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Biliary tract

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gastroenterology 3rd year

gastroenterology 3rd year

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  • 1. Disease of the Biliary Tract
  • 2. Anatomy
    • Calot triangle :
    • The triangle bounded by the common hepatic 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 cholecytectomy.
  • 3. Anatomy
    • The sphincter of Oddi :
    • The proximal bile and pancreatic ducts and the common channel are surrounded by circular and longitudinal smooth muscle, this muscle complex is known as the sphincter of Oddi .
  • 4. Special Investigation of the biliary Tract
    • Ultrasound:
    • Non-invasive,painless,
    • Easily performed
    • First choice for biliary tract disease
  • 5. Ultrasound
    • Bile duct stones:
    • Stones in gallbladder:
    • High echo which cast an acoustic shadow and which move with changes in posture
  • 6. Ultrasound
    • Jaundice differential diagnosis:
    • Dilatation of the ducts
    • CBD: diameter > 1.0cm
    • Other disease: cholecytitis, tumor ect.
    • During surgery: to detect bile duct stones
  • 7. Radiology
    • Plain abdominal radiograph:
    • Radio-opaque gallstones
    • Air in the biliary tree
    • Oral cholecystography:
    • Biliary contrast medium
    • A fatty meal
  • 8. Radiology
    • Intravenous cholangiography
    • Percutaneous transhepatic cholangi-ography (PTC)
    • show intra and extra hepatic biliary duct clearly
    • complication: bile leakage
    • cholangitis
    • hemorrhage
  • 9. Radiology
    • Endoscopic retrograde cholangio-pancreatography(ERCP)
    • outline the biliary tree and pancreatic duct
    • inspect the ampulla of Vater
    • exam of the fluid of duodenum ,bile, pancreatic fluid.
  • 10. Radiology
    • Endoscopic sphincterotomy(EST)
    • Endoscopic naso-biliary drainage
    • (ENBD)
    • Computed tomography(CT)
    • Magnetic resonance cholangio-pancreatography (MRCP)
    • Cholangiopancreatography during & operation
  • 11. Special Investigation of the Biliary Tract
    • Hepatobiliary nuclear imaging
    • 99m-Tc-EHIDA
    • Choledochoscopy
    • Operation
    • Post opertion
  • 12. Cholelithiasis
    • Including :
    • gallstones
    • biliary duct stones
  • 13. Cholelithiasis
    • In China:
    • before 1981
    • gallstones < biliary duct stones
    • cholesterol stones < pigment stones
    • now
    • gallstones > biliary duct stones cholesterol stones > pigment stones
  • 14. Classification of stones
    • Cholesterol stones: hard,layed on cross-section
    • Pigment stones:crumble when squashed
    • Mixed stones: radio-opaque
    • Black stones
  • 15. Formation of stones
    • Cholesterol stones:
    • cholesterol insoluble in water and relative proportion of cholesterol,bile salts, and phospholipid in bile .
  • 16. Formation of cholesterol stones
    • Increase of cholesterol and decrease of bile salts leads to supersaturation of bile with cholesterol ,which results in the formation of liquid crystalline phase of cholesterol
  • 17. Formation of cholesterol stones
    • Nucleation:cholesterol will crystallize if there is a nidus on which the crystals can form.
    • Nucleating factors:
    • mucus glycoprotiens from cyst wall and bilirubinate
    • Gallbladder function:
    • the motility of the cyst wall
  • 18. Clinical feature of gallstones
    • 20-40% patient without symptom which is called asymptomatic gallstones
    • Chronic cholecystitis
    • Biliary colic
    • Acute cholecystitis
  • 19. Symptoms
    • Gastrointestinal tract symptoms:
    • upper abdominal discomfort,
    • nausea,
    • after meals, eap. fatty meals.
  • 20. Symptoms
    • Biliary colic: most commom symptom
    • A large or fatty meals and changing in position when sleeping can precipitate the pain
    • Due to impaction of stone in the neck of the gallbladder: the pressure increase.
    • Occurs in the mid or the upper-right portion of the upper abdomen.
    • Severe pain starts abruptly, continuous,with restlessness, vomitting,sweating.
    • Pain radiate to the right back and shoulder.
  • 21. Symptoms
    • Mirizzi syndrome:
    • Obstruction of the common hepatic duct by a stone impacted in the cystic duct or Hartmann ’ s pouch
    • Press on the bile duct or (more commonly ) ulcerate into the duct leads to cholecystocholedochal fistula
  • 22. Sign
    • Right upper area of the abdomen tenderness, rigidity,
    • rebound tendeness.
    • Gallbladder palpable
    • Murphy sign: inspiratory arrest during subcostal palpation
    • Jaundice:common bile duct stones or Mirizzi syndrome
    • Fever and chill with infection
  • 23. Exam
    • Jaundice (choledocholithiasis):
    • blood test of the liver function, elevation of the enzyme alkaline phosphate and bilirubin
    • WBC count is high
    • Ultrasoud: the main diagnosis exam.
    • Oral cholecytography.
  • 24. Diagnosis
    • History
    • Physical exam
    • Ultrasoud exam: high echo with an acoustic shadow and moving with changes in posture
  • 25. Treatment
    • The first choice is operation:
    • symptomatic gallstones
    • gallstones with complications
  • 26. Treatment
    • Asymptomatic gallstones:
    • oral cholecytography without showing of gallbladder
    • diameter of stones > 2.0-3.0 cm
    • diabetes mellitus
    • elder or cardiac and respiratory problems
    • Need operation.
  • 27. Treatment
    • CBD exploration:
    • Preoperation
    • CBD stones
    • Cholangitis and biliary colic repeatedly
    • Pancreatitis
    • Jaundice and bile duct dilatation
  • 28. Treatmen
    • Operation: the final method
    • Emergency surgery
    • onset in 48-72 hours
    • invalidation of nonsurgical treatment
    • gangrene, perforation, pancreatitis, or inflammation of the common bile duct occurs