1. Gall Blader&Biliary Tree
Tikrit University
College of Medicine
Department of Surgery
By Assisst. Prof. Dr.Makki.K.Allaw

2. Learning Objectives To understand:
The management of obstructive jaundice.
Complication of obstructive jaundice.
Sequele of bile duct injury.
Carcinoma of gall bladder knowlegment.

3. CHOLEDOCHOLITHIASIS
Defined as the occurrence of stones in the bile ducts
May remain asymptomatic for years
Are known to pass silently into the duodenum, perhaps frequently
Tend to present as life-threatening complications such as cholangitis and acute pancreatitis
Should be followed by some type of intervention to remove the stones

4. Etiology
May pass from the gallbladder into the CBD or can form de novo in the duct
All gallstones from one patient, whether from the gallbladder or CBD, are of one type, either cholesterol or pigment
Cholesterol stones form only in the gallbladder, and any cholesterol stones found in the CBD must have migrated there from the gallbladder

5. Black pigment stones, which are associated with old age, hemolysis, alcoholism, and cirrhosis, also form in the gallbladder and only rarely migrate into the CBD
The majority of pigment stones in the CBD are the softer brown pigment stones

6. Etiology
Fifteen percent of patients with gallbladder stones also have CBD stones
Conversely, of patients with ductal stones, 95% also have gallbladder stones
Formation of pigment stones in the CBD is also a late complication of endoscopic sphincterotomy

7. In a study of the long-term consequences of endoscopic sphincterotomy in more than 400 patients, the cumulative frequency of recurrent CBD stones was 12%
All the recurrent stones were of the brown pigment type, irrespective of the chemical composition of the original gallstones

8. Clinical Features
Acute obstruction usually causes biliary pain and jaundice
Obstruction that develops gradually over several months may manifest initially as pruritus or jaundice alone
If bacteria proliferate, life-threatening cholangitis may result

9. Physical findings
The physical findings are usually normal if obstruction of the CBD is intermittent
Mild to moderate jaundice may be noted when obstruction has been present for several days to a few weeks
Deep jaundice without pain, particularly with a palpable gallbladder (Courvoisier's sign), suggests neoplastic obstruction of the CBD, even when the patient has stones in the gallbladder
With long-standing obstruction, secondary biliary cirrhosis may result, leading to physical findings of chronic liver disease

10. Laboratory Finding
Results of laboratory studies may be the only clue to the presence of choledocholithiasis
With bile duct obstruction, serum bilirubin and alkaline phosphatase levels both increase.

11. Bilirubin accumulates in serum because of blocked excretion,
whereas alkaline phosphatase levels rise because of increased synthesis of the enzyme by the canalicular epithelium.
The rise in the alkaline phosphatase level is more rapid than and precedes the rise in bilirubin level

12. The absolute height of the serum bilirubin level is proportional to the extent of obstruction, but the height of the alkaline phosphatase level bears no relationship to either the extent of obstruction or its cause
The serum bilirubin level is typically in the range of 2 to 5 mg/dLand rarely exceeds 12 mg/dL.

13. Transient “spikes” in serum aminotransferase or amylase levels suggest passage of a common duct stone into the duodenum.
The overall sensitivity of liver biochemical testing for detecting choledocholithiasis is reported to be 94%;
serum levels of gamma glutamyl transpeptidase are elevated most commonly but may not be assessed in clinical practice

14. Diagnosis
Ultrasonography actually visualizes CBD stones in only about 50% of cases whereas dilatation of the CBD to a diameter greater than 6 mm is seen in about 75% of cases
EUS has excluded or confirmed choledocholithiasis with sensitivity and specificity rates of approximately 98% as compared with ERCP
ERCP is the standard method for the diagnosis and therapy of CBD stones, with sensitivity and specificity rates of approximately 95%

15. EUS and MRCP, should be performed first when the clinical probability of choledocholithiasis is low
Percutaneous transhepatic cholangiography (percutaneous THC)
laparoscopic ultrasonography may be as accurate as surgical cholangiography in detecting CBD stones

16. Differential Diagnosis
Biliary pain is always in the differential diagnosis in patients with an intact gallbladder. The presence of jaundice or abnormal liver biochemical results strongly points to the bile duct rather than the gallbladder
Malignant obstruction of the bile duct or obstruction from a choledochal cyst may be indistinguishable clinically

17. Acute passive congestion of the liver, associated with cardiac decompensation, may cause intense RUQ pain, tenderness, and even jaundice with serum bilirubin levels higher than 10 mg/dL
Acute viral hepatitis rarely may cause severe RUQ pain with tenderness and fever
Acquired immunodeficiency syndrome (AIDS)–associated cholangiopathy and papillary stenosis

18. Treatment Choledocholithiasis warrants treatment in nearly all cases
CBD stones discovered at the time of a laparoscopic cholecystectomy present a dilemma to the surgeon. The operation can be converted to an open cholecystectomy with CBD exploration, but this approach results in greater morbidity and a more prolonged hospital stay

19. Alternatively, the laparoscopic cholecystectomy can be carried out as planned, and the patient can return for ERCP with removal of the CBD stones. Such an approach, if successful, cures the disease but runs the risk of necessitating a third procedure, namely a CBD exploration, if the stones cannot be removed at ERCP
In especially high-risk patients, endoscopic removal of CBD stones may be performed without cholecystectomy. This approach is particularly appropriate for elderly patients with other severe illnesses. Studies indicate that cholecystectomy is required subsequently for recurrent symptoms in only 10% of patients.

20. Jaundice
Definition
Accumulation of yellow pigment in the skin and other tissues (Bilirubin)

21. Definition of Jaundice
Jaundice (icterus): yellowing of the skin and sclera from accumulation of the pigment bilirubin in the blood and tissues. The bilirubin level has to exceed 35-40μ mol/L before jaundice is clinically apparent.

22. Bilirubin Metabolism Bilirubin formation
Transport of bilirubin in plasma
Hepatic bilirubin transport
Hepatic uptake
Conjugation
Biliary excretion
Enterohepatic circulation

23. Pathophysiologic classification of Jaundice
Hemolytic Jaundice
Hepatic Jaundice
Obstructive Jaundice(Cholestasis)
Congenital Jaundice

24. Etiology of Obstructive Jaundice
Intrahepatic-Liver cell Damage/Blockage of Bile Canaliculi
Drugs or chemical toxins
Dubin-Johnson syndrome
Estrogens or Pregnancy
Hepatitis-viral,chemical
Infiltrative tumors
Intrahepatic biliary hypoplasia or atresia
Primary biliary cirrhosis

25. Etiology of Obstructive Jaundice
Extrahepatic-Obstruction of bile Ducts
Compression obstruction from tumors
Congenital choledochal cyst
Extrahepatic biliary atresia
Intraluminal gallstones
Stenosis-postoperative or inflammary

26. Cholestatic jaundice
Is the result of impaired bile flow to the duodenum subsequent to the secretion of conjugated bilirubin into the bile canaliculi. The block may be intrahepatic (drugs, hepatitis, obstruction of the intrahepatic biliary tree) or extrahepatic. The latter is known as large bile duct obstruction and constitutes the most important surgical subgroup of cholestatic jaundice as it is always the result of organic disease, e.g. ductal calculi, pancreaticobiliary cancer.

27. The biochemical features of cholestasis include the following:
• Conjugated hyperbilirubinaemia. • Elevation of alkaline phosphatase, 5'-nucleotidase and γ -GT. The enzyme 5'-nucleotidase is the most reliable since its level is not influenced by bone disease and the enzyme is not induced by alcohol. • Minimal or no elevation of serum transaminases. • Presence of bilirubin in the urine: conjugated bilirubin is water soluble and is therefore filtered in the glomerulus. • Elevation of serum cholesterol and bile acid, although these are not routinely measured in patients with cholestatic jaundice. These biochemical markers of cholestasis do not distinguish between intrahepatic and extrahepatic obstruction.

28. cholestasis clinical features
pain, due to gallbladder disease, malignancy, or stretching of the liver capsule
fever, due to ascending cholangitis
palpable and / or tender gallbladder
enlarged liver, usually smooth

29. Posthepatic (obstructive) jaundice Posthepatic conjugated hyperbilirubinaemia
Anything that blocks the release of conjugated bilirubin from the hepatocyte or prevents its delivery to the duodenum. These are the most common causes of jaundice that present to a surgical service, e.g. gallstones blocking common bile duct, periampullary carcinomas, portal lymphadenopathy, sclerosing cholangitis

30. Courvoisier's law
A palpable gallbladder in the presence of jaundice is
unlikely to be due to gallstones‘
• Usually caused by a neoplastic stricture obstructing the
distal common bile duct.
Causes include periampullary tumours (pancreas,
ampulla, duodenum, distal common bile duct), pancreatic
stricture (chronic pancreatitis) or portal lymphadenopathy

31. Management of large bile duct obstruction
A well-conducted history and physical examination will allow a correct diagnosis of the cause of the jaundice in 80% of patients. Surgical obstructive jaundice (large bile duct obstruction) is always accompanied by dilatation of the biliary tract. In essence, the management entails: • establishing the cause of the jaundice; • assessment of the general condition of the patient; • staging in patients with tumours; • appropriate treatment (which may be surgical, endoscopic or radiological).

32. Management Obstructive jaundice Ultrasound of common bile
duct (CBD) and gallbladder
CBD dilated CBD dilated Other cause
No gallstones Gallstones
ERCP/MRCP ERCP ± sphincterotomy CT scan
CT scan cholecystectomy ERCP
? Periampullary neoplasm Treat cause

33. Preoperative management of obstructive jaundice
Preparation entails the correction
of metabolic abnormalities, improvement of the general
condition, and institution of specific measures designed
to minimize the incidence of complications associated
with prolonged or severe cholestasis such as:
infections (cholangitis, septicaemia, wound infections);
disorders of the clotting mechanism;
renal failure;
liver failure;
fluid and electrolyte abnormalities.

34. Postoperative sepsis after biliary tract surgery is
generally due to bacteria in the bile and the use of shortterm
prophylactic antibiotics significantly lowers the
incidence of sepsis only in patients who have bacteria in
the bile at the time of surgery.
The most common disorder of coagulation encountered
in large bile duct obstruction is a prolonged prothrombin
time resulting from deficiency of vitamin
K-dependent factors consequent on the malabsorption of
this vitamin. The intramuscular injection of phytomenadione
(10-20 mg) will reverse the clotting deficiency
within 1-3 days.

35. Adequate hydration and preoperative induction
of a natriuresis/diuresis reduces the incidence of postoperative
renal failure in jaundiced patients. It is currently
routine practice to administer intravenous fluids (5%
dextrose saline) for h before surgery followed
by an osmotic diuretic (mannitol) or a loop diuretic
(furosemide) administered intravenously at the time of
Induction.
If the jaundice is severe (> 150μ mol/L) or the patient
shows signs of impending liver failure, a period of
decompression is indicated before surgery. This is achieved
by insertion of a plastic endoprosthesis or by endoscopic
sphincterotomy in patients with periampullary cancer.

36. Bile Duct Injuries & Strictures

37. Causes of Biliary Injury in LC
Failure to properly occl. the cystic duct
Injury to the ducts in the liver bed caused by entering a plane too deep to the gallbladder
Cautery Misuse – thermal necrosisductal tissue loss
Pulling forcefully up on the gallbladder when clipping the cystic duct  tenting injury to the junction of the CBD & common hepatic duct

38. Biliary Injuries During Cholecystectomy (CCY)
Reviews revealed the incidence of biliary injury during open CCY to be %
1995 – Strasberg’s study which incl. more than 124,000 laparoscopic cholecystectomies (LC) reported in the literature found the incidence of major bile duct injury to be 0.5%.

39. Strasberg & Soper classificaiton of bile duct injuries
Type A – bile leak from minor duct still in continuity w/ the CBD…cystic duct or liver bed
Type B – occlusion of part of the biliary tree; ex. Result of an injury to an aberrant right hepatic duct.
Type C – leak from duct NOT in communication w/ CBD
Type D – lateral injury to extra-hepatic bile duct
Type E – circumferential injury

40. The Effect of Acute Cholecystitis on Biliary Injury
The incidence of bile leakage after emergency LC for acute cholecystitis is higher than that for elective.
1.37% in acute chole v % in elective

41. Diagnosis of Bile Leaks
Persistent fullness, anorexia, abdominal pain, fever & tenderness,jaundice, elev WBC
High level of suspicion following surgery
Bile draining from a drain left in the operative field

42. Radiographic Diagnosis of Biliary Injury
US/CT – detect bilomas (poss. perc drainage)

43. Radiographic Diagnosis of Biliary Injury
US/CT – detect bilomas (poss. perc drainage)
HIDA – presence of active bile leak (physiologic)

44. Radiographic Diagnosis of Biliary Injury
US/CT – detect bilomas (poss. perc drainage)
HIDA – presence of active bile leak (physiologic)
MRCP – demonstrate dilated/stenotic biliary tract; retained stones…..not physiologic nor therapeutic

45. ERCP
Provides exact anatomical diagnosis of bile duct leak; while allowing treatment w/ decompression of the biliary tree.
Principal of treatment is to establish a pressure gradient that will favor flow into the duodenum not the leak site; may entail removal of retained stone or internal stenting +/- sphincterotomy

46. Internal stenting is currently the procedure of choice for treating bile duct leaks ( types A & D)
Cessation of bile extravasation in 70-95% of cases w/in 7 days

47. Percutaneous Transhepatic Cholangiography
Another method of non-surgical mgmt of bile leak
Usually reserved for when ERCP unsuccessful; since bile ducts of normal caliber increasing the difficulty of the procedure

48. Plastic surgery meets GI surgery
BOTOX injection to sphincter of Oddi

49. Operative Management
Timing of diagnosis
Surgeon skill

50. Intraoperative Injury
Strasberg D injury - (partial injury to a major duct) should be repaired at initial operation w/ T-tube drainage
Strasberg E injury - (complete transection of major duct) may be reconstructed at the initial operation w/ a R-Y hepaticojejunostomy.
*** No primary re-anastomosis secondary to ischemic factors***

51. Detection in post-op period
Abx, nutrition support, percutaneous drainage of bile collex (US or CT)
MRCP, PTC or ERCP to delineate location of injury.
Once sepsis and leaks are controlled, then may perform definitive reconstruction w/ R-Y hepaticojejunostomy

52. Bile Duct Injuries & Strictures
Bile Duct Injuries & Strictures. Benign biliary injuries and strictures are caused by surgical trauma in about 95% of cases. The remainder result from external abdominal trauma or, rarely, from erosion of the duct by a gallstone. Prevention of injury to the duct depends on a combination of technical skill, experience, and a thorough knowledge of the normal anatomy and its variations in the hilum of the liver. The number of bile duct injuries has risen sharply in the past few years along with the shift from open to laparoscopic cholecystectomy.

53. The most common lesion consists of excision of a segment of the common duct as a result of mistaking it for the cystic duct.
Partial transection, occlusion with metal clips, injury to the right hepatic duct, and leakage from the cystic duct are other examples.
A clean incision of the duct without additional damage is best managed by opening the abdomen and suturing the incision with fine absorbable suture material.

54. Clinical Findings
Manifestations of injury to the duct may or may not be evident in the postoperative period. Following laparoscopic surgery, bile ascites, manifested by abdominal distention, bloating, and pain plus mild jaundice, is the usual presentation, since the duct is usually open to the abdomen. The symptoms are relatively mild and may for a time be thought to represent only ileus until a worsening picture requires further investigation.

55. Injuries following open cholecystectomy more often present with intermittent cholangitis or jaundice as a consequence of a biliary stricture. The first clear-cut symptoms may not be evident for weeks or months after surgery.

56. Findings are not distinctive
Findings are not distinctive. Bile ascites produces abdominal distention and ileus and, rarely, true bile peritonitis with toxicity. The right upper quadrant may be tender but usually is not. Jaundice is usually present during an attack of cholangitis

57. Laboratory Findings:
The serum alkaline phosphatase concentration is elevated in cases of stricture. The serum bilirubin fluctuates in relation to symptoms but usually remains well below 10 mg/dL.
Blood cultures are usually positive during acute cholangitis.

58. Imaging Studies
Bile ascites can be suspected on ultrasound or CT scan. Fluid should be aspirated, and if it is bile, the diagnosis is clear. THC and ERCP are necessary to depict the anatomy. After laparoscopic cholecystectomy, the most common pattern is a blocked (by a metal clip) lower duct and an upper duct draining freely into the abdomen. With a stricture, the findings most often consist of focal narrowing of the common hepatic duct within 2 cm of the bifurcation and mild to moderate dilatation of the intrahepatic ducts.

59. Differential Diagnosis
Choledocholithiasis is the condition that most often must be differentiated from biliary stricture because the clinical and laboratory findings can be identical. A history of trauma to the duct would point toward stricture as the more likely diagnosis. The final distinction must often await radiologic or surgical findings. THC or ERCP should be definitive.
Other causes of cholestatic jaundice may have to be ruled out in some cases

60. Complications
Complications develop quickly if the leak is not controlled. Bile peritonitis and abscesses may form. With stricture, persistent cholangitis may progress to multiple intrahepatic abscesses and a septic death.

61. Treatment
Bile duct injuries should be surgically repaired in all but a few patients who are likely to improve with a nonoperative approach.
Excision of the damaged duct and Roux-en-Y hepaticojejunostomy is indicated for most acute and chronic injuries.
The entire biliary tree must be outlined by cholangiograms preoperatively.
The key to success is the thoroughness of the dissection and the ability ultimately to suture healthy duct to healthy bowel. This, in turn, depends on the experience of the surgeon with this particular operation.

62. When a definitive repair is technically impossible, the stricture may be dilated with a transhepatic balloon-tipped catheter. This is particularly applicable to patients with portal hypertension, whose hepatic hilum contains numerous venous collaterals that make operation hazardous

63. Prognosis The death rate from biliary injuries is about 5%, and severe illness is frequent. If the stricture is not repaired, episodic cholangitis and secondary liver disease are inevitable. Surgical correction of the stricture should be successful in about 90% of cases. There is essentially no place for liver transplantation in this disease.

64. Carcinoma of the Gallbladder
Carcinoma of the gallbladder is an uncommon neoplasm that occurs in elderly patients. It is associated with gallstones in 70% of cases, and the risk of malignant degeneration correlates with the length of time gallstones have been present. The tumor is twice as common in women as in men, as one would expect from the association with gallstones.

65. Carcinoma of the Gallbladder
Most primary tumors of the gallbladder are adenocarcinomas that appear histologically to be scirrhous (60%), papillary (25%), or mucoid (15%).
Dissemination of the tumor occurs early by direct invasion of the liver and hilar structures and by metastases to the common duct lymph nodes, liver, and lungs.
Most invasive carcinomas, however, have spread by the time of surgery, and spread is virtually certain if the tumor has progressed to the point where it causes symptoms.

66. Clinical Findings
The most common presenting complaint is of right upper quadrant pain similar to previous episodes of biliary colic but more persistent. Obstruction of the cystic duct by tumor sometimes initiates an attack of acute cholecystitis. Other cases present with obstructive jaundice and, occasionally, cholangitis due to secondary involvement of the common duct.
Examination usually reveals a mass in the region of the gallbladder, which may not be recognized as a neoplasm if the patient has acute cholecystitis. If cholangitis is the principal symptom, a palpable gallbladder would be an unusual finding with choledocholithiasis alone and should suggest gallbladder carcinoma.

67. Imaging Studies
Oral cholecystograms almost never opacify except in patients with small incidental cancers. CT and ultrasound scans may demonstrate the extent of disease, but more often they show only gallstones.
The correct diagnosis is made preoperatively in only 10% of cases.
Complications
Obstruction of the common duct may produce multiple intrahepatic abscesses.
Abscesses in or next to the tumor-laden gallbladder are frequent.
Prevention
The incidence of gallbladder cancer has decreased in recent years as the frequency of cholecystectomy has increased.

68. Treatment
If a localized carcinoma of the gallbladder is recognized at laparotomy, cholecystectomy should be performed along with en bloc wedge resection of an adjacent 3–5 cm of normal liver and dissection of the lymph nodes in the hepatoduodenal ligament. If a small invasive carcinoma overlooked during cholecystectomy for gallstone disease is later discovered by the pathologist, reoperation is indicated to perform a wedge resection of the liver bed plus regional lymphadenectomy.

69. Prognosis Radiotherapy and chemotherapy are not effective palliative measures. About 85% of patients are dead within a year after diagnosis.

70. Thank you