1. Biliary system SHENG YAN MD. PhD. shengyan@zju.edu.cn
Good morning everybody. I am Wang weilin from Department of Hapatobiliary Pancreatic Surgery, the first affiliated hospital. I major in HBP surgery, specialized in hepatobiliary and pancreatic diseases and liver transplantation. If you have any question about my field, please contact with me by
Today I am going to present the biliary system. Next….
SHENG YAN MD. PhD.
Department of Hepatobiliary Pancreatic Surgery
The First Affiliated Hospital

2. Anatomy of Biliary System1
Methods of Investigation 2
Disorders of Gallbladder 3
Disorders of Bile Duct 4
Four parts of content will be presented including the anatomy of biliary system, the common methods of investigation. Then we will move to disorders of gallbladder and bile duct. I you have any question, please don not hesitate to interrupt me and I will give you explain as possible. Next….
Case discussion 5

3. Anatomy of Biliary System1
Firstly, we are going to talk about the anatomy of biliary system. Next…

4. Pre-Test
Bile come from?
How bile was transported?

5. Secretion of Bile
75%
About 75% bile was secreted from hepatocyte and 25% was produced by biliary epithelial.
25%
Epithelial of bile duct Biliary epithelial

6. Right Hepatic Bile duct
Anatomy of Biliary System
Intrahepatic Biliary Tract
Left Hepatic Bile duct
Right Hepatic Bile duct
The transportation of bile follows this sequence: The liver cells secrete bile, then bile flow from liver to right and left hepatic ducts. These ducts drain into the common hepatic duct. The common hepatic duct then joins with the cystic duct to form the common bile duct. About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder. When food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help digest the fats. Next….
Common Hepatic duct
Cystic duct
Common Bile duct

7. Extrahepatic Biliary Tract
Anatomy of Biliary System
Extrahepatic Biliary Tract
Bifurcation
Common hepatic duct
Common bile duct
Cystic duct
Gallbladder
The extrahepatic biliary tract consists of the bifurcation of the left and right hepatic ducts, the common hepatic duct, the common bile duct, and the cystic duct and gallbladder Next….

8. Calot triangle
The triangle is bounded by the cystic duct, the common hepatic duct, and the inferior border of the liver.
Important structures including: the cystic artery, the right hepatic artery, and the cystic duct lymph node.
The common hepatic duct, the liver, and the cystic duct define the boundaries of Calot's triangle. Located within this triangle are important structures: the cystic artery, the right hepatic artery, and the cystic duct lymph node.

9. The importance of Biliary system
Achilles’heel
In Greek mythology, when Achilles was a baby, it was foretold that he would die young
To prevent his death, his mother Thetis took Achilles to the River Styx, which was supposed to offer powers of invulnerability, and dipped his body into the water.
But as Thetis held Achilles by the heel, his heel was not washed over by the water of the magical river.

10. The importance of Biliary system
right hepatic artery
retroduodenal artery
9:00 artery
left hepatic artery
proper hepatic artery
3:00 artery
common hepatic artery
gastroduodenal artery
The use of “Achilles heel” as an expression means “area of weakness, vulnerable spot”

11. Papilla of Vater
The opening of the bile duct and panceatic duct in the descending part of the duodenum.
Through the papilla, bile and pancreatic juice pass to bowel.
obstructive jaundice or pancreatitis will happen when papilla of Vater was blocked by stones and tumors,

12. Variations of biliary branching
A Typical anatomy of the confluence.
B Trifurcation of left, right anterior, and right posterior hepatic ducts.
C Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct.
c A, Typical anatomy of the confluence. B, Trifurcation of left, right anterior, and right posterior hepatic ducts. C, Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct. D-F, Less common variations in hepatic ductal anatomy.

13. Methods of Investigation2

14. Gallbladder, with sludge and stone present
Normal Gallbladder
Gallbladder, with sludge and stone present

15. Plain CT shows multiple gallstones.

16. Multiple stones were found in the left intrahepatic bile duct.

17. MRCP showed slight dilation of CBD
Pancreatic duct
Common bile duct
MRCP showed slight dilation of CBD

18. Stones was detected in the bile duct by MRCP.
Stones in CBD
Stones was detected in the bile duct by MRCP.

19. ERCP
Left: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct.
Right: Radiographic result after the contrast medium was injected into the CBD.
ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct.
Left picture showed anatomy of upper GI: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct.
Right picture shows the radiographic result after the contrast medium was injected into the CBD.
ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct.

20. Otherwise the instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments.
ERCP: Instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments.

21. PTC
The catheter was placed into the intrahepatic bile duct through patient’s skin guiding by B-US and fixed on the skin.
The radiographic image was taken.
Obstructive lesion can be seen in this picture.
The catheter was placed into intrahepatic bile duct through patient’s skin guiding by B-ultrasound. PTC is indicated when ERCP is not suitable or has failed. It can be used to drain biliary obstructions.

22. Obstructive lesion
Obstructive lesion

23. Disorders of Gallbladder3

24. Disorders of Gallbladder
Acute cholecystitis
Gallbladder stones and sludge
Adenomyomatous hyperplasia
Gallbladder polyps
Gallbladder carcinoma ……

25. Acute Cholecystitis Calculous cholecystitis: over 90%
Clinical manifestation:
--Pain in right upper quadrant
--Radiate to right shoulder & back
--Nausea & vomiting
--Chill and/or fever
--Abdominal tenderness
--Murphy's sign (+)

26. Murphy's sign Ask the patient to breathe out
Then gently place the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder).
The patient is then instructed to inspire (breathe in).
During inspiration, the abdominal contents are pushed downward as the diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive.

27. Acute Cholecystitis: B-US
The gallbladder contains small stones in the neck and its wall shows edematous thickening (>5 mm thickness).

29. Gallbladder polyps The majority of polyps are cholesterol
Cholesterol polyps are usually 2-10mm in size
They appear as small echogenic nonshadowing foci adherent to the gallbladder wall
Lack of mobility indicates polyp
The majority of polyps are cholesterol and less often adenomatous
Cholesterol polyps are usually 2–10mm in size whereas adenomas can be up to 2 cm
They appear as small echogenic nonshadowing foci adherent to the gallbladder wall
Lack of mobility favours a polyp

30. Mirrizzi syndrome
Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct.
May result in biliary obstruction and jaundice
If not recognized preoperatively, it can result in significant morbidity and mortality

31. Open Cholecystectomy The first case was performed in 1882
One safe and effective method
Direct visualization and palpation

32. Laparoscopic Cholecystectomy

33. 7 days after operation

34. 3 Months after operation

36. Gallbladder Carcinoma
Gallbladder carcinoma is associated with stones in over 90% of patients
There is a female to male ratio of 3:1
Few patient was diagnosed prior to surgery

37. Gallbladder Carcinoma
Cancer

38. Gallbladder Carcinoma
Nodal
Metastasis
Left picture showed B-US result for gallbladder carcinoma. Polypoidal growth with breach of continuity of the underlying wall (arrow).
Right CT result show us the advanced carcinoma extending outside the fundus, with a nodal metastasis posterior to the pancreatic head (arrow)

39. TNM classification

40. TNM classification

41. Disorders of Bile Duct 4

42. Disorders of Bile Duct AOSC Choledocholithiasis/Hepatolithiasis
Choledochal cyst
Cholangiocarcinoma
Pancreatic and ampullary tumor

43. AOSC Acute obstructive suppurative Cholangitis (AOSC)
Emergency disease carries high mortality
Common obstructing factors: stones, tumor
Complete obstruction and suppurative infection
May result in septicemia & septic shock; MSOF
(multiple systemic organ failure)

44. Clinical manifestation
Charcot triad
Abrupt onset of pain in upper quadrant
Chill, high fever, may nausea and vomiting
Jaundice
May shock and altered mental status (Reynolds pentad)

45. Treatment Correct the fluid and acid-base balance
Systemic administration of antibiotics
Anti-shock treatment
Drain the biliary tract: ERCP or PTCD
Emergency operation

46. ERCP: demonstrating stone in the duct (arrow)
Choledocholithiasis/Hepatolithiasis
Stones
ERCP: demonstrating stone in the duct (arrow)

47. Choledochal cysts Cystic dilatation of the extrahepatic bile ducts
Female to male is about ration 4:1
The majority are now diagnosed in childhood
Classified into five types
Associated with various biliary tumors

48. Type I

49. Type II

50. Type III

51. Type IV

52. Type V

53. Choledochal cysts
CT Slides
MRCP Slides

54. Pancreatic and ampullary tumours ……
Bile Duct Cancer
Cholangiocarcinoma
Pancreatic and ampullary tumours ……
Cholangiocarcinoma
Pancreatic and ampullary tumours
Biliary cyctadenoma

55. Bismuth Classification
Type I tumors (upper, left) are confined to the common hepatic duct, and type II tumors (upper, right) involve the bifurcation without involvement of secondary intrahepatic ducts. Type IIIa and IIIb tumors (lower, left) extend into either the right or left secondary intrahepatic ducts, respectively. Type IV tumors (lower, right) involve the secondary intrahepatic ducts on both sides.
Type I tumors are distal to the hepatic duct confluence (HDC) while type II neoplasms extend to and involve the HDC.
Type III tumors involve the HDC and either the proximal right hepatic duct (type IIIA) or proximal left hepatic duct (type IIIB).
Type IV tumors extend into the bilateral proximal hepatic ducts up to the segmental bile ducts.

56. Quiz
Type?

57. Typical operation I: Roux-en-Y
Resection of the extrahepatic bile ducts and gallbladder with 5-10 mm bile duct margins, and regional lymphadenectomy with Roux-en-Y hepaticojejunostomy.

58. Typical operation II: Whipple
The head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct are excised.
Continuity is reestablished between the biliary, pancreatic, and GI systems.
Before
After

59. Case discussion 5

60. Case I: Clinical manifestation
42-year-old woman patient was admitted to our emergency department because of repeated upper abdominal pain for 2 years and aggravated for three days.
With nausea, vomiting, chill and fever. The highest temperature reached to 39.5℃. She also found dark urine and skin turned yellow.
PE: BP 85/52 mmHg. Yellow stained was found in the skin and sclera.
Which examination should be performed for diagnosis?

61. Laboratory test: --Blood routine test Imaging test: Examination needed
--Liver function and serum electrolyte
--Serum Amylase
Imaging test:
--B-US (First choice. Why?)
--MRCP
--CT

62. --BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l Imaging test:
Examination finding
Laboratory test:
--BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l
--Liver function: ALT 154 U/l TB/DB 194/153 mmol/l
--Serum Amylase : Normal
Imaging test:
MRCP

63. Gallstone pancreatitis?
Diagnosis
Acute Cholecystitis? No
Gallstone pancreatitis? No
Cholangitis?
Yes
AOSC, Septic shock

64. Treatment Anti-shock treatment Most important!! Antibiotic drug
Drainage: Emergency ERCP was performed and ENBD was placed
…….
Most important!!
ENBD： Endoscopic Nasobiliary Drainage
EST： Endoscopic sphincterotomy

65. ERCP

66. CT scan show multiple stone in CBD and hepatic duct
CT scan show multiple stone in CBD and hepatic duct. The catheter can be seen.

67. Treatment
When the general condition is stable and the TB level declined to 50mmol/l, choledocholithotomy was carried out and stones were removed.
The patient recovery very well without any episode.

68. Case II: Clinical manifestation
82-year-old woman patient was admitted to our hospital because of “Found mass in gallbladder for 1 month by physical examination”.
Without abdominal pain, nausea, vomiting, chill and fever. No dark urine and bloody stool.
Vital signs are normal.

69. Examination finding
Imaging test:
CT scan
Plain
A phase
V phase

70. Gallbladder Cardinoma?
Diagnosis
Gallbladder Cardinoma?
Yes
Gallstone?
Yes
T?N?M?
T3N0M0

71. Treatment
Operation ….

72. Questions?

73. THANK YOU