Biliary Diseases

Dr. Wu Yang
Dept. of Surgery
The First Affiliated Hospital of
Zhengzhou University
Anatomy
Extrahepatic biliary tree
 The extrahepatic bile duct system consists of
the hepatic ducts, common hepatic duct,
gallbladder, cystic duct and common bile duct.
 The left and right hepatic ducts join together
after leaving the liver. The confluence forms
the common hepatic duct.
 The common hepatic duct is joined at an acute
angle by the cystic duct to form the common
bile duct.
Anatomy
Extrahepatic biliary tree
 The common bile duct is lateral to the
common hepatic artery and anterior to the
portal vein. The distal one-third of the
common bile duct passes behind the pancreas
to the ampulla of Vater, also called the papilla.
 The sphincter of Oddi surrounds the common
bile duct as it traverses the ampulla of Vater
and controls bile flow.
Anatomy
Gallbladder
 The gallbladder is a pear-shaped organ
adherent to the undersurface of the liver in a
groove separating the right and left lobes.
 The wall of the gallbladder is composed of
smooth muscle and fibrous tissue.
Anatomy
Gallbladder
 Arterial supply : The gallbladder is supplied
by the cystic artery, which is usually (95% of
the time) a branch of the right hepatic artery
that passes behind the cystic duct.
 Venous return is via cystic veins to the portal
vein and small veins that drain directly into
the liver.
Physiology
 Bile is produced by the liver and transported
via the extrahepatic ducts to the gallbladder
where it is concentrated and released in
response to humoral and neural control.
 Hepatic production of bile is under neural and
humoral control. Approximately 600ml of bile
are produced daily.
Physiology

 Functions of the gallbladder include:

(1)Storage of bile.
(2)Concentration of bile.
(3)Release of bile.
Diagnosis examination of the biliary disease
 B-ultrasound is both sensitive and specific in
detecting biliary diseases, such as gallstones,
tumor, cystic lesion and obstructive jaundice,
and its major advantages are that it is rapid,
inexpensive, noninvasive and free risk. In the
investigation of gallstones, the correct
diagnosis rate is more than 95% in the
gallbladder, 70% in the extrahepatic ducts and
60% in intrahepatic ducts. In the investigation
of obstruction, the correct diagnosis rate is
more than 90%.
Diagnosis examination of the biliary disease

 Plain abdominal films demonstrate the 15% of

gallstones that are radiopaque.
 Oral cholecystography (OCG) is an alternative
method for demonstrating biliary calculi in
patients with an equivocal gallbladder
sonogram. It is rarely used today.
 Intravenous cholangiography (IVC) is no
longer performed.
Diagnosis examination of the biliary disease

 Percutaneous transhepatic cholangiography(PTC)

is useful in evaluating a jaundiced patient. It can
localize the site of the obstruction and also
allows the placement of biliary drainage
catheters.
 Endoscopic retrograde cholangiopancreatography
(ERCP) is useful in evaluating a patient with
biliary disease. The procedure is both diagnostic
and therapeutic.
Diagnosis examination of the biliary disease

 Hepatobiliary iminodiacetic acid (HIDA) scan

make use of a gamma-ray-emitting radioisotope
(i.e. 99m Tc) attached to a variety of lidocaine
analogs bound to iminodiacetic acid, which is
excreted in the bile. This test is easy to perform
and is a good method of confirming of biliary
and hepatic lesions which is especially
applicable to patients with jaundice.
Diagnosis examination of the biliary disease

 CT and MRI can be applied for the same

situations as B-US but provides little advantage
and is more expensive.
 Operative and postoperative direct
cholangiography. This procedure is frequently
performed in the operating room at the time of
exploration of biliary tract.
Gallstone & Chronic Cholecystitis
Types of stones
 Cholesterol stones is frequently single and
light in weight. About 75% of all gallstones in
China are the cholesterol type and 80% of
which are in the gallbladder.
 Pigment stones are black to dark brown.
About 37% of all gallstones in China are the
pigment type and 75% of which are in bile
duct.
 Mixed stones are usually brown and multiple.
About 6% of all gallstones in China are the
mixed type, 60% of which are in the
Symptoms and signs
 Biliary colic, the most characteristic symptom,
is caused by transient gallstone obstruction of
the cystic duct. Nausea and vomiting may
accompany the pain.
 During an attack, there may be tenderness in
the right upper quadrant, and rarely, the
gallbladder is palpable.
Laboratory findings
 An oral cholecystogram will usually show
stones in the gallbladder. Ultrasound scans are
as sensitive and specific as oral
cholecystogram, and they may be used as an
alternative method of diagnosing gallbladder
stones.
Differential diagnosis
 Duodenal ulcer
 Pancreatitis
 Myocardial infarction
 Gastric tumors
Treatment
 Surgical treatment, cholecystectomy, should
be performed in most patients with symptoms.
 Recently, as the technique of laparoscopic
cholecystectomy has been widely spreaded,
laparoscopic cholecystectomy is the best
choice for most patients.
Treatment
The decision whether to explore the duct at the
time of cholecystectomy can be made according
to the following:
 The absolute indications are preoperative
demonstration of stone by X-ray and
ultrasound, preoperative history of cholangitis
with jaundice, and a positive operative
cholangiogram.
Treatment
The decision whether to explore the duct at the
time of cholecystectomy can be made according
to the following:

 The relative indications are mild jaundice

without fever and chills, small stone, and a
dilated duct.
Treatment
 Other new methods are used to treat gallstone
and chronic cholecystitis, such as, chemical
cholecystectomy, extracorporeal shock wave
lithotripsy (ESWL) and dissolving gallstone or
taking off gallstone by percutaneous
transhepatic paracentosis, the effection of
which is not certainty.
Acute Cholecystitis
Acute cholecystitis
 In 80% of cases, acute cholecystitis results
from obstruction of the cystic duct by a
gallstone.
 About 20% of cases of acute cholecystitis
occur in the absence of cholelithiasis. Some of
these are due to cystic duct obstruction by
another process such as a malignant tumor.
Symptoms and signs
 The first symptom is abdominal pain in the
upper quadrant, sometimes associated with
referred pain in the region of the right scapula
in 75% of cases.
 Nausea and vomiting are present in about half
patients, but the vomiting is rarely severe.
Mild icterus occurs in 10% of cases. The
temperature usually ranges from 38 to 38.5℃.
Symptoms and signs
 Right upper quadrant tenderness is present,
and about a third of patients the gallbladder is
palpable.
 If instructed to breath deeply during palpation
in the right subcostal region, the patient
experiences accentuated tenderness and
sudden inspiratory arrest (Murphy’s sign).
Laboratory findings
 The leukocyte count is usually elevated to 12-
15 thousand/uL.
 A mild elevation of the serum bilirubin (in the
range of 2-4mg/dL) is common.
Imaging studies
 A plain X-ray of the abdomen may
occasionally show an enlarged gallbladder
shadow.
 Ultrasound scans show gallstones, sludge, and
thickening of the gallbladder wall.
Differential diagnosis
 Acute peptic ulcer with or without perforation
 Acute pancreatitis
 Acute appendicitis
 Acute viral hepatitis
 Severe pneumonitis in the right lung or acute
myocardial infarction
Complication
 The major complications of acute cholecytitis
are empyema, gangrene, and perforation.
Treatment
 Intravenous fluids should be given to correct
dehydration and electrolyte imbalance.
 A nasogastric tube should be inserted.
 Antibiotic should be given.
These methods are suitable for preoperative
patients and expectant management.
Treatment
 Cholecystectomy is the preferable operation in
acute cholecystitis and can be safety
performed in about 90% of patients.
 There are two approaches to the timing of
surgery:(1) Immediate surgery, that is, with in
72 hours of the onset of symptoms. (2)
Delayed surgery, that is, after recovery from
the acute attack with intravenous fluids and
antibiotics. Surgery should be performed
approximately 6 weeks after the acute
inflammation has resolved.
Treatment

 Operative cholangiography should be

performed in most cases and the common bile
duct explored if appropriate indications are
present.
Cholangitis
Etiology
 Bacterial infection of the biliary ducts.
 The principal causes are choledocholithiasis
ascariasis, biliary stricture, and neoplasm.
 Less common cause are chronic pancreatitis,
ampullary stenosis, duodenal diverticulum,
congenital cyst, and parasitic invasion.
Clinical findings
 The symptoms of cholangitis (sometimes
referred to as Charcot’s triad) are biliary colic,
jaundice, and chills and fever. Although a
complete triad is present in only 70% of cases.
 Laboratory findings include leukocytosis and
elevated serum bilirubin and alkaline
phosphatase levels.
Clinical findings
 Early in an attack, an ultrasound scan will
often give useful diagnostic information.
Further work-up (PTC, ERCP etc.) can
proceed later after the acute manifestations are
brought under control.
 Direct cholangiography is dangerous during
active cholangitis.
Clinical findings
 The term acute obstructive supperative
cholangitis (AOSC) has been used for most
severe form of this disease, which usually
occurs in complete obstruction of biliary
ducts.
 Now in China, AOSC has been replaced with
acute cholangitis of severe type (ACST).
 The diagnosis pentad of ACST consists of
abdominal pain, jaundice, high fever and
chills, mental confusion or lethargy, and
Treatment

 Most cases of cholangitis can be controlled

with intravenous antibiotic which include the
drugs of anti-anaerobes.
Treatment

 For patients with severe cholangitis, the bile

duct must be promptly decompressed. In most
instances. Laparotomy and common duct
exploration are required.
Treatment
 Cholangitis accompanying neoplastic
obstruction may be managed by insertion of a
transhepatic drainage catheter into the bile
duct, percutaneous transhepatic
cholangiodrainage (PTCD).
Treatment
 If the patients condition is precarious during
laparotomy, the septic process can be halted
by inserting a decompressing T tube and
concluding the procedure. A second operation
will then be necessary when the patient has
recovered.
Choledocholithiasis
Clinical findings
Symptoms

 Choledocholithiasis may be asymptomatic or

may produce sudden toxic cholangitis, leading
to a rapid demise.
 Biliary colic, jaundice or pancreatitis may be
isolated findings or may occur any
combination along with signs of infection
(cholangitis).
Clinical findings
Symptoms

 Choledocholithiasis should be strongly

suspected if intermittent chills, fever, or
jaundice accompany biliary colic.
 Light stools may be reported.
 Pruritus is usually the result of persistent
longstanding obstruction.
Clinical findings
Signs
 The patient may be icteric and toxic, with high
fever and chills.
 A palpable gallbladder is usually in patient
with obstructive jaundice.
 Tenderness may be present in the right upper
quadrant.
 Tender hepatic enlargment may occur,
especially if obstruction has been present for
more than several days.
Clinical findings
Laboratory finding

 In cholangitis, leukocytosis of 15000/ul is

usually present.
 A rise in serum bilirubin often appears within
24 hours of the onset of symptoms.
 The serum alkaline phosphatase levels usually
rise and may be the only chemical
abnormalities in patients without jaundice.
 X-ray findings
 Radiopaque gallstones may be seen on plain
abdominal films.
 Ultrasound scans usually show gallbladder
stones and, depending on the degree of
obstruction, dilatation of the bile duct.
 In puzzling cases, ERCP or PTC may be
indicated.
 Complications
 Multiple intrahepatic abscess.
 Hepatic failure or secondary biliary cirrhosis
may develop in unrelieved obstruction of long
duration.
 Acute pancreatitis.
 Gallstone ileus.
 Treatment
 Patients with acute cholangitis should be
treated with systemic antibiotics, this usually
controls the attack within 24-48 hours.
 If the patient’s condition worsens within 2-4
days, laparotomy and exploration of the
common bile duct should be performed.
 Treatment
 Patients with common duct stones who have
had a previous cholecystectomy are best
treated by endoscopic sphincterotomy.
 Endoscopic sphincterotomy is unlikely to be
successful in patients with large (>2cm)
stones. Laparotomy and common duct
exploration are required.
 Treatment
 If the patient still has a gallbladder,
cholecystectomy and common duct
exploration are indicated.
 Treatment
 After exploration of the duct is completed and
all stones have been removed, the inside of the
duct is inspected through the choledochoscope
and a T tube is inserted.
 Treatment
 About two week after the operation, a
postoperative cholangiogram should be
performed through the T tube. If the duct is
clear, the tube should be clamped overnight to
make certain that the ductal system is
functional. If no symptoms appear, the tube
can be pulled out.
 Treatment
 There is a variety of methods to treat retained
stones found on postoperative T tube
cholangiograms.
 For persistent stones, the easiest treatment is
through the T tube and extract the stone with
fiberoptic choledochoscope.
Intrahepatic duct stones
Clinical findings
 Besides the symptoms resulting in
extrahepatic duct stones, there are some
specialties in symptoms of intrahepatic duct
stone, such as persistent distending pain in
liver area, chest and back, chills and fever,
jaundice occuring both right and left
intrahepatic duct obstruction.
 Tender hepatic enlargement may often occur,
and with marked tenderness, there are
percussion pain in affected liver area.
 Clinical findings
 Ultrasound scans and CT scans usually show
intrahepatic duct stones and, depending on the
degree of obstruction, dilatation of the bile
duct.
 PTC and ERCP are most important examinal
methods for diagnosis of intrahepatic duct
stones .
 Treatment
 The treatment of intrahepatic duct stones is
very complex, including operation, lithotrity
dissolving stones, taking off stone by
choledochoscope, traditional medicine therapy
and so on.
 The operations include cutting high biliary
duct and taking off stones, intra-drainage.
Carcinoma of the gallbladder
Clinical findings
Symptoms and signs

 Right upper quadrant pain similar to biliary

colic.
 Obstruction of the cystic duct by tumor
sometimes initiates an attack of acute
cholecystitis.
 Some cases present with obstructive jaundice .
Clinical findings
Symptoms and signs

 A palpable gallbladder would be an unusual

finding with choledocholithiasis alone and
should suggest gallbladder carcinoma .
Laboratory findings
 Oral cholecystograms.
 CT and ultrasound scans.

♥ The correct diagnosis has been made

preoperatively in only 10% of cases.
Treatment
 If localized carcinoma of the gallbladder is
recognized at laparotomy, cholecystectomy
should be performed along with wedge
resection of an adjacent 3-5 cm of normal liver
and dissection of the lymph nodes in the
hepatoduodenal ligament.
 In the few cases where cancer has not
penetrated the muscularis mucosa,
cholecystectomy alone should suffice.
Prognosis

 Radiotherapy and chemotherapy are not

effective palliative measures.
 About 90% of patients are dead within a year
after diagnosis.
Malignant tumors of the bile duct
Clinical findings
Symptoms and signs

 The illness presents with gradual onset of

jaundice or pruritus.
 Bilirubinuria is present from the start, and
light-colored stools are usual.
 Anorexia and weight loss develop with time.
Clinical findings
Symptoms and signs

 Icterus is the most obvious physical finding.

 Hepatomegaly is common.
 If the tumor is confined to the common duct,
the gallbladder may distend and become
palpable in the right upper quadrant.
Laboratory findings
 The serum bilirubin is usually over 15 mg/dL.
 Serum alkaline phosphatase is increased.
 Fever and leukocytosis are not common.
X-ray findings
 Ultrasound or CT scans usually detect dilated
intrahepatic bile ducts.
 PTC or ERCP early depicts the lesions and is
indicated in all cases.
Treatment
 Tumors of the distal common duct should be
treated by radical pancreaticoduodenectomy
(Whipple procedure) if it appears that all
tumor could be removed.
Treatment
 Mid common duct or low hepatic duct tumors
should also be removed if possible, if the
tumor cannot be excised, bile flow should be
reestablished into the intestine by a
cholecystojejunostomy or Roux-en-Y
cholecystojejunostomy.
Treatment
 Tumors at the hilum of the liver should be
resected if possible and a Roux-en-Y
hepatijejunostomy performed.
Prognosis

 The average patient with adenocarcinoma of

the bile duct survives less than a year. The
overall 5-year survival rate is 15%.
Thank you !