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Biliary physiology
Cystic duct
The bile ducts, gallbladder and sphincter of Oddi act in concert to modify, store, and regulate the flow of bile
Choledocus
Biliary physiology
The functions of the gallbladder: -to concentrate -to store the bile Bile is concentrated 5-fold to 10-fold by the absorption of water and electrolytes a marked change in bile composition The concentration of bile may affect the solubilities of two important components: - cholesterol and - calcium the gallbladder bile becomes concentrated -several changes occur in the capacity of bile to solubilize cholesterol.
Biliary physiology
The major organic solutes in bile are: - bilirubin
- bile salts
- phospholipids - cholesterol Cholesterol = highly nonpolar
= insoluble in water
Biliary physiology
Cholesterol is maintained in solution in some complex biochemical structures:
The hidrophobic molecules of cholesterol are surounded by hidrophilic molecules
micelles
vesicles
Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and phospholipid
Gallstones formation
Supersaturated bile: - the capability of these micelles and vesicles to solubilise the cholesterol is exceded the precipitation (cristalisation) of the cholesterol occur Pronucleating factors -mucin glycoproteins -immunoglobulins
-transferrin
accelerate the precipitation of cholesterol in bile
Gallstones formation
Sludge = a mixture of cholesterol crystals, calcium bilirubinate granules, and a mucin gel matrix
The cristals of cholesterol growth, include glicroproteins from mucin gel and calcium bilirubinate
gallstones
Gallstones formation
Gallstone types
gallstones cholesterol gallstones The pathogenesis of cholesterol gallstones involves four factors: -cholesterol supersaturation in bile -crystal nucleation pigment gallstones Black pigment stones = associated with -hemolytic conditions or -cirrhosis unconjugated bilirubin increased Brown pigment stones -earthy in texture -some bacteria produces enzymatic hydrolysis of soluble conjugated bilirubin free bilirubin it precipitates with calcium
-gallbladder dysmotility
-gallbladder absorption
Gallstone types
cholesterol gallstones
Gallstone types
black gallstones
Gallstone types
brown gallstones
Gallstone types
gallstones
during years
Simptomatic gallstones
1.Pain -tipical pain: biliary colic -atipical pain
-bloating
-belching
Biliary colic
The pain: -in the right upper quadrant and/or epigastrium -frequently radiates to the back and right scapula -the intensity of the pain = severe -occurs following fatty meals (50% of patients) -the duration of pain: 1 to 5 hours (tipically) rarely persist for more than 24 hours if > 24 hours suggests an acute cholecystitis) rarely shorter than 1 hour
-the episodes of biliary colic = less frequent than one per week.
Atipical pain
Atypical pain is common -some patients do not relate their pain to meals or time of day -not all attacks are necessarily severe -the pain is continuous rather than episodic -the pain located predominantly in the back or the left upper or right lower quadrant -the less typical the pain search for another cause,
renal colic, peptic ulcer, hiatal hernia, abdominal wall hernia, liver disease, disease of the small bowell, disease of the large bowell
Diagnostic imaging
Abdominal X-ray -only 15% of gallstones contain sufficient calcium to appear on X-ray Ultrasound -noninvasive, inexpensive, and widely available -identifies gallstones and bile duct dilation -gallstones create echoes and are free-floating -the ultrasound waves cannot penetrate the stones shadowing gallstones shadowing sludge
Diagnostic imaging
Cholescintigraphy -Tc99m labeled iminodiacetic acid - injected intravenously -the radionuclide is excreted into the bile
Diagnostic imaging
Computerized Tomography
In fact the role of CT scanning is limited to the diagnosis of complications of gallstone disease such as acute cholecystitis (gallbladder wall thickening, pericholecystic fluid), choledocholithiasis (intrahepatic and extrahepatic bile duct dilation), pancreatitis (pancreatic edema and inflammation) and gallbladder cancer
Treatment
Nonoperative Therapy The nonsurgical options for the treatment of gallstone disease include: -oral dissolution therapy with the bile acids (ursodeoxycholic acid and chenodeoxycholic acid)
Treatment
Nonoperative Therapy The nonsurgical options for the treatment of gallstone disease include: -oral dissolution therapy with the bile acids (ursodeoxycholic acid and chenodeoxycholic acid) cholesterol gallstones
-contact dissolution therapy with organic solvents (methyl tert-butyl ether) cannulation of the gallbladder with direct infusion of the agent -only cholesterol gallstones
-extracorporeal shock wave biliary lithotripsy -0.5 to 2 cm diameter gallstone -risk of choledocholitiasis These treatments are rarely used today.
The cystic duct is clipped proximal and distal and divided with the hook scissors
The gallbladder is dissected from the liver by scoring the serosa with electrocautery
If the anatomy cannot be clearly identified, the gallbladder should be dissected from the fundus downward towards the gallbladder neck, making the ductal and vascular anatomy easier to identify.
Management -the treatment of choice: elective laparoscopic cholecystectomy -conversion to an open cholecystectomy is necessary in less than 5%
-additional findings suggestive of acute cholecystitis: thickening of the gallbladder wall (>4 mm) pericholecystic fluid focal tenderness directly over the gallbladder (sonographic Murphy's sign)
CT is less sensitive for these conditions than ultrasonography may show -gallbladder wall thickening -pericholecystic fluid and edema -gallstones -air in the gallbladder or gallbladder wall (emphysematous cholecystitis)
After the acute episode resolves, the patient can undergo cholecystectomy.
-localized perforation generally pericholecystic abscess -free perforation spilling of bile into the peritoneal cavity generalized peritonitis
Acute cholangitis
= a bacterial infection of the biliary ductal system -it varies in severity from mild and self-limited to severe and life threatening The clinical triad: fever jaundice pain = Charcots triad
Acute cholangitis
Pathophysiology -cholangitis results from a combination of two factors: -significant bacterial concentrations in the bile E. coli
Klebsiella pneumonia the enterococci Bacteroides fragilis.
-biliary obstruction
choledocholithiasis benign strictures biliary enteric anastomotic strictures
Acute cholangitis
Clinical Presentation -a wide spectrum of disease self-limited illness and never seek attention severe illness (toxic cholangitis) jaundice fever abdominal pain mental obtundation hypotension Fever is the most common presenting symptom and is often accompanied by shivers. Jaundice is a frequent physical finding but may be absent. Pain is also commonly present but is often mild. = Reynolds' pentad
Acute cholangitis
Diagnosis -clinical diagnosis -laboratory tests can support evidence of biliary obstruction. leukocytosis
hyperbilirubinemia elevations of alkaline phosphatase elevations of transaminases
-CT, ultrasound, and MRI scanning evidence of biliary ductal dilation and occasionally CBD stones
Acute cholangitis
Management -the initial treatment: antibiotics
toxic cholangitis:
-intensive care unit monitoring -vasopressors to support blood pressure -emergency biliary decompression endoscopically or via the percutaneous transhepatic route
Acute cholangitis
Management Endoscopic biliary drainage -endoscopic sphincterotomy and stone extraction
-or simply placement of an endoscopic biliary stent in the hemodynamically unstable patient Laparoscopic cholecystectomy after 6 to 12 weeks.
Acute cholangitis
Management Another option: percutaneous transhepatic biliary decompression
-suspected in patients with typical episodic biliary-type pain without an obvious organic cause
Treatement: -endoscopic sphincterotomy -transduodenal sphincteroplasty with transampullary septotomy
endoscopic sphincterotomy
transduodenal sphincteroplasty
Choledocholithiasis
Classification and Etiology CBD stones can be classified as - primary develop de novo within the bile ducts occur in patients with bile stasis ( brown pigment stones) -benign biliary strictures -sclerosing cholangitis -choledochal cyst disease -sphincter of Oddi dysfunction - secondary develop in the gallbladder and subsequently fall into the composition similar to gallbladder stones
Choledocholithiasis
Clinical Presentation -common duct stones are often asymptomatic -symptomatic choledocholithiasis biliary colic extrahepatic biliary obstruction cholangitis or pancreatitis
Choledocholithiasis
Clinical Presentation -Clinical features of biliary obstruction caused by CBD stones: -biliary colic -jaundice obstructive jaundice
Choledocholithiasis
Clinical Presentation -Clinical features of biliary obstruction caused by CBD stones: -biliary colic -jaundice intermittent and transient with fever -lightening of the stools -darkening of the urine benign obstructive jaundice obstructive jaundice
Choledocholithiasis
Serum liver function tests -bilirubin = elevated -mainly conjugated bilirubin -alkaline phosphatase = elevated -transaminases = elevated cholestatic hepatitis Ultrasonography -CBD dilation, which can suggest CBD obstruction -diameter greater than 10 mm -CBD stones in only 70% of patients the distal end of the bile duct is obscured by duodenal or colonic gas cholestasis
Choledocholithiasis
Magnetic Resonance Imaging Magnetic resonance cholangiopancreatography (MRCP) -high sensitivity (90%) -high specificity (100%) -advantages: no need contrast non-invasive procedure -disadvantages:
expensive lack of availability lack of therapeutic capacity
Choledocholithiasis
Endoscopic Retrograde Cholangiography = the gold standard for the diagnosis of
CBD stones
-provide also a therapeutic option
Choledocholithiasis
Endoscopic Retrograde Cholangiography
Choledocholithiasis
Other investigations methods: endoscopic ultrasound
Management of choledocholithiasis
Endoscopic ERC eendoscopic sphinncterotomy and
Management of choledocholithiasis
Endoscopic ERC eendoscopic sphinncterotomy and
Management of choledocholithiasis
Laparoscopic - 2 techniques: transcystic or through a choledochotomy
Management of choledocholithiasis
Laparoscopic - 2 techniques: transcystic or through a choledochotomy
Management of choledocholithiasis
Open Common Bile Duct Exploration
Management of choledocholithiasis
Open Common Bile Duct Exploration
Management of choledocholithiasis
Open Common Bile Duct Exploration