For medical students

1. GALLBLADDER AND BILE DUCTS
LT COL SM SHAHADAT HOSSAIN
MCPS,FCPS( Surgery),FCPS(Thoracic Surgery)
Adv Trg on Thoracoscopy,CNUH,South Korea

2. SURGICAL ANATOMY

3. Caterpillar turn’ or ‘moynihan’s hump

4. RADIOLOGICAL INVESTIGATION OF THE BILIARY TRACT
Plain radiographs:
 Radiopaque gallstones in 10% of patients.
 Mercedes–benz’ or ‘seagull’ sign.
 Porcelain’ gallbladder.

5. INVESTIGATION
Ultrasonography:
 Size of the gallbladder, presence of stones or polyps
thickness of the wall can be measured.
 Presence of inflammation of the gallbladder, size of the
common bile duct and stones can be determined.
 acoustic shadowing

6. INVESTIGATION
Cholescintigraphy:
 Iminodiacetic acid (HIDA, IODIDA) injected intravenously.
 In 90% of normal gallbladder is visualised within 30
minutes with 100% being seen within 1 hour after
injection.
 Non-visualization occur in acute cholecystitis. In chronic
cholecystitis, visualization may be reduced or delayed.

7. INVESTIGATION
Computed tomography (CT):
 It allows visualisation of the liver, bile ducts, gallbladder
and pancreas.
 It the modality of choice in the staging of cancers of the
liver, gallbladder, bile ducts and pancreas.

8. INVESTIGATION
Endoscopic ultrasonography (EUS): a specially designed
endoscope with an ultrasound transducer at its tip which
visualization of the liver and biliary.
Choledocholithiasis, tumour, biopsy

9. INVESTIGATION
Magnetic resonance cholangiopancreatography (MRCP):
 Images can be obtained of the biliary tree demonstrating
ductal obstruction, strictures or other intraductal
abnormalities.

10. Endoscopic retrograde cholangiopancreatography (ERCP)
Procedure:
 It is done under C-arm guidance and sedation like
midazolam or propofol anaesthesia.
 Patient is placed in prone position with the head turned
towards right.
 Through a side viewing gastroduodenoscope, sphincter of
Oddi is cannulated, and dye is injected.
 Biliary and pancreatic trees are visualised.

11. ERCP

12. Indications
1. Malignancy—irregular filling defect.
2. Chronic pancreatitis—‘chain-of-lakes’ appearance.
3. Congenital anomalies.
4. Stones.
5. Stricture of biliary tree.
6. Choledochal cyst.
7. Brush biopsy from tumour site.

13. Therapeutic uses
1. Extraction of stone from CBD.
2. Naso-biliary drainage.
3. Stenting of tumour in the CBD or in the pancreas.
4. Dilatation of the biliary stricture.
5. Endoscopic papillotomy.

14. Contraindicationss
1. Patients with serum bilirubin >3 mg%.
2. Acute cholecystitis.
3. Acute pancreatitis.
4. Previous gastrectomy.

15. Complications
i. Pancreatitis.
ii. Duodenal injury.
iii. Perforation.
iv. Cholangitis.
v. Bleeding.
vi. Sphincter stenosis.

16. Percutaneous transhepatic cholangiography (PTC)
Indications:
1. Failure of ERCP
2. High biliary strictures
3. Klatskin tumour
4. External biliary drainage
5. Stenting

17. Procedure
 With the help of fluoroscopy (C-arm)/US/CT guided,
Chiba or Okuda needle (15 cm long and 0.7 mm in
diameter) is passed into the liver through right 8th
intercostal space in mid axillary line.
 Once needle in the dilated biliary radicle, bile is aspirated.
 Water-soluble iodine dye is injected to visualise the
dilated biliary radicles.

18. PTC

19. GALLSTONES/CHOLELITHIASIS
 Gallstones are the most common biliary pathology.
 It affect 10–15% of the population in Western societies.
 Europe 80% are cholesterol or mixed stones, whereas in
Asia 80% are pigment stones.

20. Types
1. Cholesterol stones (Cholesterol solitaire) are 6%
common, often solitary.
2. Mixed stones are 90% common. It contains 51–99% pure
cholesterol plus an admixture of calcium salts, bile acids,
bile pigments and phospholipids.
3. Pigment stones are black or brown, small, multiple.

21. Factors associated with gallstone formation

22. PATHOGENESIS
I. Metabolic:
 Cholesterol is synthesised in liver.
 Its solubility is determined by relative concentration of
cholesterol, bile salts and lecithin.
 Altered levels of cholesterol, lecithin, and bile salts in bile
reduces the micelle concentration in the bile leading to
precipitation of insoluble cholesterol, hence, the stone
formation.

23. PATHOGENESIS
II. Infections and Infestations:
E. coli, Salmonella, Parasites like Clonorchis sinensis and
Ascaris lumbricoides.
III. Bile stasis:
Estrogen therapy, pregnancy, vagotomy and long-term
parenteral nutrition.
IV. Increased bilirubin production
Hereditary spherocytosis, sickle cell anaemia, thalassaemia,
malaria, cirrhosis.

24. Factors altering the cholesterol to bile salt ratio
 Obesity
 Drugs
–– Oral contraceptive pills, octreotide
–– Clofibrate
–– Cholestyramine
 Ileal disease
 Ileal resection
 Altered enterohepatic circulation

25. Saint’s triad
 Gallstones
 Diverticulosis of the colon
 Hiatus hernia

26. Clinical presentation
 Asymptomatic (80%).
 Symptomatic patients complain of right upper quadrant
or epigastric pain, which may radiate to the back.
 Others dyspepsia, flatulence, food intolerance.
 Biliary colic (10–25%) present severe right upper quadrant
pain associated with nausea and vomiting.
 Jaundice.

27. Effects of Gallstones
a. In the gallbladder
i. Silent stones.
iii. Acute cholecystitis.
iv. Chronic cholecystitis.
v. Empyema gallbladder.
vi. Perforation.
vii. Mucocele of gallbladder.
ix. Carcinoma gallbladder.

28. Effects of Gallstones
b. In the CBD
x. Secondary CBD stones.
xi. Cholangitis.
xii. Pancreatitis.
xiii. Mirizzi syndrome.
c. In the intestine
xiv. Gallstone ileus.

29. INVESTIGATION
 CBC: Leukocytosis.
 Blood grouping.
 RBS, LFT, Urea, S. creatinine, HBs Ag.
 ECG, X-ray chest.
 Ultrasonography of abdomen: Confirm.

30. Ultrasound

31. TREATMENT
More than 90% of cases, acute cholecystitis subside with
conservative measures.
Four principles:
1. Nil per mouth (NPO) and intravenous fluid
administration until the pain resolves.
2. Administration of analgesics.
3. Antibiotics(e.g. cefazolin, cefuroxime or
ciprofloxacillin).
4. Subsequent management. Cholecystectomy after
6weeks.

32. Treatment of Chlolilethiasis
Medical treatment:
Gall stone dissolution:
 Ursodeoxycholic acid (UDCA) – with a functioning Gall
bladder with stone less than 10 mm.
 10-15 mg/kg/day.
 Pigment stones are non responsive to medical therapy.

33. Surgical Treatment:
 Laparoscopic cholecystectomy is ideal.
 Open cholecystectomy:Right Sub-costal (KOCHERS’s)
incision