Disease of  the Biliary Tract
Anatomy  <ul><li>Calot triangle : </li></ul><ul><li>The triangle bounded by the common hepatic duct medially,the cystic du...
Anatomy  <ul><li>The sphincter of Oddi : </li></ul><ul><li>The proximal bile and pancreatic ducts and the common channel a...
Special Investigation of  the biliary Tract <ul><li>Ultrasound: </li></ul><ul><li>Non-invasive,painless, </li></ul><ul><li...
Ultrasound  <ul><li>Bile duct stones: </li></ul><ul><li>Stones in gallbladder: </li></ul><ul><li>High echo which cast an a...
Ultrasound <ul><li>Jaundice differential diagnosis: </li></ul><ul><li>Dilatation of the ducts  </li></ul><ul><li>CBD: diam...
Radiology  <ul><li>Plain abdominal radiograph: </li></ul><ul><li>Radio-opaque gallstones  </li></ul><ul><li>Air in the bil...
Radiology <ul><li>Intravenous cholangiography </li></ul><ul><li>Percutaneous transhepatic cholangi-ography (PTC) </li></ul...
Radiology <ul><li>Endoscopic retrograde cholangio-pancreatography(ERCP) </li></ul><ul><li>outline the biliary tree and pan...
Radiology <ul><li>Endoscopic sphincterotomy(EST) </li></ul><ul><li>Endoscopic naso-biliary drainage </li></ul><ul><li>(ENB...
Special Investigation of  the Biliary Tract <ul><li>Hepatobiliary nuclear imaging </li></ul><ul><li>99m-Tc-EHIDA </li></ul...
Cholelithiasis  <ul><li>Including : </li></ul><ul><li>gallstones  </li></ul><ul><li>biliary duct stones </li></ul>
Cholelithiasis <ul><li>In China: </li></ul><ul><li>before 1981  </li></ul><ul><li>gallstones  <  biliary duct stones </li>...
Classification of stones <ul><li>Cholesterol stones: hard,layed on cross-section </li></ul><ul><li>Pigment stones:crumble ...
Formation of stones <ul><li>Cholesterol stones: </li></ul><ul><li>cholesterol insoluble in water and relative proportion o...
Formation of cholesterol stones <ul><li>Increase of cholesterol and decrease of bile salts leads to supersaturation of bil...
Formation of cholesterol stones <ul><li>Nucleation:cholesterol will crystallize if there is a nidus on which the crystals ...
Clinical feature of gallstones <ul><li>20-40% patient without symptom which is called  asymptomatic gallstones </li></ul><...
Symptoms  <ul><li>Gastrointestinal tract symptoms: </li></ul><ul><li>upper abdominal discomfort,  </li></ul><ul><li>nausea...
Symptoms <ul><li>Biliary colic: most commom symptom </li></ul><ul><li>A large or fatty meals and changing in position when...
Symptoms <ul><li>Mirizzi syndrome: </li></ul><ul><li>Obstruction of the common hepatic duct by a stone impacted in the cys...
Sign <ul><li>Right upper area of the abdomen tenderness, rigidity,  </li></ul><ul><li>rebound tendeness. </li></ul><ul><li...
Exam  <ul><li>Jaundice (choledocholithiasis): </li></ul><ul><li>blood test of the liver function, elevation of the enzyme ...
Diagnosis  <ul><li>History </li></ul><ul><li>Physical exam </li></ul><ul><li>Ultrasoud exam: high echo with an acoustic sh...
Treatment  <ul><li>The first choice is operation: </li></ul><ul><li>symptomatic gallstones  </li></ul><ul><li>gallstones w...
Treatment  <ul><li>Asymptomatic gallstones: </li></ul><ul><li>oral cholecytography without showing of  gallbladder  </li><...
Treatment  <ul><li>CBD exploration: </li></ul><ul><li>Preoperation </li></ul><ul><li>CBD stones </li></ul><ul><li>Cholangi...
Treatmen <ul><li>Operation: the final method </li></ul><ul><li>Emergency surgery   </li></ul><ul><li>onset in 48-72 hours ...
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Biliary tract

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Biliary tract

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