1. BILIARY TRACT

2. Bile System Diseases Textbook of Medicine
Gallbladder primary disease
Biliary tract obstruction
Drugs
Other gastro
Neural disorders
Metabolic disorders
Gallstones, Cholecystitis
Cystic duct, Common Duct, Pancreas Head, Oddi dysfunction, Stenosis
Narcotics, Anticholinergic Agents
Irritable Bowel Syndrome
Spinal Cord Injury, Truncal Vagotomy, Achalasia
Obesity, Diabetes, Sexual Hormones, Pregnancy, Somatostatin therapy, Sprue, Vipoma, Sickle Hemoglobinopathy

3. Valves of Heister

4. Variation is common

6. Gallbladder and Bile Ducts Function
Fasting State:
High pressure Oddi
Prevents duodenal reflux
Promote gallbladder filling
AminoA
Bile storage (~30ml)
Bile concentration (water & electrolytes absorption) & mucus secretion
Bile release

7. Composition of Hepatic and Gallbladder Bile
Meq/l
Hepatic
Gallbladder Na
160
270 K 5 10 Cl 90 15
HCO3 45 Ca 4 25
Bilirubin
1.4
Protein
150 -
Bile acids 50
Phospholipids 8 40
Cholesterol 18

8. Bacteriology Bile is normally sterile
Bactibilia present in 11% to 30% in chronic biliary disease, 50% in acute cholecystitis, 60% in common bile duct stones and 95% in cholangitis
Highest in elderly (decreased motility and clearance)
Mainly gram-neg aerobe single organism, polymicrobial infection in cholangitis

9. Antibiotic Selection
Antibiotics should be used prophylactically in elective biliary tract surgery or manipulations
Not mandatory in low-risk patients as wound infection is low (1%) following laparoscopic cholecystectomy
Single dose of first generation cephalosporin provides good coverage in high risk patients
Bile infections are treated with second generation cephalosporins, aminoglycoside and fluoroquinolones

10. Imaging US Ultrasonography EUS Endoscopic ultrasonography
HIDA Hepatobiliary iminodiacetic acid scan
ERCP Endoscopic retrograde cholangio pancreatog.
PTC Percutaneous transhepatic cholangiography
IOC Intraoperative cholangiography (open or lap) CT
MRCP
Choledocoscopy (IO, ER, TH)

12. Diseases of the Gallbladder
Congenital Anomalies
Gallstones
Acute and Chronic Cholecystitis
Hyperplastic Cholecystoses

13. Congenital Anomalies Anomalies in number, size and shape
Agenesis
Duplication
Rudimentary or giant gallbladder
Diverticula
Anomalies of position or suspension
Left-sided
Intrahepatic
Floating predisposing to torsion

14. Gallbladder stasis, sludge & stone formation

15. Cholelithiasis- type of gallstones
Type of Stone
Cholesterol
Black Pigment
Brown Pigment
Location
Gallbladder
Bile Ducts
Pathogenesis
80%
Infectious
Cholesterol monohydrate
>50%
<20% ++
Calcium & Bilirubin +
+++ calcium bilirubinate
Obesity, weight loss, estrogens
Chronic hemolysis, alcoholic cirrhosis, pernicious anemia, infections, ileal disease

17. Natural History of Gallstone Disease
Silent
over 20y period, 2/3 remain symptoms free
Biliary pain by cystic duct obstruction
2/3 have further episodes within 1 year
delaying treatment contribute to high prevalence of complications (44% of cholecystectomies performed for complications)
Complications include
cholecystitis
choledocolithiasis with or without cholangitis
gallstone pancreatitis
gallstone ileus
gallbladder carcinoma

18. Migration Distension Biliary “colic” Nausea vomiting, precipitated by eating
Inflammation Obstruction
Severe steady ache or fullness in epigastrium or ruq with frequent radiation to right scapula

19. Acute Cholecystitis
Etiology: cystic duct obstruction with secondary bacterial infection (75%)
Mechanical inflammation
increased intraluminal pressure, distension, ischemia of gallbladder mucosa and wall
Chemical inflammation
release of lysolecithin and other tissue factors
Bacterial inflammation
escherichia coli, klebsiella, streptococcus, clostridium spp

20. Acute Cholecystitis Clinical presentation
women 30-80y old, prior episodes of biliary colic or previous cholecystitis (60% recurrent within 5y)
fever , nausea, vomiting
right upper quadrant pain following a fatty meal
Murphy sign, palpable mass
Diagnosis: ultrasound, HIDA, CBC, LFT, Amylase , ECG , Chest x-ray
Treatment: Cholecystectomy – immediate or delayed
Perioperative antibiotics
Cholecystostomy in high risk patients (diabetes, elderly)
Emphysematous cholecystitis

21. Acute Cholecystitis

22. Acute Cholecystitis Complications occur mainly in not-treated patients
Empyema and hydrops
Gangrenous and Perforated cholecystitis with localized / generalized peritonitis
Bilio-enteric and Cholecysto-choledocal fistula
Gallstone ileus
Calcium deposition: Limey, Porcelain
Carcinoma of gallbladder
Sepsis

23. Acalculous Cholecystitis 5-10%
Absence of gallstones
Usually complicate the outcome of severe
burns , sepsis , trauma or collagen disease
Etiology: thrombosis of cystic art sphincter spasm prolonged fasting dehydration systemic disease, sepsis

24. Hyperplastic Cholecystoses
Adenomyomatosis
Cholesterolosis
Strawberry gallbladder
Cholesterol “polyps”
Cholecystectomy when symptomatic or gallstones
Gallbladder polyp
Cholecystectomy when symptomatic or over 50 y or polyps > 10mm or gallstones or polyp growth on serial US

25. Diseases of the Bile Ducts
Congenital anomalies
Choledocolithiasis
Trauma, strictures, hemobilia (95% iatrogenic)
Extrinsic compression
Hepatobiliary parasitism
Sclerosing cholangitis
Increased risk for cholangiocarcinoma

26. Obstructive Jaundice, diagnosis
Increased production unconjugated
multiple transfusion, transfusion reaction, sepsis, burns, hemolysis, congenital hemoglobinopathies
Impaired uptake or conjugation unconjugated
Gilbert’s disease, neonatal jaundice, sepsis, viral hepatitis, drug inhibition, Crigler-Najjar syndrome
Impaired transport and excretion conjugated
cirrhosis, amyloidosis, cancer, pregnancy, hepatitis, Dubin-Johnson syndrome
Biliary obstruction conjugated
choledocolithiasis, periampullary cancer, chronic pancreatitis, primary sclerosing cholangitis, cholangiocarcinoma

27. Obstructive Jaundice, goals of imaging
Confirmation of intrahepatic and/or extrahepatic bile duct dilation
Identification of site and cause of the obstruction
Selection of treatment modality
preoperative biliary drainage?
anticipate!

28. Obstructive Jaundice: Additive Operative Risk Factors
Alterations in
hepatic and pancreatic function
gastrointestinal barrier
immune function
hemostatic mechanisms
wound healing
Malnutrition (hypoalbuminemia), cholangitis and renal insufficiency are associated with increased morbidity and mortality

29. Congenital anomalies = Risk!
Biliary Atresia and Hypoplasia
10% treatable with Kasai procedure within 1m
Chronic cholangitis, hepatic fibrosis, liver tx
Choledocal Cysts
>50% develop symptoms after 10y of age
Increased risk for cholangiocarcinoma
Congenital Biliary Ectasia
Caroli’s disease
Congenital hepatic fibrosis

30. Treatment is surgical by Complete Resection and biliary-enteric anastomosis

31. Choledocolithiasis
Asymptomatic, found in about 10 % of patients undergoing Cholecystectomy
Associated with gallstones in general
Can cause obstructive jaundice, cholangitis, or pancreatitis

32. Endoscopic view of sphincterotomy and basket extraction

33. Choledocolithiasis Complications
Cholangitis
Acute cholangitis (suppurative / non suppurative)
Chronic cholangitis, hepatic abcesses
Obstructive Jaundice
In association of cholecystitis
Pancreatitis
Secondary Biliary Cirrhosis

34. Acute Cholangitis
Infection of bile ducts by obstruction (choledocal stones, benign stricture, sclerosing cholangitis and tumors of CBD or periampullary neoplasm)
Enteric flora most common (E coli)
Charcot’s triad of right upper quadrant pain, fever and jaundice (70% of patients)
Relapse if cause not treated, life threatening with generalized sepsis, MOF. Chronic cholangitis may lead to secondary biliary liver cirrhosis

35. Cholangiopancreatography in acute cholangitis

36. Indications for Cholecystectomy
Asymptomatic gallstones?
18% cumulative risk at 15 y
for development of symptoms
or complications in male silent
gallstones patients.
-cumulative risk of death on
expectant management = small
-prophylactic cholecystectomy
not warranted
except in young age, diabetics,
large stones, anomalies

38. Choledocolithiasis diagnosed during Cholecystectomy

39. Postcholecystectomy complications
Overlooked non-biliary disorder
Biliary strictures
Retained biliary calculi
Cystic duct stump syndrome (?)
“Papillary dysfunction, papillary stenosis, sphincter of Oddi spasm, biliary dyskinesia”
Bile salt – induced diarrhea (5%, cholestyramine)

40. Operative Complications of Laparoscopic Cholecystectomy

41. Retained common bile duct stone after Cholecystectomy

42. Gallbladder adenocarcinoma: risk factors Israel & Chile: highest incidence worldwide
Chronic Gallstones: 70-90% presence
Estrogens / Female sex / Obesity
75% older than 65y
Choledocal cyst
Salmonella typhi carriers
Porcelain gallbladder (neglected cholecystitis)
Carcinogens
Gallbladder polyps
Smoking, Alcohol consumption
PSC
Repetitive epithelial repair (dysplasia to invasive carcinoma, ~15y)

43. Gallbladder AdenoCarcinoma: Spread & Staging
Early lymphatic spread: hepatoduodenal, retroperitoneal, celiac.
Direct invasion of the liver, extrahepatic biliary ducts.
Intraperitoneal seeding.
TNM*
Tumor Location
Tis
Carcinoma in situ
T1a
GB wall: mucosa
T1b
GB wall: muscle T2
Perimuscular tissue T3
Serosa,organ, liver <2 cm T4
>2 organs, liver >2 cm
N1a
Hepatoduodenal nodes
N1b
Other regional nodes M0
No distant metastases M1
Distant metastases
Stage 0
Tis N0 M0
Stage I T1
Stage II T2
Stage III
T1-2 T3 N1
N0-1
Stage IVA T4
Stage IVB
T1-4 N2
N0-2 M1

44. intraluminal mass enhancing heterogeneously after IV contrast

45. Porcelain gallbladder: 60y old woman
carcinoma in 25% of patients with "porcelain" GB

46. Gallbladder adenocarcinoma: Presentation
Fifth most common GI malignancy
Incidental finding in lap. excised gallbladders
Patients in early stages show signs and symptoms that mimic cholelithiasis and/or cholecystitis.
Patients in later stages present with weight loss, hepatomegaly, and jaundice, which are considered poor prognostic signs.
Duodenal or colonic obstruction or cholecystenteric fistula may signal GB carcinoma

47. Gallbladder adenocarcinoma: Presentation
Typically unresectable at presentation
Prognostic is poor with the exception of early-stage cases. Overall mean survival rate of 6 months, and the 5-year survival rate is 5%
In locally advanced gallbladder cancer, radical surgery with negative tumor margins is an accepted treatment; if negative margins were seen, patients achieved a 5-year survival rate Stage I, 95% Stage II, 75% Stage III, 25% Stage IV, 15% Stage V, 2%

48. Chronic Cholecystitis Cholelithiasis Small Cystic Duct Papillary Tumor
Prevention of gallbladder carcinoma by cholecystectomy?

49. Cholangiocarcinoma: risk factors
· Primary sclerosing cholangitis: 30% of CC in patients with PSC and UC (lifetime risk 10-15%).
· Choledochal cysts: related to duration of disease. 15% per year after first two decades.
· Parasitic infections: Liver flukes (Clonorchis and Opisthorchis)
· Hepatolithiasis :Asian patients with gallstones.
· Toxin exposures: auto, rubber, chemical, wood-finishing occupations
· Genetics: “cancer family" syndromes (eg, Lynch, Li-Fraumeni), Caroli’s syndrome (congenital dilation of intrahepatic ducts), multiple biliary papillomatosis

50. Cholangiocarcinoma: presentation
US cases per year. 3% of GI malignancies.
Symptoms: pruritus 60%, abdominal pain 30-50%, weight loss 30-50%, fever 20%, fatigue, clay stools , dark urine.
Signs: jaundice (often intermittent) 90%, hepatomegaly 25-40%
Lab test: increased bilirubin, increased alkaline phosphatase.
CEA elevated in some but not sensitive or specific.
CA 19-9 elevated in 80% and most helpful in pts with PSC.

51. Cholangiocarcinoma: imaging
Ultrasound: segmental dilatation, nonunion of R and L ducts, polypoid intraluminal masses, nodular smooth masses with mural thickening.
Doppler: assess vascular invasion
CT: contracted gallbladder in Klatskin tumor, Courvoisier in CBD tumor.
Cholangiography (ERCP or PTC) with cytology and biopsy.
MRCP

52. Perihilar cholangiocarcinoma: Klatskin

53. Cholangiocarcinoma: treatment
Surveillance of congenital disease and PSC!
Prognosis: 5 year survival without surgery 5-10%. With surgery 10-30% or higher.
Surgery is best option in resectable tumor
Adjuvant therapy: post-operative radiation may provide benefit in incomplete resections.
Chemotherapy combined with radiation therapy may improve survival time by up to 10 months in pts with unresectable tumors.
Palliative therapy: Stenting of biliary tree

55. Intra-pancreatic cholangiocarcinoma