胆道疾病上海交大瑞金英课件.ppt

1、 Anatomy and Pathophysiology Diagnostic techniques Stones of Biliary tract Infection of Biliary tract Biliary TumorsAnatomhy of biliary tract Intrahepatic bile duct:Intrahepatic bile duct:Biliary tract extrahepatic bile duct:extrahepatic bile duct:Left hepatic duct Left hepatic duct Right hepatic du

2、ct Right hepatic duct Common hepatic common bile ductCommon hepatic common bile ductGallbladder cystic ductGallbladder cystic ductCalot trangle:Calot trangle:Liver :Liver :upper borderupper border Common hepatic duct diameter=0.4-0.6cmCommon hepatic duct diameter=0.4-0.6cmCystic duct Cystic duct low

3、er borderlower border length 3cm length 3cmThe cystic artery runs in this triangle The cystic artery runs in this triangle Common bile duct Diameter 0.6-0.8cm 1cm abnormal Length 7-9cm supraduodenal segment retro duodenal segment retro pancreatic segment duodenal wall segmentThe papilla of Vater pan

4、creatic sphincter common sphincter biliary sphincterThe sphincter of oddiGallbladder Length:8-12cmwidth:3-5cm variablesize:40-60mlshape:pearshaped fundus body the neck The physiological function of GallbladderStore and concentrate hepatic bile Secretion of water and electrolytesEmpty bile into the c

5、ommon bile ductBile secretion Hepatocytes secrete bile 800-1200ml Bile composition:bile acids,bile pigments,cholesterol,phospholipids,inorganic electrolytes,waterDiagnostic techniquesAbdominal ultrasonography1.untraumal2.low cost3.flexibicity4.first choiceAbdominal ultrasonography Diagnose biliary s

6、tone Identify the cause of jaundice PTCD by-ultrasound guided Doppler blood flowPercutaneous Transhepatic Cholangiography Show the dilated bile duct above obstruction site Drainage of bile by PTCD Traumatic methodsComplications Bile leakage Haemorrhage Sepsis Endoscopic Retrograde Cholangiopancreato

7、graphy ERCP Directly observe papilla lesion and biopsy Show the entire biliary tract Show the biliary tract proximal to obstruction site Drain bile Complications acute pancreatitis postprocedure cholangitis Other complicationsOperative and postoperative direct cholangiography Show the entire biliary

8、 tract Display the stone and stenosis Tube cholangiography done before biliary drainge with drawnCT and MRI High resolution More accurate Expensive Show the stone,tumor,dilated duct MRCP show the entire biliary treePlain radiographs show radio-opaque calcui air in the biliary tree calcification of t

9、he gallbladderOral cholecystography Show the function of gallbladder Show the stones polyps and tumor contraindications Sensitivity to iodine Liver and renal disease pregnancyCholedochoscope Intraoperative use:Explore the CBD stone Tumor,stenosis Reduce retained stone rate Remove stone biopsyOther e

10、xamination Intravenous cholangiogram Angiography Isotopic studiesHow to choose1.B ultrasound2.MRCP and CT3.ERCP and PTCInfections of biliary tract1.Cholecystitis2.Cholangitis obstruction stone infection coreAcute cholecystitis Acute calculous cholecystitis 95%Acute acalculous cholecystitis 5%Etiolog

11、y1.Cystic duct obstructed by a gallstone impacting in Hartmanns pouch2.Bacteial infection of the stagnant bile Aerobic enteric-derived organisms Escherichia coli,klebsiella pneumoniae,streptococcus faecalis gallstone impaction mucosal damage Lecithin lysolecithin phospholipasesPathologyCystic duct o

12、bstruction gallbladder Edema suppurate gangrene pericholecystic abscess perforation Cholecyst-enteric fitula Peritonitis intestinal obstruction Acute chronic atrophyClinical features1.Sudden and severe pain mainly in the right hypochondrium radiate to the right scapular region fatty foods2.Nausea an

13、d vomiting3.Fever4.Tenderness and rigidity in the right upper quadrant5.Positive Murphys sign6.Jaundice7.A palpable gallbladder mass(1/4)Mirrizzis Syndrome The common hepatic is obstructed due to stones impacted in or extruded from Hartmans pouch of the gallbldder or the cystic duct.Cholecystobiliar

14、y or cholecystoenteric fistulae are common complication.Differential Diagnsis Perforated peptic ulcer Acute pancreatitis Retrocaecel appendicitis Right low lobe pneumonia Hepatic abscess Acute viral hepatitisLaboratory Test Leukocytosis in the range of l0000-15000 Serum bilirubin or normal Alkaline

15、phosphatase or normal Transaminase or normal Serum amylase or normalTreatmentConservative treatment1.Intravenons fluid and electrolyte replacement2.Nasogastric suction3.Systemic antibiotics4.Parenteral analgesia5.fastSurgical Treatment1.Attack within 48-72 h of diagnosis2.Deterioration in patients g

16、eneral condition3.Complications are present Perforation Peritonitis Acute obstructive suppurative cholangitis Acute pancreatitisSurgical methods Open cholecystectomy Laparoscopic cholecystectomy Acalculous CholecystitisComplications of major trauma,burns and sepsisComplications of parenteral feeding

17、Not easy to make a clear diagnosisNeed prompt surgical interventionover 70%with atheroscclerotic cardiovascular diseaseBiliary scintiscanning helpful for diagnosisAcute cholangitis and acute obstructive suppurative cholangitisEtiology Choledocholithiasis 80%Benign strictures Obstructed biliary anast

18、omotic strictures Malignant obstruction Ascarid PathophysiologyBiliary obstruction intraductal pressure 20mH20biliary stagnation bacteremia,bacteria proliferationreflux into hepatic veins and perihepatic lymphaticssystemic signs of cholangitis Clinical presentation Fever and chill Jaundice charcots

19、triad)Right upper-quadrant pain Hypotension Mental obtundation Reynolds Physical examination Tenderness Abdominal guarding Swollen gallbladder HepatomegalyLaboratory Test Leukocytosis Hyperbilirubinemia Alkaline phosphatase Aminotransferases Leukopenia Profound gram-negative sepsis and immunosuppres

20、sion lmmunosuppression Serum amylase Radiological Evaluation Ultrasonography CT MRCP PTC ERCPGeneral support Cessation of oral intake,fast Antibiotics Keep liquid and electrolyte balance Intravenous fluidsTreatmentBiliary decompression Percutanecus transhepatic biliary drainage Endoscopic drainage p

21、apillotomy and placement of a nasobiliary tube Operative decompression CBD exploration and T tube drainageCholelithiasis Classification of gallstoneCholesterol stones:light brown,smooth or faceted,single or multiple cross-section laminated/crystallineappearancePigment stone:small,black or brown,irre

22、gular cross-section a morphous/crystallineMixed stoneLocation Gallbladder stones Common bile duct stone Intrahepatic bile duct stoneExtrahepatic bile duct stoneClinical presentation Dyspepsia Right upper quadrant abdominal pain in association with or shortly after a heavy or fatty meal A feeling of

23、gaseous bloating Biliary colic Physical examination Usually normal Chronic hydrops of gallbladdermass Some times tendernessRadiological TestA plain abdominal roentgenogramOral cholecystography Ultrasonography the initial diagnostic studyCTMRIComplications Acute cholecystitis Jaundice Cholangitis Pan

24、creatitis Mtrizzi syndrome cancerSurgical Indication Accelerating symptoms Poor visualization or non-visulization on oral cholecystography Diabetas Porcelain gallbladder stone2-3cmLaparoscopic Cholecystectomy Indications:Chronic,uncomplicated cholecystitisCholelithiasisGB polyps Benefits:Reducing ho

25、spitalization and associated costsDecreasing painImproved cosmetic outcomeReduced post-operative recoveryOther treatment Dietary therapy a low-fat diet,avoidance of heavy meals Antispasmodic medication Chenodeoxycholic acid and ursodeoxycholic acid Extracorporeal shock wave lithotripsyCarcinoma of G

26、allbladder IncidenceThe commonest form of biliary tract malignancy the fifth most common gastrointestinal cancerEncountered in 1-2%of cholecystectomy specimensPredominantly occurs in elderly femalesOver 90%of patients are were 50 years of ageThe peak age of incidence is 70-75%yearsA male to female r

27、atio of 1:3Etiology Cholelithiasis Benign adenoma Polypoid gallbladder lesions(polyp greater than 1cm)Anomalous pancreaticbiliary junction Chronic inflammatory bowel diseasePathology Adenocarcinoma 80%carcinoid tumours Undifferentiated carcinoma 6%sarcoma Squamous carcinoma 3%melanoma Mixed tumor or

28、 acanthoma 1%lymphomaUICC stage:mucosa and muscular stage:total layer of the gallbladder stage:invasion into liver 2cm B stage:spread to distal organ and lymph nodeClinical Features The diagnosis of gallbladder cancer is usually made when the disease is well advanced.There are no characteristic feat

29、ures at an early and curative stageLaboratory invesitigations Cant provide diagnostic information Provide some helpful clues Anaemia Serum alkaline phosphatase CEA CA19-9 CA125 Radiological Diagnosis Plain abdominal radiography Oral cholecystography PTC ERCP CT MRI MRCPOther methods for diagnosis FN

30、AC ultrasoundTreatment UICC UICC UICC IVA UICC B cholecystectomyCurative excision procednreextended curative excisionPalliative proceduresBilliary or duodenal bypass Prognosis Piehler and crichlow Report of 6000 patients:1 year survivial rate 11.8%5 year survival rate 4.1%Palliative procedure1.Excra bile drainge T tube U tube PTCD2.Intra-drainge Biliary-enteric bypass or intubation Non-operative endoprosthetic insertionThank you