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Gall bladder & bile ducts with narration
- 1. GALL BLADDER & BILE DUCTS Dr. Chris Anthony Senior Lecturer AIMST University
- 2. Anatomy of Gall Bladder & Bile Ducts Part 1 – Surgical anatomy
- 3. Surface Anatomy of Gall Bladder Right hypochondrium Transpyloric plane : horizontal plane at level of lower border of L1 vertebral body Mid-clavicular line Angle between right costal margin & lateral border of rectus abdominis muscle Normally not palpable
- 4. Calot’s Triangle Boundaries : Lateral : cystic duct, gall bladder Medial : common hepatic duct Above : inferior surface of right lobe of liver Contents : Right hepatic artery Cystic artery Cystic lymph node of Lund
- 5. Anatomy of Cystic Duct About 3 cm long (variable), 1 to 3 mm diameter Joins common hepatic duct (80%) to form common bile duct(CBD)
- 6. Anatomy of CBD About 7.5 cm long, about 6 mm in diameter 4 parts : 1.Supraduodenal : 2.5 cm long, on free edge of lesser omentum 2.Retroduodenal : behind first part of duodenum 3.Infraduodenal : on posterior surface or through part of the pancreas 4.Intraduodenal : opens in second part of duodenum, surrounded by sphincter of Oddi Ends on summit of the ampulla of Vater
- 7. Sphincter of Oddi Muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum.
- 8. Blood Supply of GB Cystic artery, a branch of right hepatic artery Rarely, cystic artery arise from common hepatic artery Gall bladder may also get accessory artery from gastro-duodenal artery
- 10. Lymphatic Drainage & Nerve Innervation Lymph drains into cystic lymph node of Lund in Calot’s triangle, from there it drains into liver hilar lymph nodes & coeliac lymph nodes Parasympathetic from Vagus nerve (CN X) - maintain tone & contractility Afferent sympathetic fibres mediate pain of biliary colic
- 11. Physiology
- 12. At Liver : Bile production : 97% water, 1 to 2% bile salts, 1% bile pigments, cholesterol, calcium & fatty acids Excretion : about 40 mls/ hour (about 1 L/ 24 hours) At Gall Bladder : 3 main functions Reservoir for bile : during fasting Concentration of bile : 5 to 10 times, by active absorption of water Mucin secretion : about 20 ml/hr Vagus & Cholecystokinin (CCK) cause GB contraction, sphincter of Oddi relaxation - bile excreted
- 14. Imaging of Gall Bladder & Bile Ducts
- 15. Imaging of Gall Bladder & Biliary Tree Plain Xray Abdomen Ultrasonography (USG) CT scan Endoscopic Retrograde Cholangio-Pancreaticogram (ERCP) Magnetic Resonance Cholangio-Pancreaticography (MRCP) Others Oral Cholecystogram; Intravenous Cholangiogram Percutaneous Transhepatic Cholangiogram (PTC) Peroperative Cholangiogram Xrays Radio-isotope scan
- 16. Plain Xray Abdomen : Only 10% of gall stones are radio-opaque Some gall bladders may be calcified (porcelain) Gas in bile ducts (aerobilia) – ERCP/infection
- 17. Ultrasonography (USG) Most important initial imaging Safe, painless, accurate, convenient,cost-effective & readily available Gallstones, gall bladder,thickness of gall bladder wall & surrounding inflammation Biliary stones,size of ducts & sometimes stones in common bile duct & growth in pancreas
- 18. CT & MRI Scans Computed Tomography (CT) : Useful for detecting liver & pancreas lesion Staging of liver, bile duct, pancreatic cancers; check for enlarged lymph nodes Only 75% gallstones seen on CT, not for screening Magnetic Resonance Cholangio-Pancreaticogram (MRCP) : Imaging of gall-bladder & bile ducts Can show bile duct obstruction, stricture & other intraductal abnormalities
- 20. Gallstone Disease Diseases of GB & Bile ducts
- 21. Gallstones (Cholelithiasis) About 10 to 15% of adults have gallstones but 80% are asymptomatic; females 4 : 1 male Every year about 1 to 2% of asymptomatic cases will develop symptoms requiring surgery Classical teaching : Fat Fertile Flatulent Female of Forty
- 22. Stone Formation Bile salts & Lecithin Keep cholesterol in solution When stability is lost due to excess cholesterol & reduced bile salts & lecithin gallstones form (lithogenic bile)
- 23. Gallstones
- 24. Cholesterol stones Contain up to 99% pure cholesterol Supersaturation with cholesterol Usually large, yellowish Single or a few
- 25. Pigment stones Stones having less than 30% cholesterol Two types : black & brown Black pigment stones (20 to 30% of stones) : Associated with haemolysis, usually hereditary spherocytosis or sickle cell disease & liver cirrhosis
- 26. Brown pigment stones Rare in gall bladder; form in bile ducts & related to bile stasis & infected bile Also associated with foreign bodies within bile ducts, eg. endoprosthesis (stents)
- 28. Complications of gallstones Biliary colic Acute cholecystitis Chronic cholecystitis Acute pancreatitis Mucocoele of GB Empyema of GB Perforation of GB Obstructive jaundice Acute cholangitis, liver abscess Mirizzi’s syndrome Intestinal obstruction (gallstone ileus) Carcinoma of gallbladder
- 29. Common Diseases of Gall bladder & Bile ducts (Part 2)
- 30. Diseases of biliary system Gallbladder Cholelithiasis Biliary colic Acute Cholecystitis Empyema Gangrene & perforation Chronic cholecystitis Gall bladder polyps Carcinoma GB Bilary ducts Choledocholithiasis Cholangitis Striture CBD Biliary atresia Choledochal cyst Sclerosing cholangitis Ca head of pancreas Cholangiocarcinoma Periampullary carcinoma
- 31. Symptoms GB & Biliary disease Specific Pain – RHC,fatty food,radiation to back,breathless Onset - acute Jaundice,tea-coloured urine Pruritus/clay colored stools Non-specific Nausea & vomiting Fever LOA Diarrhoea Lethargy/unwell
- 32. Signs of GB & Biliary disease Jaundice Fever Tenderness, guarding Murphy’s sign Palpable GB Hepatomegaly Charcot’s triad Courvoisier’s Law
- 33. 1.Acute Cholecystitis & biliary colic Mostly associated with cholelithiasis 95% gall stone found impacted in Hartmann’s pouch or cystic duct Types of gall stones : mixed stones – commonest, multifaceted pure cholesterol stones – round, single, large pigment stones – black/ brown, irregular, hard Bacteria : Usually Gram-negative aerobes, eg. Escherichia coli, Klebsiella, Streptococcus faecalis Rarely : Bacteroides & Clostridia (gas in biliary tree)
- 34. Biliary colic Chemical cholecystitis Septic cholecystitis Empyema GB Gangrene Perforation • Obst. Cystic duct • Distension GB • Wall ischemia/oedema • Inflamation • Bacterial infection
- 35. Pathophysiology Stone obstruct bile outflow Distension & ischaemia of gall bladder Mucosa damaged by lysolecithin or trauma by stone (chemical cholecystitis) Secondary bacterial infection (septic Cholecystitis) Sequelae : Stone slip back into gall bladder with relief of obstruction & inflammation subsides (Biliary colic) Empyema of gall bladder Gangrene & perforation of gall bladder with localised abscess/ diffuse peritonitis (mortality rate of 50%)
- 36. Clinical Features Sudden onset of right hypochondrial pain Fever, nausea, vomiting Tenderness & guarding over right hypochondrium Boas’s sign : area of hyperaesthesia between right 9th & 11th ribs posteriorly Murphy’s sign : sudden holding of breath on deep palpation of right hypochondrium
- 39. Investigations Plain Xray Chest (erect) & abdomen Ultrasonography of abdomen CT scan ECG. Urinalysis. Blood counts, liver & renal function tests, amylase, cardiac enzymes
- 43. Differential diagnosis of acute cholecystitis Common Appendicitis Perforated peptic ulcer Acute pancreatitis Rare Acute pyelonephritis Myocardial infarction Pneumonia – right lower lobe
- 44. Treatment Initially : conservative followed by cholecystectomy Nil by mouth,Naso-gastric aspiration, Analgesics, antibiotics, intravenous fluids to replace & correct electrolytes & fluids losses Cholecystectomy preferably laparoscopic done 2 to 3 days after initial treatment (within 5 to 7 days of onset of infection; otherwise delay 6 weeks)
- 45. 2.Chronic Cholecystitis Shrunken, scarred, fibrotic with thickened wall Adhesions to surrounding structures Due to repeated inflammation & mechanical irritations Clinical features : Chronic recurrent right hypochondrial pain; Nausea & vomiting, abdominal fullness especially precipitated by fatty foods Flatulent dyspepsia, belching & heartburn Murphy’s sign may be positive
- 46. Management Conservative Chemical dissolution of stones using Chenodeoxycholic acid or Ursodeoxycholic acid can be tried in elderly patients Lithotripsy usually not done due to poor success rate or recurrence Surgery - cholecystectomy Laparoscopic cholecystectomy treatment of choice Open cholecystectomy through Kocher’s (right hypochondrial) incision
- 47. 3.Bile Duct Stones (Choledocholithiasis) Charcot’s triad : pain, jaundice (obstructive) & fever Obstruction to outflow of bile leads to stasis & infection Jaundice Ascending cholangitis
- 48. 4.Bile Duct stricture Intrahepatic Extra-hepatic Benign & malignant Iatrogenic – post cholecystectomy
- 50. 5.GB Polyps A gallbladder polyp is a small, abnormal growth of tissue with a stalk protruding from the lining of the inside of the gallbladder. They are relatively common. 95% benign, rarely cancerous Gallbladder polyp size is often an indication of the presence of cancer: less than <10mm in diameter — are typically benign don’t need to be treated. larger than >10mm inch in diameter have a greater likelihood of being or becoming malignant.
- 51. GB polyp
- 52. Gall bladder polyp treatment Asymtomatic RHC pain & tenderness Nausea Vomiting No treatment Regular follow up Cholecystectomy Symptoms Treatment
- 53. 6.Gallbladder cancer ●● Very rare Elderly women above 60 years old ●● Similar presentation to gallstones ●● Diagnosis by ultrasound, CT, ●● Most patients present with advanced disease ●● Surgical resection in less than 10% palliative treatment ●● Prognosis is poor – median survival approximately 6 months Cholecystectomy for any gall- bladder polyp more than 1 cm diam.
- 54. 7.Cholangiocarcinoma Uncommon malignancy Elderly, more than 65 years old Adenocarcinoma from extrahepatic bile ducts Higher risk with primary sclerosing cholangitis, hepatolithiasis, hepatitis C, ascending cholangitis, choledochal cyst, Caroli’s disease Locations : Intrahepatic : 10 to 20% Hilar cholangiocarcinoma or Klatskin tumours : 60% Distal bile duct : 20 to 30% Klatskin 60% 10-25% 20-30%
- 55. Cholangiocarcinoma Clinical features : Jaundice, abdominal pain, early satiety, cachexia Slow-growing, local invasion & lymphadenopathy Treatment Mostly inoperable, 10 to 15% can have radical resection & reconstruction of bile ducts Whipple’s operation for distal bile duct tumours Liver transplant Limited role of chemotherapy/ radiotherapy
- 56. “ Courvoisier’s Law” “ In the presence of obstructive jaundice, a palpable gall bladder is usually NOT due to gall stone obstruction of common bile duct ” Most probably it is due to Ca head of pancreas Periampullary tumour Cholangiocarcinoma Why? Gall bladder is usuallyfibrotic & contracted in chronic cholecystitis with stones, BUT there can be exceptions
- 57. Cholecystectomy
- 58. Cholecystectomy Indications Acute cholecystitis Chronic Cholecystitis Empyema GB Perforation of GB Carcinoma GB Porcelain GB Asymptomatic gallstones/Diabetes/polyps
- 59. Cholecystectomy
- 60. Mobilizing the gall bladder Dissection of cystic duct Clips applied to cystic duct
- 61. Cystic duct cut Cystic artery being dissected Galll bladder dissected from liver bed
- 62. Complications of Cholecystectomy Bleeding Infection, cholangitis, abscess, septicaemia Bile duct injury, bile leakage, duct stricture Retained stone Obstructive jaundice Acute pancreatitis After laparoscopic cholecystectomy : access complications during creation of pneumo-peritoneum: puncture vessel, bowel, etc. or bile duct injury
- 64. TOUCH creates a healing bond in health care The TOUCH provides the utmost needed by the sick - Reassurance -
- 65. THANK YOU