]

 Unrecognized post cholecystectomy causes

BILOMA(accumulation of bile in the peritoneal fluid)

liver produces bile ↓ excreted bile canaliculi

500 to 1000 ml/day average diet produced within the 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

DUODENUM Hydrochloric acid partly digested proteins

fatty acids ↓ stimulate release Secretin ↓ ↑ bile production ↑ bile flow

(3)

Liver ↓ bile flow hepatic duct

common hepatic duct ↓

common bile duct ↓

Duodenum

Intact sphincter of Oddi - bile flow is directed into the gallbladder

EFFECT OF CHOLECYSTOKININ

response to a meal

gallbladder contraction sphincter of Oddi relaxation gallbladder empties

CHOLECYSTOKININ (CCK)  stimulus for galbladder emptying

 released endogenously from the duodenal mucosa in response to a meal  After a meal  GB empties 30-40 mins 50 -70% of contents  GB refills 60-90 mins

correlated 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 inhibits contraction and causes gallbladder relaxation.

Somatostatin and its analogues are potent inhibitors of gallbladder contraction.

 high incidence of gallstones, presumably due to the inhibition of gallbladder contraction and emptying.

Somatostatin is given when there is spastic pain

because of the stones

HBT ULTRASONOGRAPHY

HBT – 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 ultrasonic transducer

 block the passage of sound waves to the region behind them

 they also produce an acoustic shadow PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM AND DRAINAGE For Obstructing Proximal CholangioCA

 bile duct strictures and tumors,

 defines the anatomy of the biliary tree proximal to the affected segment

ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY (ERC) & ENDOSCOPIC ULTRASOUND  CBD cannulated

 cholangiogram using fluoroscopy

Diagnostic and treatment procedure of choice for

CBD stones

ADVANTAGES OF ERC  direct visualization of the ampullary region

 direct access to the distal CBD

 possibility of therapeutic

DIAGNOSTIC & THERAPEUTIC PROCEDURE OF CHOICE  stones in the CBD

 associated with obstructive jaundice

 cholangitis  gallstone pancreatitis endoscopic cholangiogram ↓ (+) ductal stones sphincterotomy stone extraction ↓ (-) CBD stones

 CBD cannulation and cholangiography success rate >90%.

(4)

ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY (ERC) & ENDOSCOPIC ULTRASOUND

DEFINITION OF TERMS Cholecystitis  GB + inflammation  Cholecystolithiasis  GB + stone  Choledocholithiasis  CBD + stone  Cholelithiasis  GB / BD + stone  Cholangitis

 bile duct + inflammation

Cholecystectomy  GB + removal  Cholecystostomy  GB + tube  Choledochostomy  CBD + tube  Choledochotomy  CBD + incise

CHOLECYST - Gall bladder

CHOLEDOCHO – Common Bile Duct LITHIASIS - Stone

TECTOMY – Removal OSTOMY – Tube insertion

CHOLELITHIASIS

 Over a 20-year period, 2/3 asymptomatic patients with gallstones remain symptom free

GALLSTONE FORMATION Major organic solutes in bile:

 bilirubin  bile salts  phospholipids  cholesterol

Cholesterol solubility depends on the relative concentration of:

 cholesterol  bile salts

 lecithin (the main phospholipid in bile) SUPERSATURATION

 cholesterol hypersecretion > reduced secretion of phospholipid or bile salts

CHOLESTEROL

LECITHIN BILE SALTS

Cholesterol is secreted into bile as cholesterol-phospholipid vesicles

 Cholesterol is held in solution by micelles, a conjugated bile salt-phospholipid-cholesterol complex, as well as by the cholesterol-phospholipid vesicles

PIGMENT STONES contain <20% cholesterol

dark due to presence of calcium bilirubinate

 supersaturation  calcium bilirubinate  carbonate

 phosphate

 most often 2ndry to:  hemolytic disorders  cirrhosis

 almost always form in the gallbladder

 Unconjugated bilirubin is much less soluble than conjugated bilirubin in bile

BROWN STONES <1 cm in diameter

 brownish-yellow

 soft, and often mushy

 form either in the gallbladder or in the bile ducts, usually secondary to bacterial infection caused by bile stasis

 Precipitated calcium bilirubinate and bacterial cell bodies compose the major part of the stone

CHRONIC CHOLECYSTITIS

 About two thirds of patients with gallstone disease present with chronic cholecystitis characterized by recurrent attacks of pain

 pain develops when a stone obstructs the cystic duct, resulting in a progressive increase of tension in the gallbladder wall (distention of GB causes

pain)

pain is constant and increases in severity over the first half hour or so and typically lasts 1 to 5 hours.

located in the epigastrium or right upper quadrant

frequently radiates to the right upper back or between the scapulae

 severe and comes on abruptly, typically during the night or after a fatty meal.

 often associated with nausea and vomiting.

(5)

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 distention inflammation

edema of the gallbladder wall

Take not of the thick walls of GB and edema

GALLBLADDER 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 + LAPAROSCOPIC CHOLECYSTECTOMY 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 give antibiotics first for the inflammation. Pag wala nang inflammation (2months later), you can operate na.

PERCUTANEOUS CHOLECYSTOSTOMY/ OPEN CHOLECYSTOSTOMY 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 STONE dilated 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 via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting

Open common bile duct exploration

choledochotomy with T-tube (for small stones to

(6)

the problem with small stones, they are easily

friable, so not all of them are taken out

CHOLEDOCHODUODENOSTOMY OR ROUX-EN-Y CHOLEDOCHOJEJUNOSTOMY

 Stones impacted in the ampulla

CBD STONES COMPLICATION Cholangitis – inflammation of GB

 Gallstone pancreatitis

CHOLANGITIS

 ascending bacterial infection in association with partial or complete obstruction of the bile ducts

 Hepatic bile is sterile

 bile in the bile ducts is kept sterile by continuous bile flow (stasis causes bacterial infection)

 presence of antibacterial substances in bile, such as immunoglobulin

 Mechanical hindrance to bile flow facilitates bacterial contamination

 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 Charcot’s 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 catheters or 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 impacted stone

 Temporary obstruction by a stone passing through the ampulla may lead to pancreatitis

 ERC with sphincterotomy and stone extraction may abort 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 an abdominal operation.

 Ultrasound-guided percutaneous drainage with a pigtail catheter is the procedure of choice.

LAPAROSCOPIC CHOLECYSTOSTOMY  Absolute contraindications

 uncontrolled coagulopathy  end-stage liver disease

 Rarely

 severe obstructive pulmonary disease  CHF (EF <20%)

 may not tolerate pneumoperitoneum with C02 INTRAOPERATIVE CHOLANGIOGRAM

CHOLEDOCHAL EXPLORATION  common bile duct exploration (CBDE)

(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 for gallbladder carcinoma

 95% of patients with carcinoma of the gallbladder have 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 (Calot’s node) b. venous drainage

c. 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 <5%,

 median survival of 6 months

 T1 disease treated with cholecystectomy excellent prognosis (85 -100% 5-year survival rate)

 advanced but resectable gallbladder cancer o 5-year survival rates 20 -50%

 distant metastasis

References

Related documents

The linear attenuation coefficients for bone can be converted to mineral concentrations assuming that the bone comprises protein and pure hydroxyapatite (Ca 10( PO 4)6( OH )2 ;

The following teaching skills are most likely to have an effect on achievement of learning objectives, as perceived by the students: clearly presenting the material

Abstract Various types of gene rearrangements have been discovered in the mitogenoes of the frog family Ranidae. In this study, we determined the complete mitogenome sequence of

In relation to a proposed limit of 3.5 s for the stdTTP value in border zones, this was moderate in hemispheres supplied by a highly stenosed ICA (grp 1; a-BZ and p-BZ [stenotic

Write a program in C++ using function template to read two matrices of different data types such as integers and floating point values and perform simple arithmetic

Keywords: Carbon Fibre, CFRC, Compressive Strength, Flexural Strength, High

Corres­ pondingly, if the incomes of the top 5 per cent fell, mean income would fall, the poverty line would fall and fewer people would be counted as poor.. In fact, an increase

Section VI Visibilitv and Ceiling. Climatological tables give frequencies of occurrences of specified ranges of visibilities and heights of base of lowest cloud