外科学：bliliary tract diseases胆道疾病

1、Biliary tract diseases,Essentials of anatomy -1,Biliary tract Intra-hepatic bile duct Extra-hepatic bile duct Gallbladder Common bile duct,Essentials of anatomy -2,Intra-hepatic Bile Duct Bile canaliculi Segmental bile duct Lobal bile duct Hepatic part of left and right hepatic duct,Essentials of an

2、atomy -3,Extra-hepatic Bile Duct Left and right hepatic duct The common hepatic duct(CHB) Diameter :0.4-0.6 cm 2-4cm length Common bile duct(CBD) Diameter:0.6-0.8cm length:7-9cm Gallbladder: the body,the fundus,The neck,Essentials of anatomy -4,Calot triangle: The triangle bounded by the common hepa

3、tic duct medially,the cystic duct inferiorly and the inferior surface of the liver superiorly is known as Calot triangle. The fact that cystic artery ,right hepatic artery & para-right hepatic duct run within the triangle makes an important area of dissection during cholecystectomy.,胆囊三角,Special Inv

4、estigation of the biliary Tract -1,Ultrasound Non-invasive, painless,easily performed,repeatedly First choice for biliary tract disease nBile duct stones: Stones in gallbladder: High echo which cast an acoustic shadow and which move with changes in posture nJaundice differential diagnosis: Dilatatio

5、n of the ducts CBD: diameter 1.0cm nOther disease: cholecystitis, tumor ect. n During surgery: to detect bile duct stones,Special Investigation of the biliary Tract -2,Radiology n Plain abdominal radiograph: Radio-opaque gallstones Air in the biliary tree n Oral cholecystography: Biliary contrast me

6、dium A fatty meal n Cholangiography Percutaneous transhepatic cholangiography (PTC) show intra and extra hepatic biliary duct clearly complication: bile leakage,cholangitis,hemorrhage,Special Investigation of the biliary Tract -2,n Endoscopic retrograde cholangiopancreatography (ERCP) outline the bi

7、liary tree and pancreatic duct inspect the ampulla of Vater exam of the fluid of duodenum ,bile, pancreatic fluid. n Endoscopic sphincterotomy(EST) n Endoscopic naso-biliary drainage (ENBD) n Computed tomography(CT) Magnetic resonance cholangio-pancreatography (MRCP) n Choledochoscopy :Operation,Pos

8、t opertion,Cholelithiasis-胆石病,nCholelithiasis Including : gallstones biliary duct stones Classification of stones: n Cholesterol stones: hard,layed on cross-section n Pigment stones:crumble when squashed n Mixed stones: radio-opaque,Cholelithiasis,Cholelithiasis,Cholelithiasis,Gallstones -胆囊结石,Risk

9、factor: n Women are three times more likely than men to develop stones n Obesity n Pregnancy n Dietary factors:high energy,low in fibre n Fasting n Biliary infection n Parasitic infestation,Clinical feature of gallstones n 20-40% patient without symptom which is called asymptomatic gallstones n Chro

10、nic cholecystitis n Biliary colic n Acute cholecystitis,Gallstones -胆囊结石,Symptoms nGastrointestinal tract symptoms: upper abdominal discomfort, nausea, after meals, esp. fatty meals. Biliary colic: most commom symptom nA large or fatty meals and changing in position when sleeping can precipitate the

11、 pain,Gallstones -胆囊结石,Symptoms nDue to impaction of stone in the neck of the gallbladder: the pressure increase. nOccurs in the mid or the upper-right portion of the upper abdomen. nSevere pain starts abruptly, continuous,with restlessness, vomitting, sweating. nPain radiate to the right back and s

12、houlder.,Gallstones -胆囊结石,Mirizzi syndrome: nObstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmanns pouch nPress on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula nCholecystitis, cholangitis, and obstructive jaundic

13、e. nCholangiography: narrow of the bile duct at the porta hepatis nAnatomy variation: cyst duct runs parallel to the hepatic duct,Gallstones -胆囊结石,Gallstones -胆囊结石,Sign nRight upper area of the abdomen tenderness, rigidity, rebound tendeness. nGallbladder palpable nMurphy sign: inspiratory arrest du

14、ring subcostal palpation nJaundice:common bile duct stones or Mirizzi syndrome nFever and chill with infection,Gallstones -胆囊结石,Exam nJaundice (choledocholithiasis): blood test of the liver function, elevation of the enzyme alkaline phosphate and bilirubin nWBC count is high nUltrasoud: the main dia

15、gnosis exam.,Gallstones -胆囊结石,Diagnosis nHistory nPhysical exam nUltrasoud exam: high echo with an acoustic shadow and moving with changes in posture,Gallstones -胆囊结石,Ultrasoud,Gallstones -胆囊结石,CT,Gallstones -胆囊结石,Treatment The first choice is operation: nsymptomatic gallstones ngallstones with comp

16、lications,Gallstones -胆囊结石,CBD exploration(胆道探查) Preoperation n CBD stones n Jaundice and bile duct dilatation During operation n Cholangiography indicate CBD stone and bile duct dilatation n Palpable stones, ascarid, tumor n CBD diameter 1.0cm n Gallstone migrate into CBD n Pancreatitis n Draw out

17、purulent or haematoid bile or bile with sandy stones,Gallstones -胆囊结石,Laparoscopic cholecystectomy(LC) n first performed in 1987 n removal of the gallbladder is guided by a laparoscope n a short hospital stay, a quick recuperation, and a very small incision,Gallstones -胆囊结石,LC,Non-Surgical Therapy n

18、 unwilling to undergo surgery n who have serious medical problems that increase the risks of surgery n cannot be used for patients who have acute gallbladder inflammation,Gallstones -胆囊结石,Bile duct stones-胆管结石,Including: primary bile duct stones secondary bile duct stones Site: intrahepatic bile duc

19、t stones extrahepatic bile duct stones,Extrahepatic bile duct stones Pathology: n Biliary tract obstruction: uncompletely, bile duct dilatation n Infection: duct wall edma, congestion purulent bile blood sepsis bile duct wall ulcer fistula between bile duct and hepatic artery & portal vein,Bile duct

20、 stones-胆管结石,Clinical manifestation n May be silent n Obstructive jaundice ascending cholangitis acute pancreatitis Chacrot triad: epigastric pain jaundice fever and chill,Extrahepatic bile duct stones,Bile duct stones-胆管结石,n Abdominal pain: epigastric or right upper quadrant of the abdomen radiate

21、to the right back and shoulder, nausea , vomiting n High fever and chill: obstruction infection pressure in duct increase bacteria flows into blood sepsis temperature: 39-40 n Jaundice: intermittence, fluctuant The severe of the jaundice depends on the duration of the obstruction. Complete impactati

22、on of a stone cause severe progressive jaundice. Intolerable itching,Extrahepatic bile duct stones,Bile duct stones-胆管结石,Physical exam n Tenderness of epigastric and upper area of the abdomen n peritoneal irritation sign n Gallbladder may be palpable Lab test n WBC count is high n elevation of the e

23、nzyme alkaline phosphate and bilirubin n bilirubin in urea is high n urobillinogen in urea is low urobillinogen in feces is low,Extrahepatic bile duct stones,Bile duct stones-胆管结石,Imaging technique n Ultrosound: stones in bile duct, bile duct dilatation n CT/MRI n ERCP Diagnosis n Charcot triad n La

24、b test and imaging exam Differential diagnosis n Renal colic n Intestinal colic n Carcinoma of the Vater ampulla n Carcinoma of the head of pancreas,Extrahepatic bile duct stones,Bile duct stones-胆管结石,MRCP,Extrahepatic bile duct stones,Bile duct stones-胆管结石,Treatment n Operation is the main therapy

25、n Principles: Try to removal all stones Relief bile duct stenosis and obstruction The obstructive duct must be drained adequately n Preoperation management: control infection: antibiotics correct electrolyte and acid-alkali balance vitamin K, nutrition, etc.,Extrahepatic bile duct stones,Bile duct s

26、tones-胆管结石,Intrahepatic bile duct stones Pathology: Obstruction hepatocyte injury Infection hepatic abscess Cholangitis bile cirrhosis of liver,Bile duct stones-胆管结石,Bile duct stones-胆管结石 Intrahepatic bile duct stones,n Pigment stones mainly n Left more than right n Coexist with extra hepatic bile d

27、uct stones commonly Etiology n Infection n Cholestasis n Biliary Ascariasis Pathology n Stenosis :intra hepatic bile duct n Cholangitis n Biliary carcinoma,Intrahepatic bile duct stones,Clinical manifestation n Feature of extra hepatic bile duct stones (when coexist) n Asymptomatic or discomfort of

28、liver area and chest back n Obstruction: infection, fever,chill, acute obstructive suppurative cholangitis(AOSC) n Abscess n Bile liver cirrhosis hypertension of portal vein n Carcinoma of biliary tract: frequency attack of cholangitis, progressive jaundice, abdominal pain, fever hard to control, ag

29、e50 become thin.,Bile duct stones-胆管结石,Intrahepatic bile duct stones,Physical exam n Liver swelling asymmetrical n Tenderness at liver area n Percussion tenderness over hepatic region n Others: infection and complication Diagnosis n History n Imaging exam: ultrasoud PTC,Bile duct stones-胆管结石,Intrahe

30、patic bile duct stones,Treatment n Operation:the main method n Principle: extract all stones relief stenosis and obstruction: key point removal intrahepatic infective focus recovery the bile drainage prevent recrudescence n high positioned Cholangiolithotomy: 经肝胆管切开取石术 n Internal drainage: Roux-en Y

31、 cholangiojejunostomy：胆肠吻合术 n Removal intrahepatic infective focus local cirrhosis: left lateral lobe and right posterior lobe,Bile duct stones-胆管结石,Biliary infection-胆道感染 n Cholecystitis Cholangitis n Acute Subacute Chronic,Acute cholecystitis -急性胆囊炎,n Chemical and (or) bacterial inflammation n div

32、ided in to two categories: acute calculous cholecystitis (ACC) 9095% acute acalculous cholecystitis (AAC) 510%,Etiology nObstruction of cyst duct : 80% by an impacted gallstone others:torsion or stenosis of cyst duct, ascarid nBacterial inflammation nTrauma(previous surgery),chemical stimulus Pathol

33、ogy nAcute simple cholecystitis nAcute purulent cholecystitis nAcute gangrenous cholecystitis nPerforation of gallbladder: peritonitis,Acute cholecystitis -急性胆囊炎,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Nosogenesis n Cyst duct obstruction by gallstones the result is chemical inflamma

34、tion of the cyst wall n Secondary bacterial infection retrogression through cyst duct by blood or lymph n Others,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Clinical manifestation n female, fatty, forty, 3F n History of gallbladder disease n Typical onset: biliary colic n Patients tend

35、to move around to seek relief from the pain n It is prolonged and lasts hours or days Nausea, vomiting, and low-grade fever,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Sign nEpigastric or right upper quadrant tenderness, guarding may be found nMurphy sign (an inspiratory pause on palpat

36、ion of the right upper quadrant) nGallbladder may be palpable. nMass in the right upper quadrant nDiffusive peritonitis n Elderly patients: absence of typical physical signs the incidence of complication is higher n Uncommon in children,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Lab te

37、st n WBC count Leukocytosis with left shift Normal WBC Count does not rule out cholecystitis n Liver Function Tests (LFTs) Serum Bilirubin elevated Serum Alkaline Phosphatase elevated Serum Aminotransferases normal n Pancreatic Studies Amylase elevated,Acute cholecystitis -急性胆囊炎 Acute calculous chol

38、ecystitis,Imaging exam Ultrasound: n Enlargement of the gallbladder n Gallbladder wall thickness 3 mm n Sonographic Murphys Sign n Halo sign (gallbladder wall with a sonolucent double-lined halo) n Gallstones n Hepatobiliary scan,Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Diagnosis n T

39、ypical clinical manifestation n Lab test n Imaging exam n Easy to diagnosis Differential diagnosis n Acute pancreatitis n Acute appendicitis n Perforation of peptic ulcer n Hepatic abscess n Perforation of colon carcinoma n Hepatitis n Pneumonia and pleurisy (right),Acute cholecystitis -急性胆囊炎 Acute

40、calculous cholecystitis,Treatment nNonsurgical treatment: fasting a low fat diet when food is tolerated after the acute attack. Intravenous fluid Nasogastric suction Antibiotics pain control nOperation: the final method nEmergency surgery nOnset in 48-72 hours nInvalidation of nonsurgical treatment

41、(gangrene, perforation, pancreatitis, or inflammation of the common bile duct occurs ),Acute cholecystitis -急性胆囊炎 Acute calculous cholecystitis,Treatment Operation n Cholecystectomy:most cases n Cholecystostomy: high risk cases local severe edema, conglutination,Acute cholecystitis -急性胆囊炎 Acute acal

42、culous cholecystitis,Etiology n Uncertain n After severe trauma, operation,and burns n Severe illness cases n TPN for a long time n Be related to bile stasis Pathology n Same to acute calculous cholecystitis n High rate of necrosis and perforation of gallbladder,Acute cholecystitis -急性胆囊炎 Acute acal

43、culous cholecystitis,Clinical manifestation n More common in men than women (27 : 1) n Same to acute calculous cholecystitis n Easy to make an error diagnosis n Ultrasound is the most useful investigation n Gallbladder is palpable Treatment n Once the diagnosis is made,an immediate operation is nece

44、ssary Method: n Cholecystectomy n Cholecystostomy,胆囊造瘘(Cholecystostomy) 病情危重 不能耐受手术 胆囊炎症严重，解剖不清,Acute cholecystitis -急性胆囊炎 Acute acalculous cholecystitis,胆囊造瘘术(Cholecystostomy),Acute cholecystitis -急性胆囊炎 Acute acalculous cholecystitis,Acute obstructive suppurative cholangitis (AOSC),n Acute cholangi

45、tis of severe type(ACST) n Etiology : obstruction of bile duct biliary infection Obstructive factor: n Bile duct stones 76-88% n Biliary ascariasis 22-26% n Biliary tract stenosis 8.7-11% n Tumor of ampulla n Primary sclerosing cholangitis,Acute obstructive suppurative cholangitis (AOSC),Pathology n

46、 Complete bile duct obstruction intra or extra hepatic bile duct n Purulent infection: bile duct n Bacteria: Escherichia coli, streptococcus faecalis, Klebsiella, pseudomonas Anaerobic bacteria,Acute obstructive suppurative cholangitis (AOSC),Clinical manifestation n History of biliary disease and b

47、iliary operation n Starts abruptly and progressively n Reynolds pentad: abdominal pain jaundice fever and chills mental status changes septic shock,Acute obstructive suppurative cholangitis (AOSC),Sign n Temperature: 39C, or 120b/m n Blood pressure: low n Jaundice n Tenderness : Epigastric or right

48、upper quadrant tenderness n Mental status changes n Peritonitis n Percussion tenderness over hepatic region n Palpable gallbladder n Mild hepatomegaly,Acute obstructive suppurative cholangitis (AOSC),Lab test n WBC count is high, 20X109/L severe patients may be leukopenic PLT count is low, (10-20)X1

49、09/L n Prothrombin time(PT) is long n Liver function: Alkaline phosphatase and Bilirubin is elevated n renal function and electrolytes n Blood cultures: Between 20-30% of blood cultures are positive. Many exhibit polymicrobial infections n Amylase and/or lipase: Involvement of the lower CBD may caus

50、e elevated amylase and pancreatitis. n Biliary cultures,Acute obstructive suppurative cholangitis (AOSC),Imaging Studies Ultrasound: n used most commonly to make the diagnosis of biliary dilation n differentiate intrahepatic from extrahepatic obstruction and image dilated ducts CT scan: n adjunctive

51、 or replace ultrasound n dilated intrahepatic and extrahepatic ducts and inflammation of the biliary tree are imaged,Acute obstructive suppurative cholangitis (AOSC),Diagnosis n Reynolds pentad n Lab test n Imaging exam n T39,or 120R/M n WBC 20X109/L,PLT is low,Acute obstructive suppurative cholangi

52、tis(AOSC),Treatment Principle: n Emergency decompression to relieve bile duct obstruction and drainage n Control infection: broad-spectrum antibiotics,Acute obstructive suppurative cholangitis(AOSC),Nonsurgical management: n complementary to surgical or endoscopic treatments n broad-spectrum antibio

53、tics n fluid infusion n electrolyte imbalances corrected n others,Acute obstructive suppurative cholangitis(AOSC),Nonoperative decompression n Endoscopy: endoscopic sphincterotomy (EST) endoscopic nasobiliary drainage(ENBD) n Percutaneous transhepatic cholangiography and drainage(PTCD) If failure op

54、eration,Acute obstructive suppurative cholangitis(AOSC),Surgical decompression n To save life n Simple and helpful n Choledochotomy decompression and T-tube drainage n Cholecystostomy,Tumor of biliary tract,n Including gallbladder tumor and bile duct tumor n Benign tumors is rarely Nearly two-thirds

55、 of carcinoma arise in the gallbladder, while the remainder (cholangiocarcinoma) originate from the bile ducts and periampullary region.,Tumor of biliary tract (Gallbladder carcinoma),n The most common biliary tract tumor n Women are more commonly afflicted than men n The median age at presentation

56、of gallbladder cancer is 59.6 years Etiology and risk factors n The risk of developing gallbladder cancer is higher in patients with cholelithiasis n Chronic cholecystitis: calcified gallbladder n Gallbladder adenomas,Tumor of biliary tract (Gallbladder carcinoma),Pathology n Most located in body an

57、d fundus of gallbladder n Over 90% of gallbladder neoplasms are adenocarcinomas n The remaining 10% are squamous cell or mixed tumors n Spread locally by lymphatic, vascular, or intraneural, invasion,Tumor of biliary tract (Gallbladder carcinoma),Signs and symptoms n Early disease, asymptomatic. n L

58、ate disease right upper quadrant pain, nausea, vomiting, fatty food intolerance, anorexia, jaundice, and weight loss. Physical findings may include n tenderness n an abdominal mass n hepatomegaly n jaundice n fever n ascites,Tumor of biliary tract (Gallbladder carcinoma),Lab test and imaging exam n

59、Serum exam: CA-199,CA-125 n Ultrasound: gallbladder wall thickening a complex mass filling the gallbladder n CT scan : more helpful in assessing adenopathy and spread of disease into the liver, porta hepatis, or adjacent structures,Tumor of biliary tract (Gallbladder carcinoma),Treatment Operation n Simple cholecystectomy: Nevin I stage n Radical operation: Nevin II,III,IV stage resection should include the gallbladder bed (segments IVb and V) and a porta hepatis lymphadenectom