外科学 胆道疾病

Biliarytractdiseases

Essentialsofanatomy-1

BiliarytractIntra-hepaticbileductExtra-hepaticbileductGallbladderCommonbileductEssentialsofanatomy-2Intra-hepaticBileDuctBilecanaliculiSegmentalbileductLobalbileductHepaticpartofleftandrighthepaticduct

Essentialsofanatomy-3Extra-hepaticBileDuct

Leftandrighthepaticduct

Thecommonhepaticduct(CHB)Diameter:0.4-0.6cm2-4cmlength

Commonbileduct(CBD)Diameter:0.6-0.8cmlength:7-9cm

Gallbladder:thebody,thefundus,TheneckEssentialsofanatomy-4Calottriangle:Thetriangleboundedbythecommonhepaticductmedially,thecysticductinferiorlyandtheinferiorsurfaceoftheliversuperiorlyisknownasCalottriangle.Thefactthatcysticartery,righthepaticartery¶-righthepaticductrunwithinthetrianglemakesanimportantareaofdissectionduringcholecystectomy.胆囊三角SpecialInvestigationofthebiliaryTract-1

UltrasoundNon-invasive,painless,easilyperformed,repeatedlyFirstchoiceforbiliarytractdiseasen

Bileductstones:Stonesingallbladder:Highechowhichcastanacousticshadowandwhichmovewithchangesinposturen

Jaundicedifferentialdiagnosis:DilatationoftheductsCBD:diameter>1.0cmn

Otherdisease:cholecystitis,tumorect.n

Duringsurgery:todetectbileductstonesSpecialInvestigationofthebiliaryTract-2Radiologyn

Plainabdominalradiograph:Radio-opaquegallstonesAirinthebiliarytreen

Oralcholecystography:BiliarycontrastmediumAfattymealn

CholangiographyPercutaneoustranshepaticcholangiography(PTC)showintraandextrahepaticbiliaryductclearlycomplication:bileleakage,cholangitis,hemorrhageSpecialInvestigationofthebiliaryTract-2n

Endoscopicretrogradecholangiopancreatography(ERCP)outlinethebiliarytreeandpancreaticductinspecttheampullaofVaterexamofthefluidofduodenum,bile,pancreaticfluid.n

Endoscopicsphincterotomy(EST)n

Endoscopicnaso-biliarydrainage(ENBD)n

Computedtomography(CT)Magneticresonancecholangio-pancreatography(MRCP)n

Choledochoscopy:Operation,PostopertionCholelithiasis-胆石病nCholelithiasisIncluding:gallstonesbiliaryductstonesClassificationofstones:nCholesterolstones:hard,layedoncross-sectionn

Pigmentstones:crumblewhensquashednMixedstones:radio-opaque

CholelithiasisCholelithiasisCholelithiasisGallstones-胆囊结石

Riskfactor:n

Womenarethreetimesmorelikelythanmentodevelopstonesn

Obesityn

Pregnancyn

Dietaryfactors:high

energy,lowinfibren

Fastingn

Biliaryinfectionn

ParasiticinfestationClinicalfeatureofgallstones

n

20-40%patientwithoutsymptomwhichiscalledasymptomaticgallstonesn

Chroniccholecystitisn

Biliarycolicn

AcutecholecystitisGallstones-胆囊结石

SymptomsnGastrointestinaltractsymptoms:upperabdominaldiscomfort,nausea,aftermeals,esp.fattymeals.Biliarycolic:mostcommomsymptomnAlargeorfattymealsandchanginginpositionwhensleepingcanprecipitatethepainGallstones-胆囊结石

SymptomsnDuetoimpactionofstoneintheneckofthegallbladder:thepressureincrease.nOccursinthemidortheupper-rightportionoftheupperabdomen.nSeverepainstartsabruptly,continuous,withrestlessness,vomitting,sweating.nPainradiatetotherightbackandshoulder.

Gallstones-胆囊结石

Mirizzisyndrome:nObstructionofthecommonhepaticductbyastoneimpactedinthecysticductorHartmann’spouchnPressonthebileductor(morecommonly)ulcerateintotheductleadstocholecystocholedochalfistulanCholecystitis,cholangitis,andobstructivejaundice.nCholangiography:narrowofthebileductattheportahepatisnAnatomyvariation:

cystductrunsparalleltothehepaticduct

Gallstones-胆囊结石

Gallstones-胆囊结石

SignnRightupperareaoftheabdomentenderness,rigidity,reboundtendeness.nGallbladderpalpablenMurphysign:inspiratoryarrestduringsubcostalpalpationnJaundice:commonbileductstonesorMirizzisyndromenFeverandchillwithinfectionGallstones-胆囊结石

ExamnJaundice(choledocholithiasis):bloodtestoftheliverfunction,elevationoftheenzymealkalinephosphateandbilirubinnWBCcountishighnUltrasoud:themaindiagnosisexam.Gallstones-胆囊结石

DiagnosisnHistorynPhysicalexamnUltrasoudexam:highechowithanacousticshadowandmovingwithchangesinpostureGallstones-胆囊结石

UltrasoudGallstones-胆囊结石

CTGallstones-胆囊结石

TreatmentThefirstchoiceisoperation:

nsymptomaticgallstones

ngallstoneswithcomplicationsGallstones-胆囊结石

CBDexploration(胆道探查)Preoperationn

CBDstonesn

JaundiceandbileductdilatationDuringoperationn

CholangiographyindicateCBDstoneandbileduct

dilatationn

Palpablestones,ascarid,tumorn

CBDdiameter>1.0cmn

GallstonemigrateintoCBDn

PancreatitisnDrawoutpurulentorhaematoidbileorbilewithsandystonesGallstones-胆囊结石

Laparoscopiccholecystectomy(LC)nfirstperformedin1987n

removalofthegallbladderisguidedbyalaparoscopenashorthospitalstay,aquickrecuperation,andaverysmallincisionGallstones-胆囊结石

LCNon-SurgicalTherapyn

unwillingtoundergosurgeryn

whohaveseriousmedicalproblemsthatincreasetherisksofsurgeryn

cannotbeusedforpatientswhohaveacutegallbladderinflammation

Gallstones-胆囊结石

Bileductstones-胆管结石

Including:primarybileductstonessecondarybileductstonesSite:intrahepaticbileductstonesextrahepaticbileductstones

ExtrahepaticbileductstonesPathology:n

Biliarytractobstruction:uncompletely,bileductdilatationn

Infection:ductwalledma,congestionpurulentbilebloodsepsisbileductwallulcerfistulabetweenbileductandhepaticartery&portalveinBileductstones-胆管结石

Clinicalmanifestationn

Maybesilentn

Obstructivejaundiceascendingcholangitisacutepancreatitis

Chacrottriad:epigastricpain

jaundicefeverandchill

ExtrahepaticbileductstonesBileductstones-胆管结石n

Abdominalpain:

epigastricorrightupperquadrantoftheabdomenradiatetotherightbackandshoulder,nausea,vomiting

n

Highfeverandchill:obstructioninfectionpressureinductincreasebacteriaflowsintobloodsepsis

temperature:39-40℃n

Jaundice:intermittence,fluctuantThesevereofthejaundicedependsonthedurationoftheobstruction.Completeimpactationofastonecausesevereprogressivejaundice.

IntolerableitchingExtrahepaticbileductstonesBileductstones-胆管结石

Physicalexamn

Tendernessofepigastricandupperareaoftheabdomenn

peritonealirritationsignn

Gallbladdermaybepalpable

Labtestn

WBCcountishighn

elevationoftheenzymealkalinephosphateandbilirubinn

bilirubininureaishighn

urobillinogeninureaislowurobillinogeninfecesislow

ExtrahepaticbileductstonesBileductstones-胆管结石

Imagingtechniquen

Ultrosound:stonesinbileduct,bileductdilatationn

CT/MRIn

ERCP

Diagnosisn

Charcottriadn

Labtestandimagingexam

Differentialdiagnosisn

Renalcolicn

Intestinalcolicn

CarcinomaoftheVaterampullanCarcinomaoftheheadofpancreasExtrahepaticbileductstonesBileductstones-胆管结石

MRCPExtrahepaticbileductstonesBileductstones-胆管结石

Treatmentn

Operationisthemaintherapyn

Principles:

Trytoremovalallstones

Reliefbileductstenosisandobstruction

Theobstructiveductmustbedrained

adequately

n

Preoperationmanagement:controlinfection:antibioticscorrectelectrolyteandacid-alkalibalance

vitaminK,nutrition,etc.ExtrahepaticbileductstonesBileductstones-胆管结石

Intrahepaticbileductstones

Pathology:ObstructionhepatocyteinjuryInfectionhepaticabscess

CholangitisbilecirrhosisofliverBileductstones-胆管结石Bileductstones-胆管结石

Intrahepaticbileductstones

n

Pigmentstonesmainlyn

Leftmorethanrightn

Coexistwithextrahepaticbileductstonescommonly

Etiologyn

Infectionn

Cholestasisn

BiliaryAscariasis

Pathologyn

Stenosis:intrahepaticbileductn

CholangitisnBiliarycarcinoma

Intrahepaticbileductstones

Clinicalmanifestationn

Featureofextrahepaticbileductstones(whencoexist)n

Asymptomaticordiscomfortofliverareaandchestbackn

Obstruction:infection,fever,chill,acuteobstructivesuppurativecholangitis(AOSC)n

Abscessn

Bilelivercirrhosishypertensionofportalveinn

Carcinomaofbiliarytract:frequencyattackofcholangitis,progressivejaundice,abdominalpain,feverhardtocontrol,age>50becomethin.Bileductstones-胆管结石

Intrahepaticbileductstones

Physicalexamn

Liverswellingasymmetricaln

Tendernessatliverarean

Percussiontendernessoverhepaticregionn

Others:infectionandcomplication

Diagnosis

n

Historyn

Imagingexam:ultrasoudPTCBileductstones-胆管结石

Intrahepaticbileductstones

Treatmentn

Operation:themainmethodn

Principle:

extractallstones

reliefstenosisandobstruction:keypoint

removalintrahepaticinfectivefocus

recoverythebiledrainage

preventrecrudescencen

highpositionedCholangiolithotomy:

经肝胆管切开取石术n

Internaldrainage:Roux-en–Ycholangiojejunostomy：胆肠吻合术n

Removalintrahepaticinfectivefocuslocalcirrhosis:leftlaterallobeandrightposteriorlobeBileductstones-胆管结石

Biliaryinfection-胆道感染n

Cholecystitis

Cholangitisn

AcuteSubacuteChronicAcutecholecystitis-急性胆囊炎n

Chemicaland(or)bacterialinflammationn

dividedintotwocategories:acutecalculouscholecystitis(ACC)90~95%acuteacalculouscholecystitis(AAC)5~10%EtiologynObstructionofcystduct:80%byanimpactedgallstoneothers:torsionorstenosisofcystduct,ascaridnBacterialinflammationnTrauma(previoussurgery),chemicalstimulus

PathologynAcutesimplecholecystitisnAcutepurulentcholecystitisnAcutegangrenouscholecystitisnPerforationofgallbladder:peritonitisAcutecholecystitis-急性胆囊炎Acutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Nosogenesisn

Cystductobstructionbygallstonestheresultischemicalinflammationofthecystwalln

SecondarybacterialinfectionretrogressionthroughcystductbybloodorlymphnOthers

Acutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Clinicalmanifestationn

female,fatty,forty,3F

n

Historyofgallbladderdiseasen

Typicalonset:biliarycolicn

Patientstendtomovearoundtoseekrelieffromthepainn

ItisprolongedandlastshoursordaysNausea,vomiting,andlow-gradefeverAcutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Signn

Epigastricorrightupperquadranttenderness,guardingmaybefoundn

Murphysign(aninspiratorypauseonpalpationoftherightupperquadrant)n

Gallbladdermaybepalpable.n

Massintherightupperquadrantn

Diffusiveperitonitisn

Elderlypatients:absenceoftypicalphysicalsignstheincidenceofcomplicationishighernUncommoninchildrenAcutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Labtestn

WBCcountLeukocytosiswithleftshiftNormalWBCCountdoesnotruleoutcholecystitisn

LiverFunctionTests(LFTs)SerumBilirubinelevatedSerumAlkalinePhosphataseelevatedSerumAminotransferasesnormaln

PancreaticStudiesAmylaseelevatedAcutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

ImagingexamUltrasound:n

Enlargementofthegallbladdern

Gallbladderwallthickness>3mmn

SonographicMurphy'sSignn

Halosign(gallbladderwallwithasonolucentdouble-linedhalo)n

Gallstonesn

HepatobiliaryscanAcutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Diagnosis

n

Typicalclinicalmanifestationn

Labtestn

Imagingexamn

Easytodiagnosis

Differentialdiagnosis

n

Acutepancreatitisn

Acuteappendicitisn

Perforationofpepticulcern

Hepaticabscessn

Perforationofcoloncarcinoman

HepatitisnPneumoniaandpleurisy(right)

Acutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Treatmentn

Nonsurgicaltreatment:

fastingalowfatdietwhenfoodistoleratedaftertheacuteattack.IntravenousfluidNasogastricsuctionAntibioticspaincontroln

Operation:thefinalmethodn

Emergencysurgeryn

Onsetin48-72hoursn

Invalidationofnonsurgicaltreatment(gangrene,perforation,pancreatitis,orinflammationofthecommonbileductoccurs)Acutecholecystitis-急性胆囊炎Acutecalculouscholecystitis

Treatment

Operationn

Cholecystectomy:mostcasesn

Cholecystostomy:highriskcaseslocalsevereedema,conglutinationAcutecholecystitis-急性胆囊炎Acuteacalculouscholecystitis

Etiologyn

Uncertainn

Afterseveretrauma,operation,andburnsn

Severeillnesscasesn

TPNforalongtimen

Berelatedtobilestasis

Pathologyn

Sametoacutecalculouscholecystitisn

HighrateofnecrosisandperforationofgallbladderAcutecholecystitis-急性胆囊炎Acuteacalculouscholecystitis

Clinicalmanifestationn

Morecommoninmenthanwomen(2~7:1)n

Sametoacutecalculouscholecystitisn

Easytomakeanerrordiagnosisn

Ultrasoundisthemostusefulinvestigationn

GallbladderispalpableTreatmentn

Oncethediagnosisismade,animmediateoperationisnecessaryMethod:n

CholecystectomynCholecystostomy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Acutecholecystitis-急性胆囊炎Acuteacalculouscholecystitis

胆囊造瘘术(Cholecystostomy)Acutecholecystitis-急性胆囊炎Acuteacalculouscholecystitis

Acuteobstructivesuppurativecholangitis(AOSC)n

Acutecholangitisofseveretype(ACST)n

Etiology:obstructionofbileductbiliaryinfection

Obstructivefactor:n

Bileductstones76-88%n

Biliaryascariasis22-26%n

Biliarytractstenosis8.7-11%n

Tumorofampullan

PrimarysclerosingcholangitisAcuteobstructivesuppurativecholangitis(AOSC)Pathology

n

Completebileductobstructionintraorextrahepaticbileductn

Purulentinfection:bileductn

Bacteria:Escherichiacoli,streptococcusfaecalis,Klebsiella,pseudomonasAnaerobicbacteria

Acuteobstructivesuppurative

cholangitis(AOSC)Clinicalmanifestation

n

Historyofbiliarydiseaseandbiliaryoperationn

Startsabruptlyandprogressivelyn

Reynolds'pentad:abdominalpainjaundicefeverandchillsmentalstatuschanges

septicshockAcuteobstructivesuppurativecholangitis(AOSC)Signn

Temperature:>39C,or<36ºCn

Pulse:quickandweaken,>120b/mn

Bloodpressure:lown

Jaundicen

Tenderness:Epigastricorrightupperquadranttendernessn

Mentalstatuschangesn

Peritonitisn

Percussiontendernessoverhepaticregionn

PalpablegallbladdernMildhepatomegaly

Acuteobstructivesuppurativecholangitis(AOSC)Labtest

n

WBCcountishigh,>20X109/LseverepatientsmaybeleukopenicPLTcountislow,(10-20)X109/Ln

Prothrombintime(PT)islongn

Liverfunction:AlkalinephosphataseandBilirubiniselevatedn

renalfunctionandelectrolytesn

Bloodcultures:Between20-30%ofbloodculturesarepositive.Manyexhibitpolymicrobialinfectionsn

Amylaseand/orlipase:InvolvementofthelowerCBDmaycauseelevatedamylaseandpancreatitis.nBiliaryculturesAcuteobstructivesuppurativecholangitis(AOSC)ImagingStudiesUltrasound:n

usedmostcommonlytomakethediagnosisofbiliarydilationn

differentiateintrahepaticfromextrahepaticobstructionandimagedilatedducts

CTscan:n

adjunctiveorreplaceultrasoundn

dilatedintrahepaticandextrahepaticductsandinflammationofthebiliarytreeareimagedAcuteobstructivesuppurativecholangitis(AOSC)Diagnosisn

Reynolds'pentadn

Labtestn

Imagingexam

n

T>39℃,or<36℃n

P>120R/MnWBC>20X109/L,PLTislowAcuteobstructivesuppurativecholangitis(AOSC)TreatmentPrinciple:n

Emergencydecompressiontorelievebileductobstructionanddrainagen

Controlinfection:broad-spectrumantibioticsAcuteobstructivesuppurativecholangitis(AOSC)Nonsurgicalmanagement:n

complementarytosurgicalorendoscopictreatmentsn

broad-spectrumantibioticsn

fluidinfusionn

electrolyteimbalancescorrected

nothersAcuteobstructivesuppurativecholangitis(AOSC)

Nonoperativedecompressionn

Endoscopy:endoscopicsphincterotomy(EST)endoscopicnasobiliarydrainage(ENBD)n

Percutaneoustranshepaticcholangiographyanddrainage(PTCD)IffailureoperationAcuteobstructivesuppurativecholangitis(AOSC)Surgicaldecompressionn

Tosavelifen

Simpleandhelpfuln

CholedochotomydecompressionandT-tubedrainagenCholecystostomyTumorofbiliarytractn

Includinggallbladdertumorandbileducttumorn

BenigntumorsisrarelyNearlytwo-thirdsofcarcinomaariseinthegallbladder,whiletheremainder(cholangiocarcinoma)originatefromthebileductsandperiampullaryregion.

Tumorofbiliarytract(Gallbladdercarcinoma)n

Themostcommonbiliarytracttumorn

Womenaremorecommonlyafflictedthanmenn

Themedianageatpresentationofgallbladdercanceris59.6yearsEtiologyandriskfactorsn

Theriskofdevelopinggallbladdercancerishigherinpatientswithcholelithiasisn

Chroniccholecystitis:calcifiedgallbladdernGallbladderadenomas

Tumorofbiliarytract(Gallbladdercarcinoma)Pathology

n

Mostlocatedinbodyandfundusofgallbladdern

Over90%ofgallbladderneoplasmsareadenocarcinomasn

Theremaining10%aresquamouscellormixedtumorsnSpreadlocallybylymphatic,vascular,orintraneural,invasion

Tumorofbiliarytract(Gallbladdercarcinoma)Signsandsymptomsn

Earlydisease,asymptomatic.n

Latediseaserightupperquadrantpain,nausea,vomiting,fattyfoodintolerance,anorexia,jaundice,andweightloss.Physicalfindingsmayincluden

tendernessn

anabdominalmassn

hepatomegalyn

jaundicen

fevernascites

Tumorofbiliarytract(Gallbladdercarcinoma)Labtestandimagingexamn

Serumexam:CA-199,CA-125n

Ultrasound:gallbladderwallthickeningacomplexmassfillingthegallbladdernCTscan:morehelpfulinassessingadenopathyandspreadofdiseaseintotheliver,portahepatis,oradjacentstructures

Tumorofbiliarytract(Gallbladdercarcinoma)TreatmentOperationn

Simplecholecystectomy:NevinIstagen

Radicaloperation:NevinII,III,IVstageresectionshouldincludethegallbladderbed(segmentsIVbandV)andaportahepatislymphadenectomynPalliativeoperation:laterstagewithjaundice.Torelievesymptoms.Tumorofbiliarytract(Carcinomaofbileduct)Etiologyandriskfactorsn

Ulcerativecolitisisaclearriskfactorforbileducttumorsn

Primarysclerosingcholangitis,congenitalanomaliesofthepancreaticobiliarytreen

ParasiticinfectionsnStones

Tumorofbiliarytract(Carcinomaofbileduct)Pathologyn

50to75%ofcancersarelocatedintheupperthirdoftheextrahepaticbiliarytractn

papillarytypes,nodulartypes,sclerosingtypen

morethan95%ofbileducttumorsareadenocarcinomasnmostbileducttumorsgrowslowly,spreadingfrequentlybylocalextensionandrarelybythehematogenousrouteTumorofbiliarytract(Carcinomaofbileduct)Signsandsymptomsn

Jaundiceisthemostfrequentsymptomnonfluctuatingn

abdominalpainn

weightlossn

pruritusn

fevern

anabdominalmass:gallbladdern

nausea,vomitingncholangitisTumorofbiliarytract(Carcinomaofbileduct)Labtestandimagingexamn

totalbilirubinelevationsimilarly,n

alkalinephosphatasenultrasoundmayfunctionas