1. Biliary system Prof. Weilin Wang wam@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….
Prof. Weilin Wang
Department of Hepatobiliary Pancreatic Surgery
The First Affiliated Hospital

2. Anatomy of Biliary System1
Methods of Investigation 2
Disorders of Gallbladder 3
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….
Disorders of Bile Duct 4
Case discussion 5

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

4. 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….

5. Transportation of Bile
The liver secrete bile, 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.
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….

6. Transportation of Bile
About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder.
When food is taken, the gallbladder contracts and release stored bile into the duodeum to help digest the fats.

7. 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.

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

9. Normal gallbladder

10. Gallbladder Anatomical Variants
Agenesis of the gallbladder is extremely rare, with a prevalence of percent.
Double gallbladder occurs in about 0.03 per cent, usually with a shared cyctic duct, and the accessory gallbladder is often diseased.
In this slide, we will talk about the anatomical variants about gallbladder. Double gallbladder occurs in about 0.03 per cent, usually with a shared cystic duct, and the accessory gallbladder is often diseased.

11. B unltrosound picture shows double gallbladder.

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. Methods of investigation
Ultrasonography (B-US)
CT, Computed Tomographic
Magnetic Resonance Cholangiopancreatography
Endoscopic Retrograde Cholangopancreatography
Percutaneous Transhepatic Cholangiography
T-tube cholangiography
Radiographs
Intraoperative cholangiography
Endoscopic ultrasound ……

15. B-US
Fast, real-time, non-invasive, and no ionizing radiation, cheap and could be available even in countryside.
95% sensitivity for detection of cholelithiasis.
--Found a mobile, hyperechoic with acoustic shadowing
>90% sensitivity for detection of acute cholecystitis.
--Gallbladder wall thickening, pericholecystic fluid

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

17. CT scan
Gallstones can be seen on CT, but it is not used primarily for this purpose.
CT can be used in situations where ultrasound is difficult --such as in obese patients. It can also be used if the ultrasound is not definitive.

18. Plain CT shows multiple gallstones.

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

20. MRCP Becoming a more viable imaging technique
New tool for non-invasive evaluation of the pancreatic and biliary ductal systems.
Gradually replacing PTC and ERCP for diagnostic purposes.
MRCP becoming a more viable imaging technique, as MRI technology improves. However, CT and ultrasound are faster, easier, and more readily available, so they are used more frequently than MRCP.
MRCP is emerging as a new tool for non-invasive evaluation of the pancreatic and biliary ductal systems.
MRCP is gradually replacing PTC and ERCP for diagnostic purposes.

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

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

23. 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.

24. 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.

25. Endoscope
Stones in CBD
Pancreatic duct
ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct.
ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct.

26. Large stone was drawing out from CBD during ERCP was performing.

27. Show the procedure of removal the stones using endoscope .
Next case I am going to show you the procedure of removal the stones using endoscope. The mucosal layer of duodenum is cut and coagulated. We can see that the stone is released.
Show the procedure of removal the stones using endoscope .

28. ERCP.wmv

29. 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.

30. Obstructive lesion
Obstructive lesion

31. Before
After
Left : After injection of dye, showing a large gallstone trapped in the duct.
Right: After removal of the stone through the drainage catheter.

32. T-tube cholangiography
Postoperatively
Injection of contrast medium through a T-tube catheter placed in the CBD
Easy way to show whether there are remaining stones or any stricture

33. T-tube graphy
I will show you one case of T-tube radiography. Two months ago, this patient received side-side choledo-jejunostomy. After that operation, he did not feel well because of the liver function was abnormal. So T-tube radiography was suggested and the result showed that the contrast medium could pass through the anastomotic site.

34. Radiographs
Old technique used in the past, widely replaced by the ultrasound and MRCP.
Can be used to visualize calcified stones by abdominal x-ray film.
This was an imaging technique used in the past, but has been widely replaced by the ultrasound.
Can be used to visualize calcified stones, emphysematous cholecystitis (gas within the wall of the gallbladder), biliary fistula (gas within the biliary system), or a porcelain gallbladder.

35. Abdominal x-ray demonstrating stones in the gallbladder

36. Disorders of Gallbladder3

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

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

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

40. --Gallbladder over distension
Other B-US signs are:
--Gallbladder over distension
--Pericholecystic fluid
--GB wall thickening
-- ……
Other B-US signs includes gallbladder over distension, pericholecystic fluid, GB Wall thickening.

41. Acute Cholecystitis: CT
Less accurate than B-US
The CT findings :
--Gallbladder wall thickening
--Subserosal oedema
--Gallbladder distension
--Pericholecystic fluid
--Gallstones
CT is less accurate that B-US for acute cholecystitis. That is mean that B-US is the first choice for acute Cholecystitis.
The CT findings in acute cholecystitis include: Gallbladder wall thickening, Subserosal oedema, Gallbladder distension, pericholecystic fluid, Gallstones and gallbladder wall enhancement.

43. Sludge Fine, nonshadowing dependent echoes.
Sludge on B-US appears as fine, nonshadowing dependent echoes.
It is composed of calcium bilirubinate granules, cholesterol crystals et al.
It is more commonly seen in chronic fasting states.
Gallstones will develop in 5-15 percent.
Fine, nonshadowing dependent echoes.
Composed of calcium bilirubinate granules, cholesterol crystals.
Gallstones will develop in 5-15 percent.

44. Gallbladder, with sludge and stone present

45. 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

46. Gallbladder-Adenomyomatosis
The affected segment often contains bright echoes
Often associated with ‘comet-tail’

47. 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

48. Indication for Cholecystectomy
Symptomatic cholelithiasis
Non-functioning gallbladders (Full of stones)
Malignant considered: GB polyps (>1.2cm) or others

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

50. Laparoscopic Cholecystectomy
A less invasive way to remove the gallbladder
Smaller incisions and less pain
Shorter hospital stay and a shorter recovery time

51. Laparoscopic Cholecystectomy

54. 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

55. Gallbladder Carcinoma

56. Gallbladder Carcinoma
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)

57. TNM classification

58. TNM classification

59. Quiz
Direct invasion of the liver by gallbladder cancer in a 66-year-old woman
Should differentiate gallbladder cancer from acute cholecystitis
T?N?M?

60. Treatment
Radical surgery including segment liver resection, bile duct resection and extensive lymphadenectomy
Poor prognosis in patients with unresectable tumor
External radiation therapy may provide palliative benefit.
5-Fu and Gemcitabine can be used as chemotherapy.

61. Gall-Bladder.mp4
LC.mp4

62. Disorders of Bile Duct 4

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

64. 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

65. Clinical manifestation
Charcot triad
Abrupt onset of pain in upper quadrant
Chill, high fever, may nausea and vomiting
Jaundice
May shock, and/or Acute renal failure and ARDS

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

67. Small shadowing stone (Arrow) in dilated bile duct.
Choledocholithiasis/Hepatolithiasis
Small shadowing stone (Arrow) in dilated bile duct.

68. CT show multiple stones in hepatic bile duct
Choledocholithiasis/Hepatolithiasis
CT show multiple stones in hepatic bile duct

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

70. 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

71. Type I

72. Type II

73. Type III

74. Type IV

75. Type V

76. Choledochal cysts CT
MRCP

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

78. Cholangiocarcinoma
Most commonly at the hepatic duct bifurcation (Klatskin tumor)
Present with jaundice
Clinical Presentation:
--Jaundice (around 90% )
--Pruritus
--fever
--mild abdominal pain
--fatigue
--……
Surgical resection offer a chance for long-term disease-free survival

79. Cholangiocarcinoma B-US: nodules or focal bile duct wall thickening
CT: nodules are usually isodense or slightly hypodense
MRCP: show the proximal extent of the stricturing

80. Small hilar cholangiocarcinoma (Arrowhead) producing obstruction of the right posteral sectoral duct (Short arrow). Right anterior sectoral duct (long arrow) and left hepatic duct. (A) Thick oblique coronal MRCP. (B) Axial portal phase CT (C) Longitudinal US. (D) Transverse color Doppler US (Open arrow, normal left portal vein).

81. Bismuth Classification
Type I: confined to the common hepatic duct
type II: involve the bifurcation
Type IIIa and IIIb: extend into either the right or left secondary intrahepatic ducts, respectively
Type IV: involve the secondary intrahepatic ducts on both sides I I I I I I I II II II II II II
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.
III
III
III
III
III IV IV IV IV IV IV IV IV

82. Quiz
Type?

83. Treatment Distal lesions are usually treated with Whipple
Intrahepatic lesions are treated by hepatic resection
Perihilar (Klatskin) tumor:
--Type I and II: Resection of the extrahepatic bile ducts and gallbladder
--Type III and IV: Curative resection is difficult
Radiation therapy improves survival for patients

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

85. 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, usually to relieve obstruction caused by tumors. Continuity is reestablished between the biliary, pancreatic, and GI systems.
Before
After

86. Case discussion 5

87. Case: 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?

88. 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

89. --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

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

91. Treatment Anti-shock treatment Most important!! Antibiotic drug
Drainage: Emergency ERCP was performed and ENBD was placed
…….

92. 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.

93. 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.

94. Questions?

95. Thank You !