1、Biliary tract diseases,广西医科大学外科学教研室 叶新平,Essentials of anatomy -1,Biliary tract Intra-hepatic bile duct Extra-hepatic bile duct Gallbladder Common bile duct,Essentials of anatomy -2,Intra-hepatic Bile Duct Bile canaliculi Segmental bile duct Lobal bile duct Hepatic part of left and right hepatic duct
2、,Essentials of anatomy -3,Extra-hepatic Bile Duct Left and right hepatic duct The common hepatic duct(CHB) Diameter :0.4-0.6 cm 2-4cm length Common bile duct(CBD) Diameter:0.6-0.8cm length:7-9cm Gallbladder: the body,the fundus,The neck,Essentials of anatomy -4,Calot triangle: The triangle bounded b
3、y 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 cholecystectomy.
4、,胆囊三角,Special Investigation of the biliary Tract -1,Ultrasound Non-invasive, painless,easily performed,repeatedly First choice for biliary tract disease n Bile duct stones: Stones in gallbladder: High echo which cast an acoustic shadow and which move with changes in posture n Jaundice differential d
5、iagnosis: Dilatation of the ducts CBD: diameter 1.0cm n Other disease: cholecystitis, tumor ect. n During surgery: to detect bile duct stones,Special Investigation of the biliary Tract -2,Radiology n Plain abdominal radiograph: Radio-opaque gallstones Air in the biliary tree n Oral cholecystography:
6、 Biliary contrast medium A fatty meal n Cholangiography Percutaneous transhepatic cholangiography (PTC) show intra and extra hepatic biliary duct clearly complication: bile leakage,cholangitis,hemorrhage,Special Investigation of the biliary Tract -2,n Endoscopic retrograde cholangiopancreatography (
7、ERCP) outline the biliary tree and pancreatic duct inspect the ampulla of Vater exam of the fluid of duodenum ,bile, pancreatic fluid. n Endoscopic sphincterotomy(EST) n Endoscopic naso-biliary drainage (ENBD) n Computed tomography(CT) Magnetic resonance cholangio-pancreatography (MRCP) n Choledocho
8、scopy :Operation,Post opertion,Cholelithiasis-胆石病,nCholelithiasis Including : gallstones biliary duct stones Classification of stones: n Cholesterol stones: hard,layed on cross-section n Pigment stones:crumble when squashed n Mixed stones: radio-opaque,Cholelithiasis,Cholelithiasis,Cholelithiasis,Ga
9、llstones -胆囊结石,Risk factor: n Women are three times more likely than men to develop stones n Obesity n Pregnancy n Dietary factors:high energy,low in fibre n Fasting n Biliary infection n Parasitic infestation,Clinical feature of gallstones n 20-40% patient without symptom which is called asymptomat
10、ic gallstones n Chronic cholecystitis n Biliary colic n Acute cholecystitis,Gallstones -胆囊结石,Symptoms nGastrointestinal tract symptoms: upper abdominal discomfort, nausea, after meals, esp. fatty meals. Biliary colic: most commom symptom nA large or fatty meals and changing in position when sleeping
11、 can precipitate the pain,Gallstones -胆囊结石,Symptoms nDue to impaction of stone in the neck of the gallbladder: the pressure increase. nOccurs in the mid or the upper-right portion of the upper abdomen. nSevere pain starts abruptly, continuous,with restlessness, vomitting, sweating. nPain radiate to
12、the right back and shoulder.,Gallstones -胆囊结石,Mirizzi syndrome: nObstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmanns pouch nPress on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula nCholecystitis, cholangitis, and
13、 obstructive jaundice. nCholangiography: narrow of the bile duct at the porta hepatis nAnatomy variation: cyst duct runs parallel to the hepatic duct,Gallstones -胆囊结石,Gallstones -胆囊结石,Sign nRight upper area of the abdomen tenderness, rigidity, rebound tendeness. nGallbladder palpable nMurphy sign: i
14、nspiratory arrest during subcostal palpation nJaundice:common bile duct stones or Mirizzi syndrome nFever and chill with infection,Gallstones -胆囊结石,Exam nJaundice (choledocholithiasis): blood test of the liver function, elevation of the enzyme alkaline phosphate and bilirubin nWBC count is high nUlt
15、rasoud: the main diagnosis exam.,Gallstones -胆囊结石,Diagnosis nHistory nPhysical exam nUltrasoud exam: high echo with an acoustic shadow and moving with changes in posture,Gallstones -胆囊结石,Ultrasoud,Gallstones -胆囊结石,CT,Gallstones -胆囊结石,Treatment The first choice is operation: nsymptomatic gallstones n
16、gallstones with complications,Gallstones -胆囊结石,CBD exploration(胆道探查) Preoperation n CBD stones n Jaundice and bile duct dilatation During operation n Cholangiography indicate CBD stone and bile duct dilatation n Palpable stones, ascarid, tumor n CBD diameter 1.0cm n Gallstone migrate into CBD n Panc
17、reatitis n Draw out purulent or haematoid bile or bile with sandy stones,Gallstones -胆囊结石,Laparoscopic cholecystectomy(LC) n first performed in 1987 n removal of the gallbladder is guided by a laparoscope n a short hospital stay, a quick recuperation, and a very small incision,Gallstones -胆囊结石,LC,No
18、n-Surgical Therapy n unwilling to undergo surgery n who have serious medical problems that increase the risks of surgery n cannot be used for patients who have acute gallbladder inflammation,Gallstones -胆囊结石,Bile duct stones-胆管结石,Including: primary bile duct stones secondary bile duct stones Site: i
19、ntrahepatic bile duct stones extrahepatic bile duct stones,Extrahepatic bile duct stones Pathology: n Biliary tract obstruction: uncompletely, bile duct dilatation n Infection: duct wall edma, congestion purulent bile blood sepsis bile duct wall ulcer fistula between bile duct and hepatic artery & p
20、ortal vein,Bile duct stones-胆管结石,Clinical manifestation n May be silent n Obstructive jaundice ascending cholangitis acute pancreatitis Chacrot triad: epigastric pain jaundice fever and chill,Extrahepatic bile duct stones,Bile duct stones-胆管结石,n Abdominal pain: epigastric or right upper quadrant of
21、the abdomen radiate to the right back and shoulder, nausea , vomiting n High fever and chill: obstruction infection pressure in duct increase bacteria flows into blood sepsis temperature: 39-40 n Jaundice: intermittence, fluctuant The severe of the jaundice depends on the duration of the obstruction
22、. Complete impactation of a stone cause severe progressive jaundice. Intolerable itching,Extrahepatic bile duct stones,Bile duct stones-胆管结石,Physical exam n Tenderness of epigastric and upper area of the abdomen n peritoneal irritation sign n Gallbladder may be palpable Lab test n WBC count is high
23、n elevation of the enzyme alkaline phosphate and bilirubin n bilirubin in urea is high n urobillinogen in urea is low urobillinogen in feces is low,Extrahepatic bile duct stones,Bile duct stones-胆管结石,Imaging technique n Ultrosound: stones in bile duct, bile duct dilatation n CT/MRI n ERCP Diagnosis
24、n Charcot triad n Lab test and imaging exam Differential diagnosis n Renal colic n Intestinal colic n Carcinoma of the Vater ampulla n Carcinoma of the head of pancreas,Extrahepatic bile duct stones,Bile duct stones-胆管结石,MRCP,Extrahepatic bile duct stones,Bile duct stones-胆管结石,Treatment n Operation
25、is the main therapy n Principles: Try to removal all stones Relief bile duct stenosis and obstruction The obstructive duct must be drained adequately n Preoperation management: control infection: antibiotics correct electrolyte and acid-alkali balance vitamin K, nutrition, etc.,Extrahepatic bile duc
26、t stones,Bile duct stones-胆管结石,Intrahepatic bile duct stones Pathology: Obstruction hepatocyte injury Infection hepatic abscess Cholangitis bile cirrhosis of liver,Bile duct stones-胆管结石,Bile duct stones-胆管结石 Intrahepatic bile duct stones,n Pigment stones mainly n Left more than right n Coexist with
27、extra hepatic bile duct stones commonly Etiology n Infection n Cholestasis n Biliary Ascariasis Pathology n Stenosis :intra hepatic bile duct n Cholangitis n Biliary carcinoma,Intrahepatic bile duct stones,Clinical manifestation n Feature of extra hepatic bile duct stones (when coexist) n Asymptomat
28、ic or discomfort of liver area and chest back n Obstruction: infection, fever,chill, acute obstructive suppurative cholangitis(AOSC) n Abscess n Bile liver cirrhosis hypertension of portal vein n Carcinoma of biliary tract: frequency attack of cholangitis, progressive jaundice, abdominal pain, fever
29、 hard to control, age50 become thin.,Bile duct stones-胆管结石,Intrahepatic bile duct stones,Physical exam n Liver swelling asymmetrical n Tenderness at liver area n Percussion tenderness over hepatic region n Others: infection and complication Diagnosis n History n Imaging exam: ultrasoud PTC,Bile duct
30、 stones-胆管结石,Intrahepatic bile duct stones,Treatment n Operation:the main method n Principle: extract all stones relief stenosis and obstruction: key point removal intrahepatic infective focus recovery the bile drainage prevent recrudescence n high positioned Cholangiolithotomy: 经肝胆管切开取石术 n Internal
31、 drainage: Roux-en Y cholangiojejunostomy：胆肠吻合术 n Removal intrahepatic infective focus local cirrhosis: left lateral lobe and right posterior lobe,Bile duct stones-胆管结石,Biliary infection-胆道感染 n Cholecystitis Cholangitis n Acute Subacute Chronic,Acute cholecystitis -急性胆囊炎,n Chemical and (or) bacteria
32、l inflammation n divided in to two categories: acute calculous cholecystitis (ACC) 9095% acute acalculous cholecystitis (AAC) 510%,Etiology nObstruction of cyst duct : 80% by an impacted gallstone others:torsion or stenosis of cyst duct, ascarid nBacterial inflammation nTrauma(previous surgery),chem
33、ical stimulus Pathology nAcute simple cholecystitis nAcute purulent cholecystitis nAcute gangrenous cholecystitis nPerforation of gallbladder: peritonitis,Acute cholecystitis -急性胆囊炎,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Nosogenesis n Cyst duct obstruction by gallstones the result
34、is chemical inflammation of the cyst wall n Secondary bacterial infection retrogression through cyst duct by blood or lymph n Others,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Clinical manifestation n female, fatty, forty, 3F n History of gallbladder disease n Typical onset: biliary co
35、lic n Patients tend to move around to seek relief from the pain n It is prolonged and lasts hours or days Nausea, vomiting, and low-grade fever,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Sign n Epigastric or right upper quadrant tenderness, guarding may be found n Murphy sign (an inspi
36、ratory pause on palpation of the right upper quadrant) n Gallbladder may be palpable. n Mass in the right upper quadrant n Diffusive peritonitis n Elderly patients: absence of typical physical signs the incidence of complication is higher n Uncommon in children,Acute cholecystitis -急性胆囊炎 Acute calcu
37、lous cholecystitis,Lab test n WBC count Leukocytosis with left shift Normal WBC Count does not rule out cholecystitis n Liver Function Tests (LFTs) Serum Bilirubin elevated Serum Alkaline Phosphatase elevated Serum Aminotransferases normal n Pancreatic Studies Amylase elevated,Acute cholecystitis -急
38、性胆囊炎 Acute calculous cholecystitis,Imaging exam Ultrasound: n Enlargement of the gallbladder n Gallbladder wall thickness 3 mm n Sonographic Murphys Sign n Halo sign (gallbladder wall with a sonolucent double-lined halo) n Gallstones n Hepatobiliary scan,Acute cholecystitis -急性胆囊炎 Acute calculous ch
39、olecystitis,Diagnosis n Typical clinical manifestation n Lab test n Imaging exam n Easy to diagnosis Differential diagnosis n Acute pancreatitis n Acute appendicitis n Perforation of peptic ulcer n Hepatic abscess n Perforation of colon carcinoma n Hepatitis n Pneumonia and pleurisy (right),Acute ch
40、olecystitis -急性胆囊炎 Acute calculous cholecystitis,Treatment n Nonsurgical treatment: fasting a low fat diet when food is tolerated after the acute attack. Intravenous fluid Nasogastric suction Antibiotics pain control n Operation: the final method n Emergency surgery n Onset in 48-72 hours n Invalida
41、tion of nonsurgical treatment (gangrene, perforation, pancreatitis, or inflammation of the common bile duct occurs ),Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Treatment Operation n Cholecystectomy:most cases n Cholecystostomy: high risk cases local severe edema, conglutination,Acute c
42、holecystitis -急性胆囊炎 Acute acalculous cholecystitis,Etiology n Uncertain n After severe trauma, operation,and burns n Severe illness cases n TPN for a long time n Be related to bile stasis Pathology n Same to acute calculous cholecystitis n High rate of necrosis and perforation of gallbladder,Acute c
43、holecystitis -急性胆囊炎 Acute acalculous cholecystitis,Clinical manifestation n More common in men than women (27 : 1) n Same to acute calculous cholecystitis n Easy to make an error diagnosis n Ultrasound is the most useful investigation n Gallbladder is palpable Treatment n Once the diagnosis is made,
44、an immediate operation is necessary Method: n Cholecystectomy n Cholecystostomy,胆囊造瘘(Cholecystostomy) 病情危重 不能耐受手术 胆囊炎症严重，解剖不清,Acute cholecystitis -急性胆囊炎 Acute acalculous cholecystitis,胆囊造瘘术(Cholecystostomy),Acute cholecystitis -急性胆囊炎 Acute acalculous cholecystitis,Acute obstructive suppurative chola
45、ngitis (AOSC),n Acute cholangitis of severe type(ACST) n Etiology : obstruction of bile duct biliary infection Obstructive factor: n Bile duct stones 76-88% n Biliary ascariasis 22-26% n Biliary tract stenosis 8.7-11% n Tumor of ampulla n Primary sclerosing cholangitis,Acute obstructive suppurative
46、cholangitis (AOSC),Pathology n Complete bile duct obstruction intra or extra hepatic bile duct n Purulent infection: bile duct n Bacteria: Escherichia coli, streptococcus faecalis, Klebsiella, pseudomonas Anaerobic bacteria,Acute obstructive suppurative cholangitis (AOSC),Clinical manifestation n Hi
47、story of biliary disease and biliary operation n Starts abruptly and progressively n Reynolds pentad: abdominal pain jaundice fever and chills mental status changes septic shock,Acute obstructive suppurative cholangitis (AOSC),Sign n Temperature: 39C, or 120b/m n Blood pressure: low n Jaundice n Ten
48、derness : Epigastric or right upper quadrant tenderness n Mental status changes n Peritonitis n Percussion tenderness over hepatic region n Palpable gallbladder n Mild hepatomegaly,Acute obstructive suppurative cholangitis (AOSC),Lab test n WBC count is high, 20X109/L severe patients may be leukopen
49、ic PLT count is low, (10-20)X109/L n Prothrombin time(PT) is long n Liver function: Alkaline phosphatase and Bilirubin is elevated n renal function and electrolytes n Blood cultures: Between 20-30% of blood cultures are positive. Many exhibit polymicrobial infections n Amylase and/or lipase: Involvement of the lower CBD may cause elevated amylase and pancreatitis. n Biliary cultures,Acute obstructive suppurative cholangitis (
