I.6 – Gallbladder and the Extrahepatic Biliary System
Dr. HAZEL Z. TURINGAN, MD, FPCS, FPSGS, DPBTCVS, DMCC
July 16, 2013
ANATOMYa = 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
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
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%.
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.
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
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)
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