1. EHBA &GALLSTONES
By Dr. Mihir Vaidya
(intern)
Dept. of surgery
MGM Medical College, Research Centre and Hospital
2. Gall Bladder and EHBA
Anatomy
• Extra hepatic biliary apparatus (EHBA) collects bile
from liver, stores it in the Gall Bladder(GB) and
transmits it to the 2nd part of duodenum.
• It consists of :- 1)Right and left hepatic ducts
2) common hepatic ducts
3) gallbladder
4) cystic duct
5) bile duct
3. it is a part of the EHBA.
It is pear-shaped.
It is a reservoir of bile.
Fossa for GB extends from the
right end of the porta hepatis to
the inferior border of the liver.
Porta hepatis is a transverse
fissure of the liver. It is short, deep,
5 cm long on the left portion of
right lobe near the posterior
surface. It separates the quadrate
lobe from the caudate lobe and
caudate process.
Length of GB= 7-12 cm
Breadth = 3cm
Normally holds 5cc of bile but has
a capacity of 30-60 cc.
Gall Bladder
5. Fundus
• It is beyond inferior liver between lat. Border
of right rectus abdominus muscle and 9th IC
cartilage.
• It is surrounded by peritoneum
• Anteriorly- ant. Abdominal wall
• Posteriorly- beginning of the transverse colon
6. Body
• It lies in the fossa of GB on the liver.
• The upper right end of the body continues with
the neck at the right end of the porta hepatis.
• Superior surface is devoid of peritoneum and
adherent to the liver.
• Inferior surface is covered with peritoneum.
• It is related inferiorly to transverse colon, laterally
and superiolaterally to 1st and 2nd part of
duodenum.
7. Neck
• It is the narrow upper end of the duodenum.
• It sits near the right end of the porta hepatis.
• Curves anteriosuperiorly first, then
posteroinferiorly later.
• It becomes continuous with the Cystic duct
(CD).
• The junction with cystic duct has a
constriction.
8. • Superiorly neck is attached to the liver by
areolar tissue.
• In which cystic vessels are embedded.
• It is inferior to 1st part of duodenum.
• Mucous membrane is arranged spirally to
prevent obstruction to inflow and outflow of
bile.
• The postero medial wall is dilated outwards to
form “HARTMAN’S POUCH”.
• Gall stones may lodge here.
9. Cystic duct (CD)
• Length = 3-4 cm
• It begins at neck of GB. It runs Downwards
Backwards and Left.
• It joins with common hepatic duct to form the
CBD.
• The mucous membrane is arranged spirally to
form “SPIRAL VALVE OF HEISTER”.
• This is not a true valve.
10. Functions of GB
• Main function is storage of bile.
• 2nd function is concentration if bile by active transport of H2O, NaCl,
Bicarb by mucous membrane.
• 3rd function is secretion of mucous (20cc/day)
• Normally GB absorbs loose bile salt-cholesterol compounds.
• Whem the GB is inflamed concentration function is abnormal. Bile
salts alone are absorbed leaving cholesterol behind.
• Solvent action of bile salt on cholesterol leads to gallstone
formation.
• It regulates pressure in the bile system by appropriate dilatation
and concentration
• Thus normal Choledocho-duodenal mechanism is maintained.
11. Bile Duct (BD)
• It is formed by union of CD and common
hepatic duct near the porta hepatis.
• Length=8cm diameter=6mm
• Course and realations:- 1) supraduodenal part
2) Retroduodenal part
3) Infraduodenal part
4) Intraduodenal part
12. Supraduodenal part
• Downwards and backwards in full margin of
margin of lesser omentum.
• Anteriorly- liver
• Posteriorly-portal, epiploic foramen, left
heptaic artery (arises from common hepatic
artery)
13. Retroduodenal
• It is behind the first part of duodenum.
• Anteriorly-1st part of duodenum.
• Posteriorly- inferior venacava
• Left – gastroduodenal artery (common hepatic
art.)
14. Infraduodenal
• Its is behind or embedded in the head of
pancreas.
• Anteriorly- groove in the upper and lateral
part of the posterior surface of head of
pancreas
• Posteriorly-inferior venacava
15. Intraduodenal
• It is near the middle of left side of 2nd part of
duodenum.
• It comes in contact with pancreatic duct and
accompanies it through the wall of duodenum.
• Very oblique inside the duodenum. BD and PD
unite to form a hepatopancreatico “AMPULA OF
VATER”
• The distal constricted end opens at summit of
major duodenal pappila, 8-10 cm distal to pylorus
16. Sphincters related to BD
• Terminal part near the junction of BD and PD
is surrounded by a ring of smooth muscle
which forms “SPHINCTER CHOLEDOCHUS”.
• It normally keeps lower end of BD closed.
• The “SPHINCTER OF ODDI” surrounds Ampula
of Vater.
17. Arterial supply of EHBA
Cystic artery – it is the main artery supplying the EHBA. It is a
branch of right hepatic artery. It supplies GB, CD, HD, BD(upper
part)
Branches from posterosuperior pancreaticoduodenal artery
supplies lower part of BD.
Right hepatic artery supplies the middle part of the BD.
Arterial supply of GB is very important. It is quintessential to
preserve it during cholecystectomy as damage can cause postop
strictures and ischaemia.
The most dangerous anomalies are when hepatic artery takes
tortuous course on the front of the origin of cystic duct or hepatic
artery is tortuous and cystic artery short.
This tortuosity is called “CATERPILLAR TURN” or “MOYNIHAN’s
HUMP”
18. Venous drainage
• Superior surface of GB is drained by veins that
enter the fossa for GB and join the tributaries
of hepatic veins.
• Rest is drained by 1-2 cystic veins.
• Lower part of GB drains into the portal vein.
19.
20. Lymphatic drainage
• The GB, CD, HD, and upper part of BD is
drained by “CYSTIC NODE OF LUND”.
• It is content “CALOT’S TRIANGLE”.
• The boundaries of calots triangle are cystic
duct, common hepatic artery, and cystic
artery.
21.
22.
23. Nerve supply
Coeliac plexus+ left+right vagi+right phrenic
nerves give rise to hepatic plexus which in turn
gives to cystic plexus. This supplies the teritory of
coeliac artery.
The lower part of BD is supplied by nerve plexus
over the pancreaticoduodenal artery.
Parasympathetic nerves are motor to
musculature of GB and BD. But they are
inhibitory to the sphincters.
Sympathetic fibres from T7 T8 T9 are vasomotor
and motor to the sphincters.
24. Referred pain
• Stomach (epigastrium) – Vagus
• Inf. Angle of right scapula-lateral horn of T7
• Right shoulder- Phrenic nerve.
25. Biliary outflow
Bile is synthesized and secreted by
hepatocytes into the canaliculli. It contains
water, bile salts, bilirubin, cholesterol, fatty
acids and lecithin.
After which bile flows into progressively large
ducts until reaching the duodenum via the
greater duodenal pappilae of vater.
26. Terminal ductules(canals of Hering)
Surrounded by 3-6 ductal epithelial cells
Perilobar duct
Interlobal duct surrounded by portal vein
Septal duct
Lobar ducts
28. Physiology of EHBA
• Bile secretion servers 2 purposes- liver is a major site for
metabolism, detoxification and cellular recycling. Bile
transport allows toxin excretion. It also absorbs most lipids.
• Osmolality of bile is comparable to that of plasma as bile
salts coalesce to form spherical pockets or “MICELLES”. The
cations that are secreted into the biliary tree along with
bile salts anions provide osmotic load to draw water into
the duct and increase flow to keep bile electrochemically
neutral.
• Cholecystokinin (CCK) secreted by intestinal mucosa serves
to induce biliary tree secretion and gall bladder wall
contraction. It augments excretion of bile into the
duodenum.
29. • Bile is reabsorbed by the terminal ileum.
• Bile acids are bound to albumin and transported back
to liver for recycling.
• <5% are lost in stools.
• If significant amount of bile salts reach the colonic
lumen it can cause inflammation and diarrhoea. Na co-
transport and Na-independent pathway at space of
DISSE facilitate uptake into the hepatocytes.
• In a similar Na-independent pathway
unconjugated/indirect bilirubin is transported.
• The rate limiting step in bile salt excretion is transport
of bile salt across canalicular membrane.
32. X-RAY
• Will show radio-opaque stones in 10% cases
• Will show a rare calcification in GB which is a
premalignant condition and indication for
cholecystectomy
• Gas may be seen in the wall of the GB in
Emphysematous Cholecystitis.
• Gas can also be seen following endoscopic
sphincterectomy or surgical anastomosis
33.
34. Oral cholecystography
• Iopnoic acid BP is administered in night prior
to the examination. Control X-RAY is taken
before the administration.
• On the following day, multiple X-RAYS are
taken before and after a fatty meal.
• Fatty meal stimulates gall bladder contraction
and shows adequacy of function.
• It is obsolete now.
35.
36. Intravenous cholangiography
• Biligram-meglumine-ioglycomate test.
• It is used for radiological inventigation if BD.
• Drug is given IV. The liver rapidly distributes it to
the biliary tree.
• Careful radiography with or without tomography
can readily show GB, ducts and stones.
• Allergic reaction to the contrast medium are
increased.
• This test too is obsolete now.
37.
38. USG
• It is a non-invasive process.
• It is the standard initial imagery technique for
pt suspected of gall stones.
• It is the prime investigation for jaundice.
• It demonstrates biliary calculi, size of GB,
thickess of GB wall, presence of inflammation
around GB, size of CBD, presence of stone in
biliary tree, and also shows Ca Pancreas
occluding the CBD.
39.
40. Radio-isotope Scan
• Technitium 99m labelled derivatives of amino-
diacetic acid injected into the bile to visualize
the biliary tree.
• It shows extent of obstruction in the biliary-
enteric anastomosis.
41.
42. CT
• Only usefull in patients with Ca Gallbladder
and Ca Bileduct.
• Also uselfull to see the metastasis into the
liver as it results in a bad prognosis.
43.
44. Magnetic Resonance
Cholangiopancretography (MRCP)
• Now becoming the standard technique for
investigation of the biliary tree.
• Contrast it not necessary
• It is non-invasive.
• Clear outline biliary tree can be seen along
with the BS stones.
45.
46. Endoscopic Retrograde
Cholangiopancreatography (ERCP)
• Ampula of vater is cannulated with a fibre optic
duodenoscope.
• Using water soluble contrast, bile ducts are visualized.
• Bile-cytology, microbiological eval. And brushings
cytology from stricures can be done.
• If contrast medium fills a dialated and obstructed duct
or GB, acute cholangitis develops.
• Hence, antibiotic prophylaxis is given.
• Relief of obstruction by stenting can be done.
• If normal drainage cannot be achieved, percutaeneous
trans-hepatic drainage done.
47. • Now used therapeutically to remove stones
and stent strictures rather than diagnostically.
• Urographin 65-70% is used in our hospital.
• Dormia basket is used for stone removal.
48.
49. Percutaeneous transhepatic
cholangiography (PTC)
• Only done in absence of bleeding tendency and pt’s BT CT PT
should be checked.
• Antibiotic prophylaxis is recommended.
• Under floroscopic control, “chiba or okuda” needle of length 15cm
and diam-0.7 mm is advanced into the liver through 8th IC space
along mid-axillary line till 2 cm short of Rt margin of Vertibral
column.
• Stillet is removed and contrast is injected.
• While injecting the needle is slowly withdrawn till the contrast
starts entering the bile radicle.
• It is useful for inserting a catheter for ext. biliary drainage or
insertion of indwelling stents.
• Procedure lengthened by leaving the drainage catheter in-situ. The
tract is then dilated for a fine flexible choledochoscope to remove
the strictures, biopsy and stone removal.
50.
51. Post operative cholangiography
• During cholecystectomy, catheter is placed in
the CD and contrast is injected
• Its value is debatable.
52.
53. Operative biliary endoscopy
Choledochoscopy
• During surgery, a flexible fibreoptic endoscope
is passed down the CD into the CBD.
• Enable stone identification and removal.
• It prevents excessive prolongation of an
operative exploration of the CBD.
54. General signs and symptoms in biliary
tree pathologies
1. Pain – the pain of the biliary tract origin is called
biliary colic. Pain is constant, in the right
hypochondrium. It is associated with meals. It is
caused by forceful contraction of the GB after release
of CKK. MURPHY’S SIGN- voluntary cessation of
respiration on constant pressure on right
hypochondrium. d/d’s of murphy’s sign- acute
cholecystitis and hepatitis.
2. Fever – usually not associated with biliary colic but it
is present if cause is infetctive. Fever+hypochondrium
pain is Hallmark of biliary tract infections.
55. 3. Juandice – is due to increased bilirubin. >2.5
mg/dL causes sceral icterus and >5mg/dL
cutaneous icterus
FEVER+RT.HYPOCHONDRIAL PAIN+JAUNDICE is
called CHARCOT’S TRIAD
This indicates decreased hepatic and GB
secretion.
When charcot’s triad is coupled with
hypotension and altered mental status it is
called REYNOLD’S PENTAD.
56. Gall stones (Cholelithiasis)
• It is the most common biliary pathology.
• 85% of patients are asymptomatic.
• 1-4% of these pt develop biliary symptoms in 1
year.
• Mortality is low.
• Abnormal gall bladder function causes increased
stasis and ore time for precipitation of stones.
• Classified into 1) cholesterol stones 2) pigment
stones.
57. Cholesterol stones
• They are made up of 51-99% cholesterol and
calcium.
• Pure cholesterol stones are rare <10%.
• They are caused when concentration increases
> solubility of cholesterol.
• Thus cholesterol cystals are formed.
• The process is accelerated by proneucleating
agents such as glycoproteins and
immunoglobulins.
58.
59. Pigment stones
• Usually caused due to degradation products of
hemoglobin and precipitation of concentrated
bile pigments.
• They are formed when insoluble bile pigment
mixes with calcium carbonate or calcium
phosphate.
• They contain 30% or less cholesterol.
• They are of 2 types – black
- brown
60. Black stones
• 20-30% incidence
• Caused in cirrhosis and haemolytic conditions
such as spherocytosis and sickle cell disease.
61. Brown stones
• They contain calcium bicarbonate, palmitate,
stearate, and cholesterol.
• They are commonly formed in the BD and not
the GB.
• They are related to bile stasis and infected
bile.
• Formed in the presence of static foreign
bodies like stents and some parasites like
ascaris lumbricoides.
62.
63. Factors affecting Gall stone formation
• Super saturation of secreted bile
• Concentration of bile in the gall bladder
• Crystal nucleation
• Gall bladder dysmotility
64. • Cholesterol is secreted by phospholipid vesicles.
• Micelles hold the cholesterol in stable thermodynamic
state.
• Stones may form when cholesterol crystals neucleate in
the unilaminar phospholipids are formed when bile is
supersaturated and/or bile concentration falls.
• Nucleation of cholesterol monohydrate crystals from
multiple laminating vesicles is the crucial step.
• Pt’s with Gallstones have increased fasting and PP GB
volumes.
• GB should be removed along with gallstones to prevent
reccurence.
65. Gas in Gall stones
• It is an uncommon condition.
• Stones can have radioluscent gas in the
centre.
• Dark shapes can be seen on X-RAY.
• This is called the “MERCEDES-BENZ” sign or
the “seagul” sign.
66. Limey bile
• Occurs when GB is full with mixture of calcium
carbonate and calcium phosphate.
67. Choledocholithiasis
• It is the disease in which stone is present in the CBD.
• Primary choledocholithiasis is caused due to formation
of stone in CBD.
• Secondary choledocholithiasis is caused when stone
passes into the CBD from the GB.
• It is usually clinically silent.
• It is diagnosed by cholangiography.
• If not silent the presenting symptoms are :- biliary
colic, symptoms and manifestations of OJ, scleral
icterus and lightening of stools.
68. Diagnosis
• USG – dilated bile duct of >8mm is highly
suggestive of CBD stones when associated
with biliary colic, gall stones and jaundice.
• ERCP – diagnostic and therapeutic.
• MRCP – best diagnostic modality available
currently with 90% sensitivity.
71. Complications of gallstones
They arise due to obstruction of CD, Intrahepatic
radicles and/or Ampula of Vater.
• Cholecystitis
• Mucocele of GB
• Empyema of GB
• Cholesterosis (strawberry GB)
• Cholesterol polyposis
72. Treatment of Gall stones
1) Cholestectomy
2) Choledochoduodenostomy
3) Roux-en-Y- hepaticojejunostomy
2) and 3) are used for CBD stones.
74. Preparation for surgery
• Thorough history to be taken to rule out
complicating factors such as systemic diseases.
• Anesthetist's fitness is to be taken.
• Blood and biochemical profile to be done.
• Liver function tests in particular are of utmost
importance.
• Antibiotic prophylaxis using 2nd generation
cephalosporins.
• Patient should be counseled about the risks of
the surgery and the consent is taken.
75. Laparotomy
• Right upper transverse incision is made, centered over the lateral
border of the rectus abdominus muscle.
• Gall bladder is exposed and porta hepatis is visualized.
• An artery forcep is placed on infundibulum of GB and peritoneum.
• Gallbladder peritoneum is placed on stretch and separated from
gallbladder alone the wall of the gall bladder.
• Fat is carefully dissected until cystic duct and artery are visualized.
• Cystic duct is cleaned till the CBD to visualize the CALOT’s
TRIANGLE.
• Cystic artery and duct are ligated and GB is removed.
• The dome shaped approach is the modification to this where the
fundus is dissected off the liver.
76. Open CBD visualisation
• It is less common.
• Same incision is taken.
• KOCHER’S MANEUVER is used.
• The abdomen is opened.
• The liver is lifted giving traction.
• A small incision of about 1 cm is made on the mesentery along the
wall of the duodenum.
• A finger (smooth) or an sharp instrument is introduced behind the
duodenum and the distal/retroduodenal and infraduodenal CBD is
visualised.
• Gentle palpation of Bile duct will ensure discovery of stone.
• It can then be milked backward.
• Stay sutures are placed and choledochotomy is performed.
77. Following this,
• T-tube can be placed.
• Duct can be flushed or
• Balloon catheterization with flouroscopic
guidance can be done.
78. In CBD stones, drainage procedure is
recommended. Long term better outcome.
Side to side or end to end
choledochoduodenostomy is a fast and safe
approach which allows future endoscopic
intervention at upper biliary tree.
Transhepatic sphincteroplasty is usually done in
patients with impacted stones at the ampula of
Vater or several stones in a non-dilated tree.
82. Lap. Chol.
Advantages of Lap. Chol. Over laparatomy are :-
• Smaller incision
• Lesser pain and
• Shorter hospital stay.
83. • Intolerence to GA, Portal HTN and end stage liver
disease are contraindications.
• 4 abdominal incisions are made and 4 ports are place
at each opening.
• The first incision is made at umblicus, another is made
in the epigastrium and 2 lateral incisions are made.
• Pneumoperitoneum is created with CO2.
• CALOT’s TRIANGLE is widely opened.
• The cystic duct and artery are first divided and then
ligated.
• The GB is to be removed next from the GB bed.
• 80% of patients can be discharged after 24-36 hours
depending on the presence of complications.
84.
85. Hepatico jejunostomy
• It is a Sx done to treat a few carcinomas of the
abdominal viscera.
• One of them being Ca BD and Ca Hepatic
Duct.
86. Scientists and their contribution to
naming of structures in the biliary tree
• Duct of Luschka – Dr. Hubert Luschka (GER)
• Sphincter of Oddi- Dr. Roggero Oddi (ITA)
• Spiral valve of heister- Dr. Lorenz Heister (GER)
• Ampula of Vater- Dr. Abraham Vater (GER)
• Moynihan’s Hump- Lord Moynihan (ENG)
• Calot’s Triangle- Dr. Jean Calot
87. Bibliography
• A short practice of surgery by Bailey and Love
• Sebistan’s Textbook of surgery
• Google images
• Wikipedia Scholar
• YouTube
88. Thanking You
• Please continue forward to the next slide to
see my senior’s and professor’s remarks and
additional points.
89. Remarks and additional points
• Biliary colic/pain due to Cholelithiasis and Choledocholithiasis
usually lasts for not more than 24 hours.
• If the pain persists for more than 24 hours, you must always suspect
Acute Cholecystitis.
• It may be as a complication of stone in GB or CBD or may be
independent in the absence of a stone.
• Ca GB or Ca of the biliary tree, throws a metastasis into the liver the
patient has a poor prognosis and 100% mortality within 6 months.
• There is no treatment for such cases.
• Stenting of the CBD helps relieve the bile stasis and pain.
• Use of opiates like morphine also helps relieve the pain in these
patients.
• After laparotomy or laparoscopic cholecystectomy an abdominal
wash is recommended to remove any pus spillage or blood clots.
