Disease of the biliary tract

Anatomy review
Biliary tract
Intra-hepatic bile duct
Extra-hepatic bile duct
Gallbladder
Oddi sphincter
*right and left hepatic duct- a part of it is
in the intra-hepatic duct and some are in
the extra-hepatic duct
From bile canaliculi to the ampulla of Vater
Intra-hepatic bile duct

Bile canaliculi
Segmental bile duct
Lobal bile duct
Hepatic part of left and right
hepatic duct

Extra-hepatic bile duct

Left and right hepatic duct
The common hepatic duct
Diameter: 0.4-0.6 cm ;length:2-4
cm
Common bile duct
Diameter: 0.6-0.8cm ; length: 79cm
Gallbladder: the body, the fundus,
the neck
Cyst duct

Level of the Stones:

Gallbladder-dyspeptic symptoms
Cyst duct-acute cholecystitis
Common bile (not fully obstructed)
-dyspepesia or abdominal pain

The level of the symptoms depend where

the stone is located
*Common bile duct theory: the pancreatic
duct and the common bile duct joins
together to form single opening
Carlot 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 and para-right
hepatic duct run within the triangle
makes an important area of
dissection during cholecystectomy.
Anatomy
The sphincter of Oddi:
o 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.
*a sphincter dysfunction can cause an
additional pin to the patient
Special investigation of the biliary
tract

Gallbladder: body, fundus, neck

Ultrasound
Non-invasive, painless, easily
performed

First choice for biliary tract disease

Bile duct stones:
Stones in gallbladder:
High echo which cast an acoustic
shadow and which move with
changes in posture
Jaundice differential diagnosis:
Dialation of the ducts distl part
CBD: diameter>1.0cm
Other disease: cholecystitis, tumor
etc.
During surgery: to detect bile duct
stones

o
o
o
o

o
o

*sensitivity-the disease is there you

can see it
*specificity-the disease is not there,
cannot be seen
Radiology
o Plain abdominal radiograph:
Radio-opaque
gallstones
Air in the biliary tree
o Oral cholecystography:
Biliary contrast
medium
A fatty meal- to
contract the bile duct
o Intravenous
cholangiography
o Percutaneous transhepatic
cholangiography (PTC)
Show intra and extra
hepatic biliary duct
clearly
Complication: bile
leakage
o Cholangitis
o Hemorrhage
o Endoscopic retrograde
cholangiopancreatography
Outline the biliary
tree and pancreatic
duct
Inspect the biliary
tree and pancreatic
duct
Inspect the ampulla
of vater

Exam of fluid of
duodenum, bile,
pancreatic fluid
Endoscopic sphincterotomy
(EST)
Endoscopic naso-biliary
drainage (ENBD)
Computed tomography (CT)
Magnetic resonance
cholangiopancreatography
(MRCP)
Cholangiopancreatography
during operation
Percutaneous transhepatic
cholangiography

Cholelithiasis
Including: gallstones and biliary duct
stones
In China:
Before 1981
Gallstones < biliary duct stones
Cholesterol stones < pigment
stones
Now
Gallstones >biliary duct stones
Cholesterol stones > pigment
stones
Classification of stones
1. Cholesterol stones: yellow stones,
hard, layed on cross-section, usully
caused by infections
2. Pigment stones: crumble when
squashed
3. Mixed stones: radio-opaque
4. Black stones
*left hepatic duct=more pigment
stones

bilirubin conjugated with

glucuronide B-glucoronidase produced
by E. coli can split the molecule
unconjugated bilirubin
precipitates as salt.
Gallstones ( cholecystolithiasis)
Risk factor:
Women are three times more likely
than men to develop stones
Obesity
Pregnancy
Dietary factors: high energy, low in
fiber
Fasting
Biliary infection
Parasitic infestation
Deaibetes mellitus
TPN
Gastric surgery
Cirrhosis of liver
Chronic haemolyticanaemia
Formation of cholesterol stones:
Cholesterol insoluble in water and
relative proportion of cholesterol, bile
saltes, and phospholipid in bile.
Increase of cholesterol and decrease of
bile saltes leads to supersaturation of bile
with cholesterol, which results in the
formation of liquid crystalline phase of
cholesterol
Nucleation: cholesterol will crystallize if
there is a nidus on which the crystals can
form.
Nucleating factors: mucus glycoproteins
from cyst wall and bilirubinate
Alteration of the gallbladder function:
the motility of the cyst wall
Formation of stones
Extraheptic duct: contains either primary
pigment stones or cholesterol stones
Intrahepatic stone: primary pigment
stones
Pigment stones:- due to infection
form of calcium bilirubunate

Clinical feature of gallstones

20-40% patient without symptom
which is called asymptomatic
gallstones
Chronic cholecystitis
Biliary colic
Acute cholecystitis
Symptoms
Biliary colic: most common 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 upperright portion of the upper abdomen

Severe pain starts abrubtly,
continuous, with restlessness,
vomiting, sweating
Pain radiate to the right back and
shoulder
Mirizzi syndrome:
-Obstruction of the common
hepatic duct by a stone
impacted in the cystic duct
or hartmanns pouch
-press on the bile duct or
(more commonly) ulcerate
into the ducts leads to
cholecystocholedochal
fistula
-cholecystitis, cholangitis,
and obstructive jaundice
-cholangiography: narrow of
the bile duct at the
portahepatis
-anatomy variation: cyst
duct runs parallel to the
hepatic duct
Mucoceole of the gallbladder:
-a stone impacts in the
cystic duct without bacterial
infection
-bile reabsorbed
-the epithelium continues to
secrete mucous, which is
called white bile
Stones migrate though the cystic
duct into the common bile duct:
infection, jaundice
Impaction of a small stone at the
ampulla of Vater and occlusion of
the pancreatic duct causes
pancreatitis
o
o

Painjaundicefever= charcots
triad, obstruction of common bile
duct
Feverpainjaundice= viral
hepatitis/ infection

Jaundicefeverpain= pancreatic
cancer

Sign
Right upper area of the abdomen
tenderness, rigidity, rebound
tenderness
Gallbladder palpable
Murphy sign: inspiratory arrest
during subcostal palpation
Jaundice: common bile duct stones
or Mirizzi syndrome
Fever and chill with infection
Treatment
The first choice is operation:
-symptomatic gallstones
-gallstones with complications

Pathophysiology- insult leads to leakge

of pancreatic enzymes into pancreatic and
peripancreatic tissue leading to acute
inflammatory reaction
Etiologies
o
o
o
o
o
o
o
o
o
o
Pancreatitis

Idiopathic
Gallstones(or other
obstructive lesions
EtOH
Trauma
Steroids
Mumps(& other viruses
CMV, EBV)
Autoimmune (SLE,
polyarthritis nodosa)
Scorpion sting
Hyper Ca, TG
ERCP (5-10% of points
undergoing procedure)
Drugs (thiazides,
sulfonamides, ACE-I,
NSAIDs, azathioprine)

EtOH and gallstones account for 60-70%

ofcases
Signs and Symptoms

Severe epigastric abdominal painabrupt onset (may radiate to back)

Nausea & vomiting
Weakness

Tachycardia
+/- Fever, +/- hypotension or shock
Grey turner sign-flank discoloration
due to retroperitoneal bleed in pt.
with pancrearic necrosis (rare)
Cullens sign- periumbillical
discoloration (rare)

Ranson Criteria
Admission
o
o
o
o
o

Age > 55
WBC > 16, 000
Glucose > 200
LDH > 350
AST >250

During first 48 hrs

o
o
o
o
o

Hematocrit drop >10%

Serum calcium <8
Base deficit > 4.0
Increase in BUN > 5
Fluid sequestration > 6L

5% mortality risk with <2 signs

15-20% mortality risk with 3-4 signs
40% mortality risk with 5-6 signs
99% mortality risk with >7 signs

Therapy
Remove offending agent (if
possible)
Supportive
#1- NPO (until pain free)
-NG suction for patients with
ileus or emesis
- TPN may be needed
#2 aggressive volume repletion
with IVF
o Keep an eye on fluid
balance/ sequestration and
electrolyte disturbances

>1cm = dilation of the bile duct

Alcohol/gallstone= leading cause of
pancreatitis
Gray turner sign= seen in the flanks
Cullen sign= seen in the periumbillical
area
Somatostatin= is the only gastric peptide
that has an inhibitory effect
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