The document discusses the anatomy and surgical considerations of the gallbladder and bile ducts. It describes the structures and relationships of the gallbladder, cystic duct, common hepatic duct, and common bile duct. It also discusses the blood supply, lymphatics, variations in anatomy, and imaging modalities used to investigate the biliary tract such as ultrasound, cholescintigraphy, and endoscopic ultrasound.
This document provides an overview of abdominal wall hernias, including definitions, types, etiologies, anatomy, clinical features, and treatments. It describes the main types of groin hernias such as indirect, direct, and femoral hernias. It discusses the composition of hernias and provides classifications. For groin hernias specifically, it outlines the anatomy of the inguinal canal and contents, compares indirect and direct hernias, and describes surgical repair techniques like Bassini, Shouldice, and Lichtenstein. Femoral hernias are also summarized, including the anatomy of the femoral ring and canal.
Please find the power point on Carcinoma of rectum. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
This document discusses the management of appendicular lumps. It notes that appendicular lumps are inflammatory tumors consisting of the inflamed appendix and surrounding tissues. Treatment options include emergency surgery, conservative management followed by interval surgery, or totally conservative management without interval surgery. Conservative treatment is associated with a risk of missing hidden pathologies. Emergency surgery carries a high risk of complications while interval surgery risks appendicular abscess or perforation during the waiting period. Randomized controlled trials have found that conservative treatment without interval surgery appears to be the best approach for appendicular masses and abscesses. The document examines factors to consider in decision making and presents cases studies from a tertiary care center.
This document discusses different types of ventral hernias, including umbilical, epigastric, incisional, and paraumbilical hernias. It describes the causes, clinical features, diagnosis, and treatment options for each type. For treatment, it compares open surgical repair techniques like primary closure or mesh placement versus laparoscopic approaches. Complications of surgery like seroma, infection, and injury are also reviewed.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
This document discusses jaundice and diseases of the biliary tract. It covers the anatomy and physiology of the biliary system, pathophysiology of jaundice, etiologies including gallstones and cancer, clinical features such as itching and pale stools, diagnostic tests like liver enzymes and imaging, and treatment modalities for various biliary diseases. Key topics include cholecystitis, cholangitis, choledocholithiasis, biliary atresia, choledochal cysts, and hepatobiliary cancers.
This document provides an overview of abdominal wall hernias, including definitions, types, etiologies, anatomy, clinical features, and treatments. It describes the main types of groin hernias such as indirect, direct, and femoral hernias. It discusses the composition of hernias and provides classifications. For groin hernias specifically, it outlines the anatomy of the inguinal canal and contents, compares indirect and direct hernias, and describes surgical repair techniques like Bassini, Shouldice, and Lichtenstein. Femoral hernias are also summarized, including the anatomy of the femoral ring and canal.
Please find the power point on Carcinoma of rectum. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
This document discusses the management of appendicular lumps. It notes that appendicular lumps are inflammatory tumors consisting of the inflamed appendix and surrounding tissues. Treatment options include emergency surgery, conservative management followed by interval surgery, or totally conservative management without interval surgery. Conservative treatment is associated with a risk of missing hidden pathologies. Emergency surgery carries a high risk of complications while interval surgery risks appendicular abscess or perforation during the waiting period. Randomized controlled trials have found that conservative treatment without interval surgery appears to be the best approach for appendicular masses and abscesses. The document examines factors to consider in decision making and presents cases studies from a tertiary care center.
This document discusses different types of ventral hernias, including umbilical, epigastric, incisional, and paraumbilical hernias. It describes the causes, clinical features, diagnosis, and treatment options for each type. For treatment, it compares open surgical repair techniques like primary closure or mesh placement versus laparoscopic approaches. Complications of surgery like seroma, infection, and injury are also reviewed.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
This document discusses jaundice and diseases of the biliary tract. It covers the anatomy and physiology of the biliary system, pathophysiology of jaundice, etiologies including gallstones and cancer, clinical features such as itching and pale stools, diagnostic tests like liver enzymes and imaging, and treatment modalities for various biliary diseases. Key topics include cholecystitis, cholangitis, choledocholithiasis, biliary atresia, choledochal cysts, and hepatobiliary cancers.
1) Inguinal hernias are common, with approximately 700,000 repairs performed annually in the US, mostly occurring in males.
2) There are two main types of inguinal hernias - indirect and direct. Indirect hernias are congenital while direct hernias are acquired lesions that occur through the posterior inguinal wall.
3) Common surgical repair options include the Lichtenstein tension-free repair using mesh, the Shouldice repair with overlapping tissue layers, and laparoscopic repairs like TAPP and TEP which utilize a mesh placed laparoscopically.
This document outlines the presentation, causes, diagnosis, treatment, and nursing care of volvulus, which is the twisting of a loop of intestine that cuts off blood flow. It most commonly affects the sigmoid colon. Key points include that volvulus can be acute, sub-acute, or chronic; surgical intervention is usually needed to untwist the intestine; and nursing care involves pain management, fluid replacement, monitoring for complications, and educating patients and families.
Blood supply and lymphatic drainage of stomachMonitoshPaul
The document summarizes the blood supply and lymphatic drainage of the stomach. It discusses the arterial supply from branches like the left gastric, right gastric, and gastroepiploic arteries. It also discusses the venous drainage which parallels the arterial supply. The lymphatic drainage is described through 4 zones that primarily drain to the celiac nodes. The document provides surgical importance for preserving certain vessels and ligating others in procedures like gastrectomy and splenectomy.
This document provides information on various benign anorectal diseases. It discusses the anatomy of the rectum and anal canal and describes common conditions such as hemorrhoids, anal fissures, anorectal abscesses, anal fistulas, proctitis, pruritis ani, and rectal prolapse. For each condition, it covers definitions, causes, symptoms, examinations, investigations and treatments. The document also provides details on the clinical features, diagnosis and management of various anorectal diseases.
The document discusses the anatomy of the esophageal hiatus and types of hiatal hernia. It describes four types of hiatal hernia, with type I being the most common sliding hernia associated with GERD. Surgical options for repair include laparoscopic and open approaches, with the goals being to relieve symptoms and prevent complications by reducing reflux and returning the GE junction below the diaphragm. Post-operative care involves a progressive diet and activity plan, with most patients finding symptom relief but recurrence rates remaining between 20-40% even at large centers.
This document discusses Mirizzi syndrome, which refers to common hepatic duct obstruction caused by an impacted gallstone. It can occur in 0.1-2.5% of gallstone cases. Large stones can impact in the cystic duct or gallbladder neck, causing mechanical obstruction or inflammation of the common hepatic duct. Patients often present with jaundice, abdominal pain, or cholangitis. Diagnosis is difficult but can be aided by imaging like MRCP or ERCP. Surgical treatment depends on the classification and may involve cholecystectomy with possible bile duct repair or bypass. Complications can include bile duct injury, bleeding, or stricture.
The document discusses surgical management of chronic pancreatitis. It describes various surgical procedures for treating chronic pancreatitis including resection procedures like Whipple procedure, drainage procedures like Puestow's procedure, and hybrid procedures like Frey procedure. Studies have shown that duodenum-preserving pancreatic head resection procedures and longitudinal pancreaticojejunostomy provide better postoperative outcomes and pain control compared to resection procedures while preserving exocrine and endocrine function. The document concludes that surgery is effective for relieving pain in chronic pancreatitis and duodenum-preserving pancreatic head resection procedures have advantages over other surgical options.
This document summarizes intestinal obstruction, including:
1. The pathology and clinical features of mechanical obstruction proximal and distal to the obstruction site. Distension results from gas, fluid, and electrolyte imbalances.
2. Types of obstruction include internal and external strangulation, closed loop, and special types like internal hernia, strictures, and intussusception.
3. Clinical features include the classic pain, vomiting, distension, and constipation quartet. Treatment involves gastrointestinal drainage, fluid replacement, and surgical relief of the obstruction.
The document discusses liver anatomy, injuries, and management approaches. It provides details on:
1) The surface anatomy and blood supply of the liver.
2) Common causes and presentations of liver injuries including blunt trauma, penetrating trauma, and associated injuries.
3) Classification systems for grading liver injuries based on CT imaging findings.
4) Treatment approaches including non-operative management with observation for lower grade injuries or angioembolization for bleeding, and operative management using packing, Pringle maneuver, and resection for higher grade or unstable injuries.
Femoral hernia is the third common hernia after inguinal and incisional hernias. The swelling in femoral hernia is below and lateral to pubic tubercle. It is more common in females. Strangulation is very common in this hernia.
Management of enterocutaneous fistulas involves several phases:
1) Recognition and stabilization including resuscitation, controlling sepsis and drainage, nutrition support, and skin care.
2) Investigation using fistulograms and CT scans to define the fistula anatomy and underlying pathology.
3) Decision on management which depends on factors predicting spontaneous closure like output, nutrition status and bowel health.
4) Definitive surgery including bowel resection and anastomosis if needed, otherwise a staged approach with bypass.
5) Post-surgical recovery focusing on preventing recurrent fistula and hernia.
This document discusses abdominal abscesses, including:
- Definitions and types of abdominal abscesses
- Pathophysiology, factors that favor abscess formation, and clinical features
- Diagnostic tests including X-ray, CT scan, USG, and MRI
- Management including adequate resuscitation, antimicrobial therapy, and source control through percutaneous or surgical drainage
- Specific discussions of pyogenic liver abscesses, amoebic liver abscesses, prerequisites and complications of percutaneous drainage, and criteria for drain removal
The document discusses inguinal hernia and its management. It defines hernia and inguinal hernia, describing their types as direct or indirect. It details the anatomy of the inguinal region including structures like the inguinal canal, rings, and layers. It also discusses the etiology, risk factors, investigations and classifications of inguinal hernias. The management section summarizes techniques for hernia repair like herniotomy, herniorrhaphy, hernioplasty and laparoscopic repair. It highlights pioneers in the field including Bassini, Shouldice and modifications to their open tension-free techniques.
1. Inguinal hernia repair is the most common operation performed in the United States, with 75% of abdominal wall hernias occurring in the groin region. Inguinal hernias are more common in males, with a peak incidence before age 1 and after age 40.
2. Inguinal hernias can be direct, indirect, or femoral based on their anatomical location. Surgical repair with mesh is the definitive treatment, while conservative management with trusses is not recommended due to risk of complications.
3. Incarcerated or strangulated hernias require emergent surgery, while asymptomatic or minimally symptomatic hernias can often be initially managed non-oper
This is a powerpoint slideshow discussing some of the commonest disorders of colon; namely Hirschsprung's disease, Diverticular diseases of colon, ulcerative colitis, pseudomembranous colitis and ischemic colitis.
Anatomy, physiology and diagnosis of oesophageal diseasesAnwaaar
This document discusses the anatomy, physiology, and diagnosis of oesophageal diseases. It covers the surgical anatomy of the oesophagus, its physiology during swallowing, common symptoms of oesophageal diseases, and investigations used in diagnosis including barium swallow, endoscopy, endosonography, manometry, and pH monitoring. It also discusses specific oesophageal diseases and conditions such as congenital lesions, benign tumors, cancer, foreign bodies, perforations, gastroesophageal reflux disease, hiatal hernia, and motility disorders.
The document discusses the anatomy, physiology, and various disorders that can affect the small intestine, including Crohn's disease, intestinal tuberculosis, intestinal ameobiasis, Campylobacter infection, Salmonellosis, diverticula, mesenteric ischemia, intestinal fistulas, Celiac disease, bacterial overgrowth, and neoplasms. It provides details on the pathogenesis, clinical features, investigations, and management of these small intestinal disorders. The document also compares ulcerative and hyperplastic forms of intestinal tuberculosis and discusses conditions like Meckel's diverticulum, intestinal tumors, and Peutz-Jeg
This document defines and describes different types of internal hernias. It begins by defining an internal hernia as the protrusion of viscera through a normal or abnormal opening within the peritoneal cavity. It then lists common types of internal hernias such as paraduodenal, foramen of Winslow, and transmesenteric hernias. The document provides details on symptoms, diagnosis, and treatment for several specific types of internal hernias such as paraduodenal and transmesenteric hernias. It concludes by noting that high clinical suspicion and prompt surgical management are important for treating internal hernias.
Extra Levator Abdomino Perineal Resection Dr Harsh Shah
This document discusses extralevator abdominoperineal excision (ELAPE) for rectal cancer. It describes how ELAPE aims to improve on conventional abdominoperineal resection (APR) by removing a larger volume of tissue, including the levator muscles, to obtain clear margins. Meta-analyses have found ELAPE results in lower rates of circumferential resection margin involvement, local recurrence, and involved nodes compared to APR. However, ELAPE also increases morbidity risks and requires perineal wound reconstruction. While ELAPE shows potential oncological benefits, more high-quality studies are still needed to prove its superiority over selective approaches.
Dumping syndrome occurs after gastric surgery when food empties too quickly from the stomach into the small intestine. It has early and late forms. Early dumping causes GI symptoms like nausea within 30 minutes and cardiovascular symptoms like palpitations. Late dumping 2-3 hours later can cause hypoglycemia. Treatment involves dietary changes and medications like octreotide. Other post-gastrectomy syndromes include afferent loop obstruction and vitamin deficiencies. Surgery may be needed to correct mechanical issues or revise reconstructions.
Gallbladder and the Extrahepatic Biliary System.docxAtler1
This document describes the anatomy of the gallbladder and extrahepatic biliary system. It discusses the structure and positioning of the gallbladder, cystic duct, common hepatic duct, common bile duct, and sphincter of Oddi. It notes the blood supply, lymphatic drainage, innervation, and histology of these structures. Variations in anatomy are also described.
The document summarizes the key parts and functions of the digestive system. It describes the small intestine absorbing most nutrients and transporting waste to the large intestine. It then details the liver processing nutrients and filtering blood, before waste is expelled by the large intestine and rectum.
1) Inguinal hernias are common, with approximately 700,000 repairs performed annually in the US, mostly occurring in males.
2) There are two main types of inguinal hernias - indirect and direct. Indirect hernias are congenital while direct hernias are acquired lesions that occur through the posterior inguinal wall.
3) Common surgical repair options include the Lichtenstein tension-free repair using mesh, the Shouldice repair with overlapping tissue layers, and laparoscopic repairs like TAPP and TEP which utilize a mesh placed laparoscopically.
This document outlines the presentation, causes, diagnosis, treatment, and nursing care of volvulus, which is the twisting of a loop of intestine that cuts off blood flow. It most commonly affects the sigmoid colon. Key points include that volvulus can be acute, sub-acute, or chronic; surgical intervention is usually needed to untwist the intestine; and nursing care involves pain management, fluid replacement, monitoring for complications, and educating patients and families.
Blood supply and lymphatic drainage of stomachMonitoshPaul
The document summarizes the blood supply and lymphatic drainage of the stomach. It discusses the arterial supply from branches like the left gastric, right gastric, and gastroepiploic arteries. It also discusses the venous drainage which parallels the arterial supply. The lymphatic drainage is described through 4 zones that primarily drain to the celiac nodes. The document provides surgical importance for preserving certain vessels and ligating others in procedures like gastrectomy and splenectomy.
This document provides information on various benign anorectal diseases. It discusses the anatomy of the rectum and anal canal and describes common conditions such as hemorrhoids, anal fissures, anorectal abscesses, anal fistulas, proctitis, pruritis ani, and rectal prolapse. For each condition, it covers definitions, causes, symptoms, examinations, investigations and treatments. The document also provides details on the clinical features, diagnosis and management of various anorectal diseases.
The document discusses the anatomy of the esophageal hiatus and types of hiatal hernia. It describes four types of hiatal hernia, with type I being the most common sliding hernia associated with GERD. Surgical options for repair include laparoscopic and open approaches, with the goals being to relieve symptoms and prevent complications by reducing reflux and returning the GE junction below the diaphragm. Post-operative care involves a progressive diet and activity plan, with most patients finding symptom relief but recurrence rates remaining between 20-40% even at large centers.
This document discusses Mirizzi syndrome, which refers to common hepatic duct obstruction caused by an impacted gallstone. It can occur in 0.1-2.5% of gallstone cases. Large stones can impact in the cystic duct or gallbladder neck, causing mechanical obstruction or inflammation of the common hepatic duct. Patients often present with jaundice, abdominal pain, or cholangitis. Diagnosis is difficult but can be aided by imaging like MRCP or ERCP. Surgical treatment depends on the classification and may involve cholecystectomy with possible bile duct repair or bypass. Complications can include bile duct injury, bleeding, or stricture.
The document discusses surgical management of chronic pancreatitis. It describes various surgical procedures for treating chronic pancreatitis including resection procedures like Whipple procedure, drainage procedures like Puestow's procedure, and hybrid procedures like Frey procedure. Studies have shown that duodenum-preserving pancreatic head resection procedures and longitudinal pancreaticojejunostomy provide better postoperative outcomes and pain control compared to resection procedures while preserving exocrine and endocrine function. The document concludes that surgery is effective for relieving pain in chronic pancreatitis and duodenum-preserving pancreatic head resection procedures have advantages over other surgical options.
This document summarizes intestinal obstruction, including:
1. The pathology and clinical features of mechanical obstruction proximal and distal to the obstruction site. Distension results from gas, fluid, and electrolyte imbalances.
2. Types of obstruction include internal and external strangulation, closed loop, and special types like internal hernia, strictures, and intussusception.
3. Clinical features include the classic pain, vomiting, distension, and constipation quartet. Treatment involves gastrointestinal drainage, fluid replacement, and surgical relief of the obstruction.
The document discusses liver anatomy, injuries, and management approaches. It provides details on:
1) The surface anatomy and blood supply of the liver.
2) Common causes and presentations of liver injuries including blunt trauma, penetrating trauma, and associated injuries.
3) Classification systems for grading liver injuries based on CT imaging findings.
4) Treatment approaches including non-operative management with observation for lower grade injuries or angioembolization for bleeding, and operative management using packing, Pringle maneuver, and resection for higher grade or unstable injuries.
Femoral hernia is the third common hernia after inguinal and incisional hernias. The swelling in femoral hernia is below and lateral to pubic tubercle. It is more common in females. Strangulation is very common in this hernia.
Management of enterocutaneous fistulas involves several phases:
1) Recognition and stabilization including resuscitation, controlling sepsis and drainage, nutrition support, and skin care.
2) Investigation using fistulograms and CT scans to define the fistula anatomy and underlying pathology.
3) Decision on management which depends on factors predicting spontaneous closure like output, nutrition status and bowel health.
4) Definitive surgery including bowel resection and anastomosis if needed, otherwise a staged approach with bypass.
5) Post-surgical recovery focusing on preventing recurrent fistula and hernia.
This document discusses abdominal abscesses, including:
- Definitions and types of abdominal abscesses
- Pathophysiology, factors that favor abscess formation, and clinical features
- Diagnostic tests including X-ray, CT scan, USG, and MRI
- Management including adequate resuscitation, antimicrobial therapy, and source control through percutaneous or surgical drainage
- Specific discussions of pyogenic liver abscesses, amoebic liver abscesses, prerequisites and complications of percutaneous drainage, and criteria for drain removal
The document discusses inguinal hernia and its management. It defines hernia and inguinal hernia, describing their types as direct or indirect. It details the anatomy of the inguinal region including structures like the inguinal canal, rings, and layers. It also discusses the etiology, risk factors, investigations and classifications of inguinal hernias. The management section summarizes techniques for hernia repair like herniotomy, herniorrhaphy, hernioplasty and laparoscopic repair. It highlights pioneers in the field including Bassini, Shouldice and modifications to their open tension-free techniques.
1. Inguinal hernia repair is the most common operation performed in the United States, with 75% of abdominal wall hernias occurring in the groin region. Inguinal hernias are more common in males, with a peak incidence before age 1 and after age 40.
2. Inguinal hernias can be direct, indirect, or femoral based on their anatomical location. Surgical repair with mesh is the definitive treatment, while conservative management with trusses is not recommended due to risk of complications.
3. Incarcerated or strangulated hernias require emergent surgery, while asymptomatic or minimally symptomatic hernias can often be initially managed non-oper
This is a powerpoint slideshow discussing some of the commonest disorders of colon; namely Hirschsprung's disease, Diverticular diseases of colon, ulcerative colitis, pseudomembranous colitis and ischemic colitis.
Anatomy, physiology and diagnosis of oesophageal diseasesAnwaaar
This document discusses the anatomy, physiology, and diagnosis of oesophageal diseases. It covers the surgical anatomy of the oesophagus, its physiology during swallowing, common symptoms of oesophageal diseases, and investigations used in diagnosis including barium swallow, endoscopy, endosonography, manometry, and pH monitoring. It also discusses specific oesophageal diseases and conditions such as congenital lesions, benign tumors, cancer, foreign bodies, perforations, gastroesophageal reflux disease, hiatal hernia, and motility disorders.
The document discusses the anatomy, physiology, and various disorders that can affect the small intestine, including Crohn's disease, intestinal tuberculosis, intestinal ameobiasis, Campylobacter infection, Salmonellosis, diverticula, mesenteric ischemia, intestinal fistulas, Celiac disease, bacterial overgrowth, and neoplasms. It provides details on the pathogenesis, clinical features, investigations, and management of these small intestinal disorders. The document also compares ulcerative and hyperplastic forms of intestinal tuberculosis and discusses conditions like Meckel's diverticulum, intestinal tumors, and Peutz-Jeg
This document defines and describes different types of internal hernias. It begins by defining an internal hernia as the protrusion of viscera through a normal or abnormal opening within the peritoneal cavity. It then lists common types of internal hernias such as paraduodenal, foramen of Winslow, and transmesenteric hernias. The document provides details on symptoms, diagnosis, and treatment for several specific types of internal hernias such as paraduodenal and transmesenteric hernias. It concludes by noting that high clinical suspicion and prompt surgical management are important for treating internal hernias.
Extra Levator Abdomino Perineal Resection Dr Harsh Shah
This document discusses extralevator abdominoperineal excision (ELAPE) for rectal cancer. It describes how ELAPE aims to improve on conventional abdominoperineal resection (APR) by removing a larger volume of tissue, including the levator muscles, to obtain clear margins. Meta-analyses have found ELAPE results in lower rates of circumferential resection margin involvement, local recurrence, and involved nodes compared to APR. However, ELAPE also increases morbidity risks and requires perineal wound reconstruction. While ELAPE shows potential oncological benefits, more high-quality studies are still needed to prove its superiority over selective approaches.
Dumping syndrome occurs after gastric surgery when food empties too quickly from the stomach into the small intestine. It has early and late forms. Early dumping causes GI symptoms like nausea within 30 minutes and cardiovascular symptoms like palpitations. Late dumping 2-3 hours later can cause hypoglycemia. Treatment involves dietary changes and medications like octreotide. Other post-gastrectomy syndromes include afferent loop obstruction and vitamin deficiencies. Surgery may be needed to correct mechanical issues or revise reconstructions.
Gallbladder and the Extrahepatic Biliary System.docxAtler1
This document describes the anatomy of the gallbladder and extrahepatic biliary system. It discusses the structure and positioning of the gallbladder, cystic duct, common hepatic duct, common bile duct, and sphincter of Oddi. It notes the blood supply, lymphatic drainage, innervation, and histology of these structures. Variations in anatomy are also described.
The document summarizes the key parts and functions of the digestive system. It describes the small intestine absorbing most nutrients and transporting waste to the large intestine. It then details the liver processing nutrients and filtering blood, before waste is expelled by the large intestine and rectum.
The document summarizes the key parts and functions of the digestive system. It describes the small intestine absorbing most nutrients and transporting waste to the large intestine. It then details the liver which filters blood and produces bile, and the gallbladder which stores and concentrates bile. Diseases like cirrhosis and conditions like jaundice are also mentioned.
The document summarizes the key parts and functions of the digestive system. It describes the small intestine absorbing most nutrients and transporting waste to the large intestine. It then details the liver processing nutrients and filtering toxins from the bloodstream before waste is expelled from the body. Complications like cirrhosis and its effects on blood flow are also summarized.
The extrahepatic biliary apparatus consists of the right and left hepatic ducts, common hepatic duct, gallbladder, cystic duct, and bile duct. The hepatic ducts emerge from the liver and join to form the common hepatic duct, which then joins with the cystic duct from the gallbladder to form the bile duct. The gallbladder is a reservoir for bile located in the liver that concentrates and stores bile before releasing it through the cystic duct into the bile duct for transport to the duodenum. The bile duct courses through the liver and pancreas, joining with the pancreatic duct before entering the duodenum.
This document provides an overview of abdominal radiological anatomy. It discusses the anatomy of major abdominal organs including the liver, biliary tract, spleen, pancreas, kidneys, adrenal glands, and gastrointestinal tract. For each organ, it describes key anatomical features visible on imaging modalities like ultrasound, CT, and MRI. It also reviews some common anatomical variants seen in these structures.
The human biliary system is composed of the liver, gallbladder, and bile duct. Understanding these complex systems will guide the students in training for better anatomical knowledge in the vein, artery, lymph nodes, and functional activities.
This document provides an overview of the anatomy, physiology, development and investigations of the extrahepatic biliary apparatus (EHBA) which includes the gallbladder, cystic duct, common hepatic duct, bile duct, and sphincters. It describes the key structures and their relationships, functions of bile storage and concentration, arterial supply, venous and lymphatic drainage. Common investigations discussed are ultrasound, CT, MRCP, ERCP and cholangiography.
Power point presentation on Radiological anatomy of LiverNavyaChandragiri2
The document discusses the liver including its embryology, anatomy, and normal sonographic appearance. Regarding embryology, the liver bud develops from the endoderm during the 4th week and differentiates into hepatocytes and cholangiocytes. Anatomically, the liver is divided into three lobes - right, left, and caudate. The normal liver extends from the 5th intercostal space down to the costal margin and is homogeneous with fine echoes similar to the renal cortex. Sonographically, the hepatic and portal veins within the liver parenchyma are visible.
The document discusses various congenital anomalies of the pancreas including annular pancreas, pancreas divisum, ectopic pancreatic tissue, horseshoe pancreas, and variations in pancreatic ductal anatomy. It describes the embryological development of the pancreas and defines important anatomical structures such as the pancreatic ducts. Imaging features of different pancreatic anomalies on modalities like CT, MRI, ERCP, and ultrasound are provided.
The document summarizes the anatomy of the biliary tree. It describes how bile is produced in the liver and stored in the gallbladder before being released into the duodenum during digestion. It outlines the structures that make up the biliary tree, including the hepatic ducts, cystic duct, common bile duct, and sphincter of Oddi. It also discusses important anatomical landmarks surgeons must be aware of when performing cholecystectomies, such as Calot's triangle, the cystic lymph node of Lund, Hartmann's pouch, and Rouviere's sulcus.
The document discusses the history and development of hepatobiliary surgery over the past few centuries. Key points include:
- Surgery on the liver was rarely successful until the past 3 decades due to its complex anatomy and abundant blood supply.
- Laparoscopic cholecystectomy, developed in the 1980s, opened up the field of minimally invasive surgery for hepatobiliary diseases.
- Hepatic resections and liver transplantation have become much safer procedures over recent decades due to improved technology and understanding of liver anatomy and physiology. Liver transplantation was first successfully performed in the 1960s.
Gentiourinary system ANATOMY AND PHYSIOLOGY & ASSESSMENTRAJAG58
The document describes the anatomy and physiology of the urinary system. It details the major structures including the kidneys, ureters, bladder, and urethra. It explains that the kidneys filter waste from the blood to produce urine and regulate important processes in the body. Urine travels from the kidneys through the ureters to the bladder, then exits through the urethra. Key functions of the urinary system include waste excretion, fluid and electrolyte balance, and blood pressure regulation.
The document provides information about the gallbladder and pancreas. It describes the location, structure, parts, layers, blood supply, functions, clinical disorders, and removal of the gallbladder. It also details the location, structure, parts, ducts, blood supply, congenital defects, acute pancreatitis, and imaging findings of the pancreas. The document contains detailed anatomical and physiological information about both organs presented through text and diagrams.
The gallbladder is normally located in the liver and has four parts: the fundus, body, infundibulum, and neck. The cystic duct connects the gallbladder to the common hepatic duct. Variations can include agenesis, duplication, wandering position, abnormal shapes like Phrygian caps, or ectopic locations in or outside the liver. The cystic artery typically originates from the right hepatic artery but can also arise from other sources.
The document discusses the anatomy and functions of the digestive system, describing the tubular nature of the digestive tract and its individual organs like the liver, gallbladder, pancreas, and sections of the small and large intestines. It provides details on the histology and microscopic structure of the digestive organs and discusses their roles in digestion and absorption of nutrients. The major blood vessels supplying the digestive system and regions like the duodenum, jejunum and ileum of the small intestine are also outlined.
The gallbladder develops from the hepatic diverticulum in the 4th week of gestation. It is a pear-shaped sac located on the inferior surface of the liver that stores and concentrates bile. It receives its blood supply from the cystic artery and drains into the hepatic portal system. The gallbladder contracts in response to cholecystokinin to empty bile into the duodenum after meals. Anatomical variations include abnormal positioning, duplication, and anomalous arterial supply.
The urinary system includes the kidneys, ureters, urinary bladder, and urethra. The kidneys filter the blood to remove wastes and produce urine. The ureters are tubes that carry urine from the kidneys to the bladder. The bladder stores urine until urination. The urethra then carries urine from the bladder to the outside of the body. Key structures of the urinary system were described in detail including locations, blood supply, and clinical relevance.
Lect. 14 digestive system - associated glandsHara O.
This document provides information about the accessory organs of the digestive system, including the salivary glands, liver, and pancreas. It describes the structure and function of the parotid, submandibular, and sublingual salivary glands. It also discusses the role of the liver in vascular functions, metabolism, secretion, and excretion. Additionally, it outlines the structure of liver lobules and hepatocytes. The document concludes by examining the exocrine and endocrine functions of the pancreas.
The document discusses the anatomy and function of the parathyroid glands. It describes how the four parathyroid glands typically develop in the neck and regulate calcium levels through the production and release of parathyroid hormone (PTH). PTH acts on the kidneys, bone, and gastrointestinal tract to increase calcium resorption and absorption. The parathyroid glands and PTH work to maintain serum calcium levels within a narrow range.
This document provides guidelines for perioperative care in elective colorectal surgery as part of an Enhanced Recovery After Surgery (ERAS) protocol. It makes recommendations for several preadmission items including preadmission counselling and education, preoperative optimization of medical conditions, prehabilitation, preoperative nutrition, management of anemia, and prevention of postoperative nausea and vomiting. The recommendations are based on reviews of the available evidence and are intended to reduce complications and facilitate early recovery after colorectal surgery.
This study analyzed data from over 27,000 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent elective colorectal resection from 2012 to 2015. The study found that while mechanical bowel preparation alone did not reduce postoperative infections, the combination of mechanical and antibiotic bowel preparation resulted in significantly fewer surgical site infections and Clostridium difficile infections compared to no preparation or antibiotic preparation alone. The authors conclude that combined mechanical and antibiotic bowel preparation should be used for elective colorectal resections when possible due to its effectiveness in reducing infectious complications.
The document discusses the history and evolution of surgery from ancient times to the modern era. It describes early surgical techniques performed by Sushruta in 800 BC India, including the first recorded cataract surgery. It discusses the hurdles faced by early surgeons due to lack of anesthesia, antiseptics, and other modern medical advances. Key figures discussed include Andreas Vesalius in the 1500s, Joseph Lister introducing antiseptics in the 1860s, William Morton demonstrating ether anesthesia in 1846, William T. Bovie and Harvey Cushing developing electrosurgery in the 1920s, and Emil Theodor Kocher pioneering aseptic surgery and thyroidectomy techniques.
MRI uses strong magnetic fields and radio waves to produce images of the inside of the body. It provides excellent soft tissue contrast without needing ionizing radiation or intravenous contrast in some cases. During an MRI scan, protons in the body are aligned with the magnetic field and exposed to radio pulses that cause them to produce signals detectable by the MRI machine. Different pulse sequences produce T1-weighted, T2-weighted, or proton density weighted images depending on how tissues release energy. Contrast agents containing gadolinium can also be used to enhance images. MRI has advantages over other modalities due to lack of radiation exposure and ability to image pregnant patients or those with renal issues.
The document provides details on the anatomy of the neck, including:
- Surface anatomy landmarks of neck structures like arteries, nerves and thyroid gland.
- The cervical triangles - anterior, posterior and contents.
- Fascial layers like superficial, deep cervical and visceral fascia.
- Fascial spaces in the neck.
- Cutaneous nerves and superficial veins of the neck.
- Structures in the anterior triangle like the carotid triangle and its contents.
This document provides definitions and guidelines for the management of septic shock. It begins with definitions of terms like SIRS, sepsis, septic shock, and qSOFA. It then discusses the pathophysiology of sepsis, including the host immune response and organ dysfunction. Manifestations across organ systems are outlined. Recommended markers for sepsis diagnosis are described. Treatment protocols emphasize early fluid resuscitation, screening programs, appropriate cultures before antibiotics, initiating broad-spectrum antibiotics within 1 hour, and optimizing antibiotic dosing and duration. Combination empiric therapy for septic shock may be considered but should be de-escalated once infection is controlled.
This document discusses newborn physiology across multiple body systems. It covers thermal regulation in newborns, cardiovascular physiology including ductus arteriosus closure and treatment of patent ductus arteriosus. It also discusses pulmonary development and surfactant, immunology, fluid management, nutrition and total parenteral nutrition. Other topics covered include blood volume, thermoregulation, pain management, and extracorporeal life support. The document provides detailed information on the anatomical and physiological differences between newborns and older children or adults.
The document discusses the surgical management of primary tumors, regional lymph nodes, and distant metastases. It covers topics like radical vs conservative surgery, lymphadenectomy, sentinel lymph node biopsy, and criteria for resection of distant metastases. It also discusses the use of chemotherapy, including neoadjuvant chemotherapy and response evaluation criteria.
This document discusses various topics related to nutrition including:
1. Three subtypes of malnutrition associated with starvation, chronic disease, or acute disease/injury.
2. Formulas for calculating ideal body weight and interpreting BMI.
3. Methods for assessing nutritional status like serum albumin levels and energy expenditure equations.
4. The metabolic response to starvation involving the breakdown of glycogen, amino acids, and fat stores over time.
This document discusses hypovolemic shock and hypothermia. It defines hypovolemic shock as a systemic state of low perfusion caused by inadequate fluid volume. It describes the pathophysiology as reduced perfusion leading to cellular hypoxia, microvascular injury, and systemic responses like tachycardia and vasoconstriction. The document outlines methods for assessing fluid status, such as the modified shock index and fluid challenge tests. It also discusses the risks of hypothermia for trauma patients, like coagulopathy, and different techniques for warming patients, with active internal warming through conduction seen as most effective.
This document discusses electrolytes, specifically sodium disorders like hyponatremia and hypernatremia. It defines hyponatremia as a plasma sodium concentration below 135 mM and divides it into three categories based on volume status: hypovolemic, euvolemic, and hypervolemic. Common causes of euvolemic hyponatremia include syndrome of inappropriate antidiuretic hormone secretion. Treatment depends on symptoms and involves slow correction to avoid osmotic demyelination syndrome. Vaptan antagonists and fluid restriction are effective therapies. Hypernatremia occurs when sodium levels rise above 145 mM due to water loss exceeding sodium loss.
The document discusses strategies for preventing surgical site infections (SSIs) in perioperative patients, including proper use of antibiotics, glycemic control to reduce blood glucose levels, and maintaining normothermia in patients. It defines different types of SSIs and provides guidelines for non-parenteral antimicrobial prophylaxis. Factors that influence antibiotic administration like renal function, renal support, and liver failure are also reviewed. The effects of patient comorbidities and optimal dosing of various antibiotic classes are discussed.
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
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2. SURGICAL
ANATOMY
1.Gallbladder
It is a pear-shaped structure, 7.5– 12 cm long, with a normal
capacity of about 25–30 mL.
The anatomical divisions are a fundus, a body and a neck that
terminates in a narrow infundibulum.The muscle fibres in the wall
of the gallbladder are arranged in a criss-cross manner, being
particularly well developed in its neck.The mucous membrane
contains indentations of the mucosa that sink into the muscle
coat; these are the crypts of Luschka.
3. SURGICAL
ANATOMY
1.Gallbladder
The gallbladder is entirely surrounded by peritoneum, and is in
direct relation to the visceral surface of the liver.
It lies in close proximity to the following structures:
1. Anteriorly and superiorly – inferior border of the liver and the
anterior abdominal wall.
2. Posteriorly – transverse colon and the proximal duodenum.
3. Inferiorly – biliary tree and remaining parts of the duodenum.
7. SURGICAL
ANATOMY
2.Cystic Duct
The cystic duct is about 3 cm in length but the length is variable.
The lumen is usually 1–3 mm in diameter.The mucosa of the cystic
duct is arranged in spiral folds known as the valves of Heister and
the wall is surrounded by a sphincteric structure called the
sphincter of Lütkens.
The cystic duct joins the supraduodenal segment of the common
hepatic duct in 80% of cases, however the anatomy may vary and
the junction may be much lower in the retroduodenal or even
retropancreatic part of the bile duct
9. SURGICAL
ANATOMY
3.Common
Bile Duct
The common hepatic duct is usually less than 2.5 cm long and is
formed by the union of the right and left hepatic ducts.
The common bile duct is about 7.5 cm long and formed by the
junction of the cystic and common hepatic ducts. It is divided into
four parts:
1. the supraduodenal portion, about 2.5 cm long, runs in the free
edge of the lesser omentum;
2. the retroduodenal portion;
3. the infraduodenal portion lies in a groove, but at times in a
tunnel, on the posterior surface of the pancreas;
4. the intraduodenal portion passes obliquely through the wall of
the second part of the duodenum, where it is surrounded by
the sphincter of Oddi, and terminates by opening on the
summit of the ampulla ofVater.
10. The Biliary
Tree
The biliary tree is a series of gastrointestinal ducts allowing newly
synthesized bile from the liver to be concentrated and stored in
the gallbladder (prior to release into the duodenum).
Bile is initially secreted from hepatocytes and drains from both
lobes of the liver via canaliculi, intralobular ducts and collecting
ducts into the left and right hepatic ducts.These ducts
amalgamate to form the common hepatic duct, which runs
alongside the hepatic vein.
11. The Biliary
Tree
As the common hepatic duct descends, it is joined by the cystic
duct – which allows bile to flow in and out of the gallbladder for
storage and release.At this point, the common hepatic duct and
cystic duct combine to form the common bile duct.
The common bile duct descends and passes posteriorly to the
first part of the duodenum and head of the pancreas. Here, it is
joined by the main pancreatic duct, forming the
hepatopancreatic ampulla (commonly known as the ampulla of
Vater) – which then empties into the duodenum via the major
duodenal papilla.This papilla is regulated by a muscular valve, the
sphincter of Oddi.
15. Vasculature
ofGallbladder
The arterial supply to the gallbladder is via the cystic artery – a
branch of the right hepatic artery (which itself is derived from the
common hepatic artery, one of the three major branches of the
coeliac trunk).
Venous drainage of the neck of the gallbladder is via the cystic
veins, which drain directly into the portal vein.
Venous drainage of the fundus and body of the gallbladder flows
into the hepatic sinusoids.
18. Calot’s
triangle, or the
hepatobiliary
triangle
It was initially described by Calot as the space bordered by the
cystic duct inferiorly, the common hepatic duct medially and the
superior border of the cystic artery.
This has been modified in contemporary literature to be the area
bound superiorly by the inferior surface of the liver, laterally by the
cystic duct and the medial border of the gallbladder and medially
by the common hepatic duct.
21. Lymphatics
The lymphatic vessels of the gallbladder (subserosal and
submucosal) drain into the cystic lymph node of Lund (the
sentinel lymph node), which lies in the fork created by the junction
of the cystic and common hepatic ducts.
Efferent vessels from this lymph node go to the hilum of the liver,
and to the coeliac lymph nodes.
The subserosal lymphatic vessels of the gallbladder also connect
with the subcapsular lymph channels of the liver, and this accounts
for the frequent spread of carcinoma of the gallbladder to the
liver.
22. Surgical
physiology
Bile is produced by the liver and stored in the gallbladder, from
which it is released into the duodenum.
As it leaves the liver it is composed of 97% water, bile salts (cholic
and chenodeoxycholic acids, deoxycholic and lithocholic acids),
phospholipids, cholesterol and bilirubin.
The liver excretes bile at a rate estimated to be approximately 40
mL/hour.
About 95% of bile salts are reabsorbed in the terminal ileum
(enterohepatic circulation).
23. Functions of
the gallbladder
1. Areservoir for bile. During fasting, resistance to flow through
the sphincter of Oddi is high, and bile excreted by the liver is
diverted to the gallbladder.After feeding, the resistance to
flow through the sphincter is reduced, the gallbladder contracts
and the bile enters the duodenum.These motor responses of
the biliary tract are in part affected by the hormone
cholecystokinin.
2. Concentration of bile by active absorption of water, sodium
chloride and bicarbonate via the mucous membrane of the
gallbladder.The hepatic bile which enters the gallbladder
becomes concentrated 5–10 times, with a corresponding
increase in the proportion of bile salts, bile pigments,
cholesterol and calcium.
3. Secretion of mucus – approximately 20 mL is produced per day.
With complete obstruction of the cystic duct in an otherwise
healthy gallbladder, a mucocoele may develop as a result of
ongoing mucus secretion by the gallbladder mucosa.
24. RADIOLOGICAL
INVESTIGATION
OFTHE BILIARY
TRACT
1.Xray Plain radiograph showing
radiopaque stones in the
gallbladder.
Radiopaque stones are rare
(10%).
Porcelain
gallbladder.
Gas in the gallbladder
and gallbladder wall
(Clostridium
perfringens).
Emergency surgery is
indicated.
25. RADIOLOGICAL
INVESTIGATION
OFTHE BILIARY
TRACT
2.
Ultrasonography
Transabdominal ultrasonography is the initial imaging modality
of choice as it is accurate, readily available, inexpensive and quick
to perform. However, it is operator dependent and may be
compromised by excessive body fat and intraluminal bowel gas.
The size of the gallbladder can be seen, the presence of stones or
polyps determined and the thickness of the wall measured.
Additionally, the presence of inflammation around the
gallbladder, the size of the common bile duct and, occasionally,
the presence of stones within the extrahepatic biliary tree can be
determined.
For the patient who presents with obstructive jaundice, it can
identify intra- and extrahepatic biliary dilatation and often the
level of obstruction. In addition, the cause of the obstruction may
also be determined, such as gallstones in the gallbladder,
common hepatic or common bile duct stones, lesions within the
wall of the common bile duct suggestive of a cholangiocarcinoma
or enlargement of the pancreatic head indicative of a pancreatic
carcinoma.
27. RADIOLOGICAL
INVESTIGATION
OFTHE BILIARY
TRACT
2.
Ultrasonography
Endoscopic ultrasonography (EUS) utilises a specially designed endoscope
with an ultrasound transducer at its tip which allows the gastroenterologist to
visualize the liver and biliary tree from within the stomach and duodenum.
It is accurate in imaging the bile duct and detecting the presence of
choledocholithiasis. In addition, it has been shown to be useful in diagnosing
and staging both pancreatic and periampullary cancers. Biopsies can be taken
from suspicious areas for either cytological or histopathological analysis.
28. 3. Cholescintigraphy
Technetium-99m (99mTc)-labelled derivatives of iminodiacetic acid
(HIDA, IODIDA) when injected intravenously are selectively taken
up by the retroendothelial cells of the liver and excreted into the
bile. This allows visualization of the biliary tree and gallbladder. In
90% of normal individuals the gallbladder is visualized within
30 minutes following injection, with 100% being seen within 1
hour.
The bowel is seen, usually within 1 hour, in the majority of
patients. Non- visualization of the gallbladder is suggestive of
acute cholecystitis. If the patient has a contracted gallbladder,
as often seen in chronic cholecystitis, the gallbladder visualization
may be reduced or delayed.
An abnormally low gallbladder ejection fraction may be suggestive
of gallbladder dyskinesia; however, the diagnosis and
interpretation of cholescintigraphy in this context are
controversial.
Biliary scintigraphy may also be helpful in diagnosing bile leaks
and iatrogenic biliary obstruction.
29. 4.Computed
tomography
(CT)
CT is less affected by body habitus
and is not operator dependent. It
allows visualisation of the liver, bile
ducts, gallbladder and pancreas.
It is particularly useful in detecting
hepatic and pancreatic lesions and
is the modality of choice in the
staging of cancers of the liver,
gallbladder, bile ducts and
pancreas. It can identify the extent
of the primary tumour and define
the relationship of the tumour to
other organs and blood vessels.
In addition, the presence of
enlarged lymph nodes or
metastatic disease may be seen.
However, as only 75% of gallstones
are identified by CT, it is not used
as a screening modality for
uncomplicated gallstones.
30. 5. Endoscopic
retrograde
cholangiopancreato
graphy (ERCP)
Using a side-viewing endoscope the
ampulla ofVater can be identified and
cannulated. Injection of water-soluble
contrast directly into the bile duct
provides excellent images of the ductal
anatomy and can identify causes of
obstruction such as calculi or malignant
strictures.
It is especially useful in determining
the cause and level of obstruction.
During ERCP, bile aspirates can be
sent for cytological and
microbiological examination, and
endoluminal brushings can be taken
from strictures for cytological
studies.
Therapeutic interventions such as
stone removal or stent placement to
relieve the obstruction can be
performed.
31. 6. Magnetic
resonance
cholangiopanc
reatography
(MRCP)
Images can be obtained
of the biliary tree
demonstrating ductal
obstruction, strictures or
other intraductal
abnormalities.
Images comparable to
those obtained using
ERCP or PTC can be
achieved non-invasively
without the potential
complications of either
technique.
By use of the water
content of bile, a
cholangiopancreatogram
can be created, which
makes it an excellent
modality for cross-
sectional imaging of the
biliary tree.
32. 7. Percutaneous
transhepatic
cholangiography
(PTC)
Under radiological control (either
ultrasound or CT) a bile duct is cannulated.
Successful entry is confirmed by contrast
injection or aspiration of bile.Water-
soluble contrast medium is injected to
visualise the biliary system. Multiple
images can be taken demonstrating areas
of strictures or obstruction. Bile can be
sent for cytology.
In addition, this technique enables
placement of a catheter into the bile ducts
to provide external biliary drainage or the
insertion of indwelling stents.The scope
of this procedure can be further extended
by leaving the drainage catheter in situ for
a number of days and then dilating the
track sufficiently for a fine flexible
choledochoscope to be passed into the
intrahepatic biliary tree in order to
diagnose strictures, take biopsies and
remove stones
In general, if a malignant stricture at the
level of the confluence of the right and left
hepatic ducts or higher is suspected in a
jaundiced patient, a PTC is preferred to
ERCP because successful drainage is more
likely.
33. CONGENITAL
ABNORMALITIES
OFTHE
GALLBLADDERAND
BILE DUCTS
Absence of the gallbladder
The Phrygian cap
Floating gallbladder
Absence of the cystic duct
usually a pathological, as opposed to an anatomical, anomaly and
indicates the recent passage of a stone or the presence of a stone at
the lower end of the cystic duct, which is ulcerating into the
common bile duct.The main danger at surgery is damage to the bile
duct, and particular care to identify the correct anatomy is essential
before division of any duct.
Low insertion of the cystic duct
An accessory cholecystohepatic duct
34. EXTRAHEPATIC
BILIARY
ATRESIA
The extrahepatic bile ducts are progressively destroyed by an
inflammatory process which starts around the time of birth.
The inflammatory destruction of the bile ducts has been
classified into three main types:
type I: atresia restricted to the common bile duct;
type II: atresia of the common hepatic duct;
type III: atresia of the right and left hepatic ducts.
Associated anomalies occur in about 20% of cases and include
cardiac lesions, polysplenia, situs inversus, absent vena cava and a
preduodenal portal vein.
35.
36. EXTRAHEPATIC
BILIARY
ATRESIA
Clinical features
About one-third of patients are jaundiced at birth. In all, however,
jaundice is present by the end of the first week and deepens
progressively. Liver function tests show an obstructive pattern
with elevated bilirubin and alkaline phosphatase.
The meconium may be a little bile stained, but later the stools are
pale and the urine is dark. Prolonged steatorrhoea gives rise to
osteomalacia (biliary rickets). Pruritus is severe.
Clubbing and skin xanthomas, probably related to raised serum
cholesterol, may be present.
37. Treatment
A simple biliary–enteric anastomosis is not possible in the majority
of cases in which the proximal hepatic ducts are either very small
(type II) or atretic (type III).
These are treated by the Kasai procedure, in which radical
excision of all bile duct tissue up to the liver capsule is performed.
A Roux-en-Y loop of jejunum is anastomosed to the exposed area
of liver capsule above the bifurcation of the portal vein, creating a
portoenterostomy.
The chances of achieving effective bile drainage after
portoenterostomy are maximal when the operation is performed
before the age of 8 weeks, and approximately 90% of children
whose bilirubin falls to within the normal range can be expected to
survive for 10 years or more.
38. Treatment
Early referral for surgery is critical. Postoperative complications
include bacterial cholangitis, which occurs in 40% of patients.
Repeated attacks lead to hepatic fibrosis, and 50% of long-term
survivors develop portal hypertension, with one-third having
variceal bleeding.
Liver transplantation should be considered in children in whom a
portoenterostomy is unsuccessful.
Results are improving, with 70–80% alive 2–5 years following
transplant
39. CONGENITAL
DILATATIONOF
THE
INTRAHEPATIC
DUCTS
(CAROLI’S
DISEASE)
This rare congenital condition is characterised by multiple
irregular saccular dilatations of the intrahepatic ducts, separated
by segments of normal or stenotic ducts, with a normal
extrahepatic biliary system.
In Caroli’s syndrome, the biliary dilatation is associated with
congenital hepatic fibrosis
40. CONGENITAL
DILATATIONOF
THE
INTRAHEPATIC
DUCTS
(CAROLI’S
DISEASE)
The presentation is varied, with many patients presenting with
abdominal pain, cholangitis or end-stage liver disease.
The majority of patients present before the age of 30.
Sex distribution is equal.
Management is multidisciplinary: cholangitis or jaundice are
treated with appropriate antibiotic therapy and endoscopic or
interventional stenting.
Malignancy is a complication of long- standing disease.
42. CHOLEDOCHAL
CYST
Choledochal cysts are congenital dilations of the intra and/or
extrahepatic biliary system.The pathogenesis is unclear.
Anomalous junctions of the biliary pancreatic junction are
frequently observed, but whether or not these play a role in the
pathogenesis of the condition is unclear.
43. Symptoms
Patients may present at any age with jaundice, fever, abdominal
pain and a right upper quadrant mass on examination; Pancreatitis
is not an infrequent presentation in adults.
Patients with choledochal cysts have an increased risk of
developing cholangiocarcinoma with the risk varying directly with
the age at diagnosis.
44. Investigations
Ultrasonography will confirm the presence of an abnormal cyst
and magnetic resonance imaging (MRI/MRCP) will reveal the
anatomy, in particular the relationship between the lower end of
the bile duct and the pancreatic duct. CT is also useful for
delineating the extent of the intra- or extrahepatic dilatation.
45. Classification oftypes of
choledochalcyst.TypeIa
andb: diffusecystic. Note
extension into pancreasof
type Ib.Type
II: diverticulum ofcommon
bile duct.Type III:
diverticulum within
pancreas.
Type IV: extension into the
liver.TypeV: cystic
dilatation only of
the intrahepatic ducts.
46. Treatment
Radical excision of the cyst is the treatment of choice, with
reconstruction of the biliary tract using a Roux-en-Y loop of
jejunum. Complete resection of the cyst is important because of
the association with the development of cholangiocarcinoma.
Resection and roux-en-Y reconstruction are also associated with a
reduced incidence of stricture formation and recurrent cholangitis.
47. TRAUMA
Iatrogenic injury is perhaps more frequent than external trauma.
The physical signs are those of an acute abdomen. Management
depends on the location and extent of the biliary and associated
injury. In the stable patient a transected bile duct is best repaired
by a Roux-en-Y choledochojejunostomy.
Injuries to the gallbladder can be dealt with by cholecystectomy
48. TORSIONOF
THE
GALLBLADDER
This is very rare and requires a long mesentery, and therefore
often occurs in an older patient with a large mucocoele of the
gallbladder.The patient presents with extreme pain and an acute
abdomen. Immediate exploration is indicated, with
cholecystectomy as the only treatment.
49. GALLSTONES
(CHOLELITHIASIS)
Gallstones are the most common biliary pathology.
Gallstones can be divided into three main types: cholesterol,
pigment (brown/black) or mixed stones.
Pigment stone is the name used for stones containing <30%
cholesterol.There are two types: black and brown. Black stones
are largely composed of an insoluble bilirubin pigment polymer
mixed with calcium phosphate and calcium bicarbonate.
Overall, 20–30% of stones are black.The incidence rises with age.
Black stones are associated with haemolysis, usually hereditary
spherocytosis or sickle cell disease.
Brown pigment stones contain calcium bilirubinate, calcium
palmitate and calcium stearate, as well as cholesterol. Brown
stones are rare in the gallbladder.They form in the bile duct and
are related to bile stasis and infected bile.
51. Clinical
presentation
Gallstones may remain asymptomatic, being detected incidentally
as imaging is performed for other symptoms. If symptoms occur,
patients typically complain of right upper quadrant or epigastric
pain, which may radiate to the back.
This may be described as colicky but more often is dull and
constant. Other symptoms include dyspepsia, flatulence, food
intolerance particularly to fats and some alteration in bowel
frequency. Biliary colic is typically present in 10–25% of patients.
This is described as a severe right upper quadrant pain which ebbs
and flows, associated with nausea and vomiting.
Pain may radiate to the chest.The pain is usually severe and may
last for minutes or even several hours. Frequently, the pain starts
during the night and wakes the patient. Minor episodes of the
same discomfort may occur intermittently during the day.
Dyspeptic symptoms may coexist and be worse after such an
attack.
54. Diagnosis
In the acute phase the patient may have right upper quadrant
tenderness that is exacerbated during inspiration by the
examiner’s right subcostal palpation (Murphy’s sign).A positive
Murphy’s sign suggests acute inflammation and may be
associated with a leukocytosis and moderately elevated liver
function tests. A mass may be palpable as the omentum walls off
an inflamed gallbladder.
While the presentation and examination may suggest acute
cholecystitis, a definitive diagnosis can only be made following
appropriate imaging studies (US or CT).
55. Treatment
Prophylactic cholecystectomy may be considered for diabetic
patients, those with congenital haemolytic anaemia and those
patients who are undergoing bariatric surgery for morbid obesity
because it has been found in these groups that the risk of
developing symptoms is increased.
For patients with symptomatic gallstones, cholecystectomy is the
treatment of choice if there are no medical contraindications.
Experience shows that, in more than 90% of cases, the symptoms
of acute cholecystitis subside with conservative measures.
56. Treatment
Non-operative treatment is based on four principles:
●● Nil per mouth (NPO) and intravenous fluid administration until
the pain resolves.
●● Administration of analgesics.
●● Administration of antibiotics. As the cystic duct is blocked in most
instances, the concentration of antibiotic in the serum is more
important than its concentration in bile. A broad-spectrum antibiotic
effective against gram-negative aerobes is most appropriate (e.g.
cefazolin, cefuroxime or ciprofloxacillin).
●● Subsequent management. When the temperature, pulse and
other physical signs show that the inflammation is subsiding, oral
fluids are reinstated, followed by a regular diet..
57. Treatment
Ultrasonography is performed to confirm the diagnosis.
If jaundice is present MRCP is performed to exclude
choledocholithiasis.
If there is any concern regarding the diagnosis or presence of
complications such as perforation CT should be performed.
Cholecystectomy may be performed on the next available list, or the
patient may be allowed home to return later when the inflammation
has completely resolved
59. EMPYEMAOF
THE
GALLBLADDER
Empyema may be a sequel to acute cholecystitis or the result of a
mucocoele becoming infected. The gallbladder is distended with
pus. The optimal treatment is drainage (cholecystostomy) and, later,
cholecystectomy.
60. Acalculous
cholecystitis
Acute acalculous cholecystitis is particularly seen in critically ill
patients and those recovering from major surgery, trauma and
burns.
The diagnosis is often missed and the mortality rate is high.
61. THE
CHOLECYSTOSES
(CHOLESTEROSIS,
POLYPOSIS,
ADENOMYOMATO
SISAND
CHOLECYSTITIS
GLANDULARIS
PROLIFERANS)
Cholesterosis (‘strawberry gallbladder’)
In the fresh state, the interior of the gallbladder looks something like a
strawberry in patients with this condition; the yellow specks
(submucous aggregations of cholesterol crystals and cholesterol esters)
correspond to the seeds. It may be associated with cholesterol stones.
Cholesterol polyposis of the gallbladder
Ultrasound may show a non-mobile defect in the gallbladder lumen
which does not exhibit an associated acoustic shadow.The differential
is an adenomatous polyp, and interval follow-up is indicated to ensure
stability. Surgery is only advised if there is a diagnostic dilemma.
Cholecystitis glandularis proliferans (polyp, adenomyomatosis and
intramural diverticulosis)
A polyp of the mucous membrane is fleshy and granulomatous.All
layers of the gallbladder wall may be thickened, but sometimes an
incomplete septum forms that separates the hyperplastic from the
normal. Intraparietal ‘mixed’ calculi may be present.These can be
complicated by an intramural, and later extramural, abscess and
potentially fistula formation. If symptomatic, the patient is treated by
cholecystectomy
63. Diverticulosis
of the
gallbladder
Diverticulosis of the gallbladder is
usually manifest as black pigment
stones impacted in the
outpouchings of the lacunae of
Luschka. Diverticulosis of the
gallbladder may be demonstrated
by cholecystography, especially
when the gallbladder contracts
after a fatty meal.There are small
dots of contrast medium just
within and outside the gallbladder.
A septum may also be present, to
be distinguished from the
Phrygian cap.
The treatment is cholecystectomy
64. Typhoid
infection of the
gallbladder
Salmonella typhi or Salmonella typhimurium can infect the
gallbladder.
Acute cholecystitis can occur.
More frequently chronic cholecystitis occurs, the patient
becoming a typhoid carrier excreting the bacteria in the bile.
Gallstones may be present (surgeons should not give patients
their stones after their operation if there is any suspicion of
typhoid!).
It is debatable whether the stones are secondary to the
Salmonella cholecystitis or whether pre-existing stones
predispose the gallbladder to chronic infection. Salmonellae can,
however, frequently be cultured from these stones.
Treatment with ampicillin and cholecystectomy are indicated. In
cases of penicillin allergy a quinolone antibiotic can be used.
65. Stricture of the
bile duct
Causes of benign biliary stricture
Congenital
●● Biliary atresia
Bile duct injury at surgery
●● Cholecystectomy
●● Choledochotomy
●● Gastrectomy
●● Hepatic resection
●● Transplantation
Inflammatory
●● Stones
●● Cholangitis
●● Parasitic
●● Pancreatitis
●● Sclerosing cholangitis
●● Radiotherapy
Trauma
Idiopathic
66. Stricture of the
bile duct
Radiological investigation of biliary strictures
●● Ultrasonography
●● Cholangiography via T-tube, if present
●● ERCP
●● MRCP
●● Percutaneous transhepatic cholangiography
●● CT scan
67. PRIMARY
SCLEROSING
CHOLANGITIS
Primary sclerosing cholangitis is an idiopathic fibrosing
inflammatory condition of the biliary tree that affects both
intrahepatic and extrahepatic ducts.
It is of unknown origin but the association of
hypergammaglobulinaemia and elevated markers such as smooth
muscle antibodies and antinuclear factor suggest an
immunological basis.
The majority of patients are between 30 and 60 years of age.
There appears to be a male predominance and a strong
association with inflammatory bowel disease, especially
ulcerative colitis.
68. PRIMARY
SCLEROSING
CHOLANGITIS
Common symptoms include right upper quadrant discomfort,
jaundice, pruritus, fever, fatigue and weight loss.
Investigation reveals a cholestatic pattern to the liver function
tests with elevation of the serum alkaline phosphatase and γ-
glutamyl transferase and smaller rises in the aminotransferases.
Bilirubin values can be variable and may fluctuate.
Imaging studies such as MRCP or ERCP may demonstrate
stricturing and beading of the bile ducts .
A liver biopsy is helpful to confirm the diagnosis and may help
guide therapy by excluding cirrhosis.
The important differential diagnoses are secondary sclerosing
cholangitis and cholangiocarcinoma.
The latter may be very difficult to diagnose and a high index of
suspicion is required especially in the setting of unexplained
clinical deterioration.
69. PRIMARY
SCLEROSING
CHOLANGITIS
Medical management with antibiotics, vitamin K, cholestyramine,
steroids and immunosuppressant drugs such as azathioprine is
generally unsuccessful.
Endoscopic stenting of dominant strictures and, in selected
patients with predominantly extrahepatic disease, operative
resection may be worthwhile.
For patients with cirrhosis, liver transplantation is the best option.
Five-year survival following transplantation in high-volume
centres is in excess of 80%.
70. Immunoglobul
in (Ig)G4-
related
cholangitis
This recently recognised entity presents with diffuse or segmental
narrowing of the intra- or extrahepatic bile ducts.
Its features may make differentiation from primary sclerosing
cholangitis (PSC), cholangiocarcinoma or pancreatic cancer
difficult.
However, patients often have elevated serum IgG4 levels and
concomitant autoimmune pancreatitis, IgG4- related sialadenitis
or retroperitoneal fibrosis.
Biliary biopsies show lymphoplasmacytic sclerosing cholangitis.
Treatment is with systemic steroids.
Failure to respond to steroid therapy should make one reconsider
the diagnosis and exclude an underlying malignancy.
71. Biliary
ascariasis
The roundworm Ascaris lumbricoides commonly infests the
intestines of inhabitants ofAsia, Africa and Central America.
It may enter the biliary tree through the ampulla ofVater and
cause biliary pain.
Complications include strictures, suppurative cholangitis, liver
abscesses and empyema of the gallbladder.
In the uncomplicated case, antispasmodics can be given to relax
the sphincter of Oddi and the worms will return to the small
intestine to be dealt with by anthelminthic drugs.
Operation may be necessary to remove the worms or deal with
complications.
Worms can be extracted via the ampulla ofVater by ERCP.
72. Clonorchiasis
(Asiatic
cholangiohepa
tis)
This disease is endemic in the Far East.The fluke, up to 25 mm
long and 5 mm wide, inhabits the bile ducts, including the
intrahepatic ducts.
Fibrous thickening of the duct walls occurs.
Many cases are asymptomatic.
Complications include biliary pain, stones, cholangitis, cirrhosis
and bile duct carcinoma.
Choledochotomy andT-tube drainage and, in some cases,
choledochoduodenostomy are required.
Because a process of recurrent stone formation is set up, a
choledochojejunostomy with a Roux loop fixed to the adjacent
abdominal wall is performed in some centers to allow easy
subsequent access to the duct system.
73. Hydatid
disease
A large hydatid cyst may obstruct the hepatic ducts. Sometimes,
a cyst will rupture into the biliary tree and its contents
cause obstructive jaundice or cholangitis, requiring appropriate
surgery
74. Benign
tumours of the
bile duct
Benign neoplasms causing biliary obstruction may be
classified as follows:
●● papilloma and adenoma;
●● multiple biliary papillomatosis;
●● granular cell myoblastoma;
●● neural tumours;
●● leiomyoma;
●● endocrine tumours.
75. Malignant
tumours of the
biliary
tract
Bile duct cancer (cholangiocarcinoma)
●● Rare, but incidence increasing
●● Most patients present with abnormal liver function tests or
frank jaundice
●● Diagnosis by ultrasound, CT or MRCP scanning
●● The majority of patients receive palliative care only
●● Complete surgical excision possible in <10%
●● Prognosis poor: 90% die within 1 year, from liver failure or
biliary sepsis
●● Adjuvant chemoradiation therapy has a limited role
77. Clinical
features
Early symptoms of cholangiocarcinoma are often non-specific,
with abdominal pain, early satiety, anorexia and weight loss
commonly seen.
Symptoms associated with biliary obstruction (puritus and
jaundice) may be present in a minority of patients. In these
patients, examination often demonstrates clinical signs of
jaundice, cachexia is often noticeable and a palpable gallbladder
present if the obstruction is in the distal common bile duct
(Courvoisier’s sign).
78. Investigations
Biochemical
investigations will
confirm the presence of
obstructive jaundice
(elevated bilirubin,
alkaline phosphatase and
γ-glutamyltransferase).
The tumour-marker CA
19-9 may also be
elevated.
Imaging studies such as
ultrasound, MDR-CT and
MRI/MRCP are essential
for diagnosis and staging.
These studies allow the
level of biliary
obstruction to be defined
and determine the
locoregional extent of
disease and the presence
of metastases
79. Investigations
Direct cholangiography using ERCP or PTC is also used following
non-invasive studies. Both can define the level of obstruction and
allow access to the biliary system for biopsy and placement of
endobiliary stents for biliary drainage.The choice between the
modalities depends on local availability and the anatomical site of
the tumour.
PTC preferred for more proximal lesions and ERCP favoured for
distal tumours.
Cytology can be obtained from either procedure but it is often
non-diagnostic.
Positron emission tomography (PET) is useful in detecting lymph
node and distant metastases but has limited value in assessment
of local resectability.
81. Treatment
A multidisciplinary approach is required in all cases.The choice of
treatment depends on the site and extent of the disease.
Unfortunately, the majority of patients present with advanced
disease.
Whether or not the disease is resectable depends on patient factors
(comorbidities, presence or absence of chronic liver disease), and
tumour factors (extent of disease within the biliary tree, vascular
involvement, presence or absence of metastatic disease). Depending
on the site of disease, surgery may involve either a standard or
extended hepatic resection with en bloc lymphadenectomy and
reconstruction of the biliary tree. Distal common duct tumours may
require a pancreaticoduodenectomy (Whipple procedure). Local
resection should be avoided.
In selected patients, liver transplantation has been recommended for
those with locally unresectable disease without evidence of distant
metastases.Transplantation is often combined with neoadjuvant
chemoradiation therapy.
Biliary obstruction can be relieved by either endoscopic (ERCP) or
percutaneous (PTC) methods. Surgical bypass rarely has a role apart
from in patients who present with a distal bile duct lesion and are
found to have unresectable disease at operation.
82. Cancer of the
gallbladder
Highest incidence is among Chileans,American Indians and
residents in parts of northern India.
●● Similar presentation to benign biliary disease i.e., gallstones
●● Diagnosis by ultrasound, CT, MRI/MRCP
●● Most patients present with advanced disease
●● Surgical resection in less than 10% – remainder receive
palliative treatment
●● Prognosis is poor – median survival approximately 6 months
Patients may be asymptomatic at the time of diagnosis.
Jaundice and anorexia are late features. A palpable mass is a late
sign.
83. Investigation
Serum CA19-9 is elevated in approximately 80% of patients.
The preoperative diagnosis is often made on ultrasonography, and
confirmed by a CT scan or MRI/MRCP.
Preoperative staging should aim to determine the local extent of
disease and exclude the presence of distant metastases.
A percutaneous biopsy under radiological guidance is often done
to obtain tissue for pathological examination.
In selected cases, laparoscopic examination is useful in staging the
disease. Laparoscopy can detect peritoneal or liver metastases
which would preclude further surgical resection
PET scanning also has a role in detecting metastatic disease.
84. Aims of
staging
gallbladder
cancer
●● Assessment of local disease
●● Detection of metastatic disease:
Liver
Peritoneal
Lymphatic
Extra-abdominal disease
85. Treatment and
prognosis
Cholecystectomy should be performed for all gallbladder polyps
greater than 1 cm.
Polyps less than 1 cm can be followed with serial ultrasonography
to detect any change in size or character as the incidence of
malignancy in polyps less than 1 cm is extremely low.
Radical en bloc resection that may include segmental or extended
hepatectomy, bile duct resection and regional lymphadenectomy
should be considered in selected patients.
86. Treatment and
prognosis
The aim is to remove the tumour entirely and achieve negative
histopathological margins.
Patients can have the disease diagnosed following
histopathological examination of the gallbladder removed for
presumed benign disease.
In these cases, the need for further surgery is determined by the
stage of disease.
For early-stage disease, confined to the mucosa or muscle of the
gallbladder, no further treatment is indicated.
87. Treatment and
prognosis
However, for transmural disease, a radical en bloc resection of the
gallbladder fossa and surrounding liver along with the regional
lymph nodes should be performed.
If the initial procedure was performed laparoscopically, the
surgeon should examine the laparoscopic port sites.
Routine resection of port sites is no longer recommended.
However, it is recognised that the finding of disease at the port
sites is a sign of generalised peritoneal disease and carries a very
poor prognosis.