Gallbladder and Hepato-biliary Tree Cystic duct - 3.

8 cm in length; 3mm in diameter

Intern’s Report 081020
Common bile duct - joins the pancreatic duct to
ANATOMY empty at the Ampulla of Vater in the 2nd portion of
Gallbladder – pear shaped sac, around 7-10 cm duodenum through the Sphincter of Oddi which
long, ave capacity of 30 - 50mL. Location: at the controls the flow of bile into the duodenum
anatomic fossa on the inferior surface of the liver
Diameter:
Four anatomic areas: common hepatic duct 4mm~
• fundus
cystic duct 3mm~
•body
•infundibulum common bile duct 5-10mm
•neck
ANATOMIC VARIANTS
Four anatomic areas: Variations of the Cystic Duct
• Fundus - contains most of the smooth muscle • Variations of the cystic duct and its point of
• Body - contains most of the elastic tissue union with the common hepatic duct are
• Infundibulum - mucosal outpouching surgically important and knowing these
• Neck - connects with the cystic duct variations can help avoid inadvertent injury
to the biliary tree especially during
BLOOD SUPPLY cholecystectomy.
Cystic Artery - branch of R hepatic a.
Cystic Vein - drains directly into the portal v. Variations on the arterial supply
--The cystic artery supplying the gallbladder
LYMPH DRAINAGE is usually a branch of the right hepatic artery
Cystic Lymph node - near the neck of the (more than 90% of the time).
gallbladder
Physiology
NERVE SUPPLY Bile Formation and Composition
Sympathetic and parasympathetic vagal fibers ● 500 to 1000 mL of bile per day
from celiac plexus ● Hepatic branches of the vagus nerve →
increases secretion of bile
TRIANGLE OF CALOT ● Celiac plexus → decreased bile flow
BOUNDARIES: ● HCl, partly digested proteins, and fatty
● Inferior edge of the liver acidsl → release of secretin from S-cells of
● Common Hepatic Duct the duodenum → increases bile production
● Cystic duct and flow
CONTENTS:
● Cystic A. ● Bile composition
● Cystic V. ○ Major components: water, mixed
● Cystic LN. with bile salts and acids, cholesterol,
● Lund’s node phospholipids (lecithin), proteins,
and bilirubin
BILE DUCTS ○ Minor components: electrolytes and
● Right and left hepatic ducts vitamins
● Common hepatic duct
● Cystic duct ● Two fundamental roles of bile
● Common bile duct ○ Aid in the digestion of and
absorption of lipids and lipid-soluble
Right and left hepatic ducts - left is longer; vitamins
greater propensity for for dilation ○ Eliminate waste products (bilirubin
and cholesterol) through secretion
Common hepatic duct - 1-4 cm in length; 4mm in into bile and elimination in feces
diameter

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 ● Cholesterol → primary bile acids: cholic acid
and chenodeoxycholic acid
● Conjugated to either glycine or taurine
before secretion into the biliary system
● Gut bacteria can remove glycine and taurine
from bile salts or remove the hydroxyl group
from the primary bile acids → secondary
bile acids: deoxycholic acid and lithocholic
acid
● Primary bile salts: excreted into the bile by
hepatocytes and aid in the digestion and
absorption of fats in the intestines.
● 80% of the secreted conjugated bile acids:
reabsorbed in the terminal ileum.
● 20% are deconjugated: absorbed in the
colon and can then be transported back to
the liver
● Primary and secondary bile salts and bile
acids: absorbed primarily by active transport
in the terminal ileum
● Absorbed bile salts: transported back to the
liver in the portal vein and reexcreted in the
bile
● The continuous process of secretion of bile
salts in the bile, their passage through the
intestine, and their subsequent return to the
liver: enterohepatic circulation
● 5% is excreted in the stool, allowing the
relatively small quantity of bile acids
produced to have maximal effect
● Those lost in the stool are replaced by
synthesis in the liver.
● Bilirubin excretion
○ Urobilinogen (yellow): conjugated in
the liver can be excreted through the
urine
○ Stercobilinogen (brown) : remaining
excess bile pigment that are
converted by bacteria when it
passes into the intestines; excreted
through the stool
Gallbladder Function
Main function: concentrate and store hepatic bile in
order to deliver it in a coordinated fashion to the
duodenum in response to a meal
Gallbladder Function: Absorption and Secretion
● Fasting state: approximately 80% of the bile
secreted by the liver is stored in the
gallbladder
○ Gallbladder mucosa has the greatest
absorptive power per unit area
○ Prevent a potentially dangerous rise
in pressure within the biliary system
as bile is produced and stored
● Mucosal cells of the gallbladder
○ Glycoprotein: protect the mucosa
from the corrosive action of bile and
facilitate the passage of bile through
the cystic duct
■ Creates the colorless “white
bile”: seen in hydrops of the
gallbladder
○ Hydrogen ions: decrease the pH of
stored bile
■ Helps prevent the
precipitation of calcium salts
Gallbladder Function: Motor Activity
● Sphincter of Oddi: normal gallbladder filling
● Phase II of interdigestive migrating
myenteric motor complex (MMC):
repeatedly empties small volumes of bile in
into the duodenum
● Cholecystokinin: empties 50% to 70% of
gallbladder contents with 30 to 40 minutes,
over the following 60 to 90 minutes, the
gallbladder gradually refills as CCK levels
drop
Gallbladder Function: Neurohormonal
Regulation
● Neural inputs
○ Hepatic branches of the vagus
nerve → stimulates contraction of
the gallbladder
○ Celiac plexus → inhibits motor
activity of gallbladder
● Hormonal inputs
○ Cholecystokinin (CCK): acts directly
on smooth muscle receptors of the
gallbladder → contraction; relaxes
the terminal bile duct, the sphincter
of Oddi, and the duodenum →
forward bile flow
○ Vasoactive intestinal peptide (VIP)
and somatostatin: potent inhibitors of
gallbladder contraction
Sphincter of Oddi
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 ● Regulates the flow of bile and pancreatic
juice into the duodenum
● Prevents the regurgitation of duodenal
contents into the biliary tree
● Diverts bile into the gallbladder
● Creates a high pressure zone between the
bile duct and duodenum
● Basal resting pressure: 13mmHg above the
duodenal pressure
GALLSTONE DISEASE
Prevalence and Incidence
● Prevalence of gallstones is 10% - 15%
● Risk factors: Age, Gender, Diet, BMI, ethnic
background Obesity, pregnancy, dietary
factors, gastric surgery, thalassemia,
somatostatin analogues, etc
● More prevalent to develop in women than
men (3:1)
● First-degree relatives of patients with
gallstones have twofold greater prevalence
Natural History
● Most patients (80%) with gallstones are
asymptomatic
● 2-3% will become symptomatic per year
● 3-5% of symptomatic cases may progress
to complications per year:
○ Acute cholecystitis
○ Choledocholithiasis
○ Cholangitis
○ Gallstone pancreatitis
○ Gallbladder carcinoma
● Prophylactic cholecystectomy is advisable
to:
○ individuals who will be isolated from
medical care for extended periods of
time
○ populations with increased risk of
gallbladder cancer
● Porcelain gallbladder
○ Absolute indication for
cholecystectomy even when
asymptomatic
Gallstone formation
● Form as a results of solids settling out of
solution
● Two classifications:
○ Cholesterol stones- 80% of cases
○ Pigment stones (Black or Brown) -
15-20% of cases
Cholesterol stones
● Pure cholesterol stones (<10%)
○ usually occur as single large stones
with smooth surfaces
● Other cholesterol stones ( variable amounts
of bile pigments and calcium)
○ usually multiple, of variable size, and
may be hard and faceted or
irregular, mulberry-shaped, and soft
○ Whitish yellow and green to black
● Most are radiolucent >90%
● Formation is due to supersaturation of bile
with cholesterol
Admirand’s triangle
● Depicts the 3 major components of bile
plotted on triangular coordinates
○ Bile salts
○ Lecithin
○ Cholesterol
● Micellar liquid area: range of concentration
where cholesterol is fully soluble
● Metastable zone: bile composition exceeds
the solubilization capacity of cholesterol and
precipitation of cholesterol occurs
Pigment stones
● Contain <20% cholesterol and calcium
bilirubinate
● Black pigment stones
○ Small, brittle, black, and spiculated
○ formed by supersaturation of
calcium bilirubinate, carbonate, and
phosphate
○ Forms in the gallbladder
● Brown pigment stones
○ <1 cm diameter
○ Brownish yellow, soft, and often
mushy
○ Forms in the gallbladder or bile
ducts
○ Composed of precipitated calcium
bilirubinate and bacterial cell bodies
Symptomatic Cholelithiasis
● Patients typically present with recurrent pain
● Obstruction of the cystic duct causes pain
● If untreated, about two-thirds of these
patients will develop chronic cholecystitis.
● Mucosa is initially normal or hypertrophied
but becomes atrophied leading to formation
of Aschoff-rokitansky sinuses
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 ● Clinical presentation:
○ Biliary colic
○ Severe progressing pain intensity
lasts up to 1-5 hours
○ Typically occurs during the night or
after a fatty meal
○ Nausea and vomiting
○ PE: RUQ tenderness that frequently
radiates to the right upper back or
between the scapulae
● Diagnosis:
○ Abdominal ultrasound - standard
diagnostic test
■ Hyperechoic stones with
posterior sonic shadowing
○ Abdominal radiographs or CT scans
● Management
○ Symptomatic patients should be
advised to have elective
laparoscopic cholecystectomy.
○ Advised to avoid dietary fats and
large meals
○ Diabetic patients: cholecystectomy
○ Pregnant women: laparoscopic
cholecystectomy during the second
trimester.
Acute cholecystitis
● 90-95% caused by gallstones
● Obstruction of the cystic duct by a gallstone
● <1% caused by tumor
● Initially it is an inflammatory process,
mediated by the mucosal toxin lysolecithin
as well as bile salts and platelet-activating
factor
● Gallbladder wall becomes grossly thickened
and reddish with subserosal hemorrhages.
● Pericholecystic fluid is often present
● May lead to acute gangrenous cholecystitis
○ 5% to 10% of cases progresses and
leads to ischemia and necrosis of
the gallbladder wall
● Secondary bacterial contamination is
thought to occur in only 15% to 30% of
patients.
● Emphysematous cholecystitis
○ Gas seen in the gallbladder lumen
and wall on radiographs
● Clinical manifestations:
○ Biliary colic
○ RUQ or epigastric pain that radiates
right upper part of the back or the
interscapular area
○ Unremitent, persists for several days
○ Febrile, anorexia, nausea, vomiting
○ PE: Focal tenderness, guarding, (+)
Murphy’s sign’, (+) Boas sign
● Laboratory findings:
○ mild to moderate leukocytosis
(12,000–15,000 cells/mm3)
○ high WBC count (above 20,000),
suggestive of gangrenous
cholecystitis, perforation, or
associated cholangitis
○ mild elevation of serum bilirubin, <4
mg/mL
○ mild elevation of alkaline
phosphatase, transaminases, and
amylase
● Severe jaundice
○ obstruction of the bile ducts by
severe pericholecystic inflammation
secondary to mirizzi’s syndrome
● Diagnostics:
○ Ultrasonography
■ Thickened wall (>0.4cm in
diameter)
■ (+) Pericholecystic fluid
around the gallbladder
■ bile duct diameter >0.8cm
○ Scintigraphy (HIDA / Hepatobiliary
Imino-diacetic Acid scan)
■ absence of disease =
gallbladder is visualized
within 1 hour of the injection
of a radioactive tracer
■ Gallbladder is not visualized
within 4 hours after the
injection indicates
cholecystitis or cystic duct
obstruction
■ Mucosa may show
hyperemia and patchy
necrosis.
○ CT scan
■ thickening of the gallbladder
wall
■ pericholecystic fluid,
■ presence of gallstones as
well as air in the gallbladder
wall
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 ● Treatment:
○ IV fluids
○ Pain control (temporary relief)
○ Antibiotics (temporary relief)
■ To cover for gram (+) and
gram (-) organisms (1st or
2nd generation
cephalosporins).
■ For patients with allergy to
cephalosporin, an
aminoglycoside with
metronidazole is appropriate
to prevent secondary
infections.
○ Surgery
■ Laparoscopic
cholecystectomy
■ Open cholecystectomy
■ Tube cholecystostomy
Tokyo Guidelines 2018 Diagnostic Criteria
A. Local signs of inflammation
a. (+) Murphy’s sign
b. RUQ mass/ pain/ tenderness
B. Systemic signs of inflammation
a. Fever
b. Elevated CRP
c. Elevated WBC count
C. Imaging findings
a. Imaging findings characteristic of
acute cholecystitis
Suspected diagnosis- one item in A + one item in B
Definite diagnosis- One item in A+one item in B,+ C
Choledocholithiasis
● Stones obstructing the common bile duct
● Found in 6% to 12% of patients with stones
in the gallbladder.
● Two classifications:
○ Primary CBD stones
■ Formed in the common bile
duct
■ Usually brown pigment type
■ Associated with biliary stasis
and infection
○ Secondary CBD stones
■ Formed within the
gallbladder and migrate
towards the common bile
duct
■ Usually cholesterol stones
● Clinical manifestations:
○ Colicky abdominal pain
○ Nausea and vomiting
○ PE: Mild epigastric or RUQ
tenderness, mild icterus
○ Completely impacted stones may
cause severe progressive jaundice
● Diagnostics:
○ ⅔ of patients have elevated bilirubin
levels particularly B2 and elevated
alkaline phosphatase
○ Ultrasound: Dilated common bile
duct (>8mm diameter)
○ Magnetic resonance
cholangiography (MRC) Sensitivity
95%, specificity 89% (>5mm
diameter stones)
○ Endoscopic cholangiography
(ERCP)
● Treatment:
○ ERCP with stone extraction
(sphincterotomy and ductal
clearance of the stones) followed by
intraoperative cholangiogram then
laparoscopic cholecystectomy
Cholangitis
● Inflammation of the bile ducts with bacterial
infection of the bile
● Mechanical hindrance to bile flow facilitates
bacterial contamination
○ Gallstones most common cause
● Bacterial etiologic agents:
○ Escherichia coli, Klebsiella
pneumoniae, Streptococcus
faecalis, Enterobacter, and
Bacteroides fragilis
● Clinical manifestation:
○ Charcot’s triad: Fever, Chills, RUQ
pain
○ Reynold’s pentad: Charcot’s triad +
hypotension (shock) and Behavioral
changes (altered mental status)
● Diagnostics:
○ CBC (leukocytosis)
○ Elevated bilirubin levels, B2
○ Elevated ALP
○ Ultrasound
○ Endoscopic retrograde
cholangiography
● Treatment:
○ Antibiotics to cover gram (-) aerobes
and anaerobes
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 ■ 2nd & 3rd Cephalosporins,
Aminoglycosides + anaerobic
coverage: Metronidazole
○ ERCP
○ Percutaneous transhepatic drainage
○ Cholecystectomy
○ Emergency biliary decompression
may be required
Tokyo Guidelines 2018 Diagnostic Criteria
A. Systemic inflammation
a. Fever and/or shaking chills
b. Laboratory data: Evidence of
inflammatory response
B. Cholestasis
a. Jaundice
b. Laboratory data: Abnormal liver
function tests
C. Imaging
a. Biliary dilatation
b. Evidence of the etiology on imagine
(stricture, stone, stent etc.)
Suspected diagnosis- one item in A + one item in
either B or C
Definite diagnosis- One item in A, one item in B,
and one item in C
Gallstone Pancreatitis
● Most common cause of acute pancreatitis
● Caused by the obstruction of the pancreatic
duct by an impacted stone
● Clinical features and labs:
○ epigastric pain with radiation to the
back
○ nausea, vomiting
○ elevated amylase and lipase
● Diagnostics:
○ HBT Ultrasound
● Treatment:
○ Preop: bowel rest, hydrate, allow the
pancreatitis subside.
○ Cholecystectomy with intraoperative
cholangiogram
■ gallstones are present and
the pancreatitis is mild and
self-limited
○ ERCP with sphincterotomy and
stone extraction
■ gallstones are present
obstructing the duct and the
pancreatitis is severe
Cholangiohepatitis
● Recurrent pyogenic cholangitis
● Etiologies:
○ E. coli, Klebsiella species,
Bacteroides species, or
Enterococcus faecalis of the biliary
○ Biliary parasites
● Pathology:
○ Bacterial enzymes > deconjugation
of bilirubin > bile sludge > brown
pigment stones> Partial obstruction>
Cholangitis> Biliary stricture> further
stone formation, infection, hepatic
abscesses, and liver failure
● Clinical features:
○ Recurrent RUQ or epigastric pain
○ Recurrent fever
○ Recurrent jaundice
○ w/o intervention > malnutrition and
hepatic insufficiency.
● Diagnostics and therapeutic:
○ Ultrasound
○ MRCP and PTC
OPERATIVE INTERVENTIONS FOR
GALLSTONE DISEASE
Percutaneous Transhepatic Cholecystostomy
Tubes
● Decompresses and drains the distended,
inflamed, hydropic, or purulent gallbladder
● Ultrasound-guided percutaneous drainage
with a pigtail catheter is the procedure of
choice
● The catheter can be removed when the
inflammation has resolved and the patient’s
condition improved.
Cholecystectomy
● Surgical removal of the gallbladder
● Absolute contraindications:
○ uncontrolled coagulopathy
○ End-stage liver disease
● Preoperative preparation
○ CBC, Liver function test
○ Low molecular weight Heparin or
compression stockings
○ Empty urinary bladder
○ Orogastric tube if distended stomach
● Two types: Laparoscopic and Open
cholecystectomy
Laparoscopic cholecystectomy
Critical view of safety in laparoscopic
cholecystectomy
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 1. The hepatocystic triangle is cleared of fat
and fibrous tissue.
2. The lower one third of the gallbladder is
separated from the liver to expose the cystic
plate
3. Two and only two structures should be seen
entering the gallbladder (Cystic duct and
cystic artery)
Open cholecystectomy
● Same surgical principles apply for
laparoscopic and open cholecystectomies
● Long incision (Kocher) usually done in the
subcostal area, under right rib cage, cutting
through the rectus muscle
● After the cystic artery and cystic duct have
been identified, the gallbladder is dissected
free from the liver bed, starting at the
fundus.
● The dissection is carried proximally toward
the cystic artery and the cystic duct, which
are then ligated and divided.
Common Bile Duct Exploration
● Common bile duct stones may be managed
with laparoscopic choledochal exploration
as a part of the laparoscopic
cholecystectomy procedure.
● Small stones may be flushed into the
duodenum with saline irrigation
● If irrigation is unsuccessful, a balloon
catheter may be passed via the cystic duct
and down the common bile duct, where it is
inflated and withdrawn to retrieve the stones
Laparoscopic bile duct exploration.
I. Transcystic basket retrieval using
fluoroscopy.
A. The basket has been advanced past the stone
and opened.
B. The stone has been entrapped in the basket,
and together, they are removed from the cystic
duct.
II. Transcystic choledochoscopy and stone
removal.
C. The basket has been passed through the
working channel of the scope, and the stone is
entrapped under direct vision.
D. Entrapped stone.
E. A view from the choledochoscope.
III. Choledochotomy and stone removal.
F. A small incision is made in the common bile
duct.
G. The common bile duct is cleared of stones.
H. A T tube left in the common bile duct with one
end taken out through the abdominal wall for
decompression of the bile ducts.
Common Bile Duct Drainage Procedures
● Choledochocal drainage
○ Done when the stones cannot be
cleared and/or when the duct is very
dilated (>1.5cm diameter)
● Choledochoduodenostomy
○ performed by mobilizing the second
part of the duodenum (a Kocher
maneuver) and anastomosing it side
to side with the common bile duct.
● Choledochojejunostomy
○ done by bringing up a 45-cm Roux-
en-Y limb of jejunum and
anastomosing it end to side to the
common bile duct.
Diagnostic Studies
➔ Blood tests
➔ Transabdominal Ultrasonography
➔ Computed Tomography
➔ Hepatobiliary Scintigraphy
➔ Magnetic Resonance Imaging
➔ Endoscopic Retrograde
Cholangiopancreatography
➔ Endoscopic Choledochoscopy
➔ Endoscopic Ultrasound
➔ Percutaneous Transhepatic
Cholangiography
Blood Tests
● Complete Blood Count
-May indicate or raise suspicion of
cholecystitis, choledocholithiasis, cholangitis
● Bilirubin: B1 (Unconjugated/indirect) and B2
(Conjugated/Direct)
- Elevated levels may indicate presence of
liver disease or biliary disease
● Alkaline Phosphatase
- Elevated in cases of cholangitis,
choledocholithiasis
● Aminotransferases: Aspartate
Transaminase (AST) and Alanine
Transferase (ALT)
- Liver parenchymal enzymes
- Elevated in cases of liver injury
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 ● Prothrombin time (protime or PT) and
International Normalized Ratio (INR)
- Obstruction of dysfunction may
compromise clotting factor secretion;
hence higher risk for bleeding
- Normal range:
PT: 8.8- 11.6 sec
INR: 0.8-1.1 sec
Imaging
A. Transabdominal Ultrasonography
- Most frequent imaging test
- Is used in initial investigation of patients with
suspected biliary tree disease
- Good for visualizing solid organs. Not good for
hollow organs like the bowels or stomach, as the
presence of air will interfere with the echoes that
bounce back
- Can also be used to assess intrahepatic and
proximal portion of the extrahepatic bile ducts
- Has Sensitivity and Specificity of >90%
- Sonographic Sign: (Murphy’s Sign)
Thickened gallbladder wall, pericholecystic fluid,
local tenderness or direct tenderness by the probe
over the fundus of the gallbladder
B. Hepatobiliary Iminodiacetic Acid (HIDA)
scan
- A nuclear medicine type test
- Highly diagnostic for acute cholecystitis which
appears as a non-visualized gallbladder, with
prompt filling of the common bile duct duodenum
- 99m technetium-labeled derivatives of dimethyl
iminodiacetic acid are injected into the peripheral
vein and there is a tracer scan.
- Uptake by the liver is detected within 10
minutes, and the gallbladder, the bile ducts
and the duodenum are visualized within 60
minutes in fasting subjects
- Has sensitivity and specificity of 95%
C. CT Scan
- More accurate than ultrasound in imaging the
biliary tree
- Enables viewing of the course and status of the
extrahepatic biliary tree and adjacent structures
- Used for detecting biliary problems because it is
not affected by presence of air which also allows
viewing of the abdomen as well
- It is also an integral part of the differential
diagnosis of obstructive jaundice
D. Percutaneous Transhepatic Cholangiogram
- A needle is used to puncture the liver
percutaneously with the help of ultrasound and CT
Scan, into the dilated bile duct; after which, contrast
material is injected to highlight the biliary tree
- Water soluble contrast is administered to a dilated
duct and a series of x-rays are done to visualize the
biliary tree.
- an intrahepatic bile duct is accessed
percutaneously with a small needle under
fluoroscopic guidance. Once the position in a bile
duct has been confirmed, a guidewire is passed
and subsequently a catheter passed over the wire.
- Through the catheter, a cholangiogram can be
performed and therapeutic interventions can be
done.
E. Magnetic Resonance Imaging
-Purely diagnostic
-Also called Magnetic Resonance
Cholangiopancreatography (MRCP) in the
gallbladder and biliary tree.
-Most accurate test to determine presence of bile
duct obstruction
-Offers a single non-invasive test for the diagnosis
of biliary tract and pancreatic disease.
F. Endoscopic Retrograde
Cholangiopancreatography
-Combination of both an endoscopy and a contrast
study. Both diagnostic and therapeutic modality
-A scope is inserted through the mouth into the
esophagus. The scope passes through the
stomach, duodenum and into the ampulla where a
catheter is inserted and a contrast dye is injected.
Series of x-rays taken.
-Provides direct visualization of the ampullary
region and direct access to the distal common bile
duct, with the possibility of therapeutic intervention.
• If a stone is identified, the endoscopist can insert
a device (stone basket extractor) inside the bile
duct through the ampulla, which can pull out the
stone.
• If a stone is too large to remove, ERCP can be
used to place a stent to bypass the obstruction and
allow drainage.
• Called retrograde because it is done from below
the ampulla
G. Intraoperative Cholangiogram
-Performed during surgery
-While the abdomen is open, a catheter is placed
through the cystic duct where a water-soluble
contrast material is injected and the biliary tree is
visualized upon x-ray.
H. Fiber Optic Choledochoscopy (FOC)
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 - Endoscopic procedure done
intraoperatively, wherein a small endoscope
is inserted into the biliary tree
- This provides dIrect visualization of the
biliary system
OTHER BENIGN DISEASES
AND LESIONS
BILIARY DYSKINESIA
•Disorders affecting the normal motility and function
of the gallbladder and sphincter of Oddi
•(+) typical biliary type symptoms, (-) stones on
imaging
•decreased gallbladder ejection fraction on HIDA
scanning (EF <35%) = diagnostic of biliary
dyskinesia
•Management: cholecystectomy
SPHINCTER OF ODDI DYSFUNCTION
•Primary or recurrent
•Benign stenosis of the outlet of the common bile
duct is usually associated with inflammation,
fibrosis, or muscular hypertrophy.
SPHINCTER OF ODDI DYSFUNCTION
• Diagnosis of exclusion: if other causes are ruled
out, such as retained stones, strictures, or
periampullary tumors
•Dilated common bile duct difficult to cannulate
during ERCP or delayed emptying of contrast from
the biliary tree after ERCP are useful diagnostic
features.
ACALCULOUS CHOLECYSTITIS
•Acute inflammation of the gallbladder in the
absence of gallstones
•Rare, typically develops in critically ill ICU patients
•At risk: patients on parenteral nutrition, with
extensive burns, sepsis, major operations, multiple
trauma, or prolonged illness with multiple organ
system failure
•Causative factors: gallbladder distention, bile
stasis, and ischemia
ACALCULOUS CHOLECYSTITIS
•Gallbladder wall reveals edema of the serosa and
muscular layers, with patchy thrombosis of
arterioles and venules
•Signs and symptoms: RUQ pain and tenderness,
fever, leukocytosis, elevation of alkaline
phosphatase and bilirubin
•Diagnostic test of choice: Ultrasonography
demonstrates the distended gallbladder with
thickened wall, biliary sludge, pericholecystic fluid,
and the presence/absence of abscess formation
ACALCULOUS CHOLECYSTITIS
•Urgent intervention: early broad-spectrum
antibiotics and fluid resuscitation
•Most definitive treatment: laparoscopic
cholecystectomy or percutaneous cholecystectomy
CHOLEDOCHAL CYSTS
•Biliary cysts
•Congenital cystic dilatations of the extrahepatic
and/or intrahepatic biliary tree
•Rare, affect females 3-8x more than males, ½
diagnosed in adults
•Cause unknown; weakness of the bile duct wall
and increased pressure secondary to partial biliary
obstruction
CHOLEDOCHAL CYSTS
• >90% of patients have an anomalous
pancreaticobiliary duct junction
•Typical clinical triad: abdominal pain, jaundice, and
a palpable mass
•UTZ or CT Scan = confirmatory
•ERCP or MRCP = essential for anatomy
assessment and formulation of surgical plan
CHOLEDOCHAL CYSTS
•Risk for cholangiocarcinoma is 20-30 fold higher
•Excision is recommended when diagnosed
•Fusiform CBD dilations = most common type
(50%), highest risk of malignancy (>60%)
•Choledochoceles = lowest malignancy risk (~2%)
CHOLEDOCHAL CYSTS
•Classification:
Type I – Fusiform or cystic dilations
of extrahepatic BT
Type II – Saccular diverticulum
Type III – Choledochoceles
Type IV – Multiple cysts
IVa – Intrahepatic involvement
IVb – Extrahepatic
Type V – Caroli disease
PRIMARY SCLEROSING CHOLANGITIS
•Inflammatory strictures involving the intrahepatic
and extrahepatic biliary tree → secondary biliary
cirrhosis
•Affects 30-45 y/o men more than women
•Signs and symptoms: intermittent jaundice,
fatigue, weight loss, pruritus, or abdominal pain
•Pathogenesis: autoimmune reaction, chronic low-
grade bacterial or viral infection, toxic reaction, and
genetic factors
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•Hepatic duct bifurcation – most severely affected
segment
•Liver biopsy – determines the degree of hepatic
fibrosis and presence of cirrhosis
•10% – 15% will develop cholangiocarcinoma
•ERCP revealing multiple dilatations and strictures
(beading) of the intra- and extrahepatic biliary tree
confirms the diagnosis
•Surgical management: resection of the
extrahepatic biliary tree and hepaticojejunostomy or
liver transplantation
BILE DUCT STRICTURES
•Mostly caused by operative injury, most commonly
during cholecystectomy
•Other causes:
- fibrosis due to chronic pancreatitis
- common bile duct stones
- acute cholangitis
- Mirizzi’s syndrome
- sclerosing cholangitis
- cholangiohepatitis
- strictures of a biliary-enteric anastomosis
•Complications: recurrent cholangitis, secondary
biliary cirrhosis, portal hypertension
•Most commonly result in recurrent episodes of
cholangitis but may present with isolated jaundice
without infection.
•Elevated bilirubin and alkaline phosphatase
•UTZ or CT: dilated bile ducts proximal to the
stricture
•MRCP: gives more detailed anatomic information
about the location and the degree of dilatation
•Cholangiography: will outline the biliary tree,
define the stricture and its location, and allow for
therapeutic interventions
•Percutaneous or endoscopic dilatation and/or stent
placement
•Roux-en-Y choledochojejunostomy or
hepaticojejunostomy – for persistent or complex
strictures; good or excellent outcomes in 80% -
90% of patients
•Choledochoduodenostomy – choice for strictures
in the distal-most part of the CBD
INJURY to the BILIARY TRACT
GALLBLADDER
● Uncommon
● Usually caused by penetrating trauma or
medical procedures
● Nonpenetrating trauma is extremely rare
● Cholecystectomy - treatment of choice
● Prognosis is directly related to the injury
EXTRAHEPATIC BILE DUCTS
● Penetrating trauma to the extrahepatic bile
ducts is rare
● Majority of the injuries occur are iatrogenic
● Biliary tract injury may also occur
● Inadequate exposure or failure to identify
structures (most common)
STRASBERG CLASSIFICATION
o Type A: injury to the cystic duct or from
minor hepatic ducts draining the liver bed
o Type B: occlusion of the biliary tree,
commonly aberrant right hepatic duct(s)
o Type C: transection without ligation of
aberrant right hepatic duct(s)
o Type D: lateral injury to a major bile duct
o Type E: injury to the main hepatic duct;
classified according to the level of injury
o E1 (bismuth type 1): injury more
than 2cm from the confluence
o E2 (bismuth type 2): injury less
than 2 cm from the confluence
o E3 (bismuth type 3): injury at the
confluence; confluence intact
o E4 (bismuth type 4): destruction of
the biliary confluence
o E5 (bismuth type 5): injury to the
aberrant right hepatic duct
DIAGNOSIS
● 25% of the bile duct injuries are recognized
at the time of surgery
● Elevated liver function test
● CT scan
● Ultrasound
● HIDA scan
MANAGEMENT
● Injured duct < 3mm - can be ligated
● Injured duct > 4mm - T-tube placement
● Minor bile duct injuries
○ Placement of T-tube
● Major bile duct injuries
○ Reconstruction with biliary-enteric
anastomosis
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 ● Major bile duct injuries diagnosed post - op ● T2
○ percutaneous drainage of intra- ○ Tumor invades perimuscular
abdominal bile connective tissue without extension
to serosa or into the liver
Carcinoma of the Gallbladder ■ Extended cholecystectomy
● Rare malignancy ● >70% for patients that
● Aggressive tumor underwent Extended
● 6th most common GI malignancy Cholecystectomy
● Prognosis: ● 25% to 40% for
patients that
○ 5 year survival rate: 5%
underwent
○ Median survival: 6 months Laparoscopic
● Female - more common Cholecystectomy
● 7th decade of life - peak incidence ● T3
○ Tumors that grow beyond the
Risk factors serosa, or invade the liver or other
○ Cholelithiasis adjacent organs
■ MOST IMPORTANT risk ■ Complete tumor excision with
factor an extended right
■ 85% of patients have hepatectomy and possible
gallstones caudate lobectomy with
○ Polyps lymphadenectomy
■ >10mm - risk for malignancy ● 5-year survival rates
○ Porcelain GB of 20% to 50%
○ Choledochal cyst ● T4
○ Sclerosing cholangitis ○ Tumors have grown into major blood
○ Exposure to carcinogens vessels or structures outside the
liver
Clinical Manifestation ■ Palliative Care
● Abdominal discomfort ● 5-year survival rates
● Right upper quadrant pain of 20% to 50% -
● Nausea resectable tumors
● Vomiting ● Median survival 1 to 3
● Jaundice months
● Weight loss ● Recurrence after resection of gallbladder
● Anorexia cancer
● Ascites ○ Poor prognosis
● Abdominal masses are less common ○ Palliative is provided
● Death most commonly secondary to biliary
Diagnostics sepsis or liver failure
● Ultrasound
● CT scan Cholangiocarcinoma
● MRCP ● Rare tumor may occur anywhere along the
● Endoscopic ultrasound (EUS) biliary tree
● Tissue diagnosis ● Half occuring at the hepatic bifurcation
● 40% distally
Treatment ● 10% intrahepatic
● T1 ● Male predominance
○ Tumor limited to the lamina propria ● 50 - 70 years
or muscular layer ● 95% are adenocarcinoma
■ Laparoscopic
cholecystectomy Risk Factor
● results in a near ● Choledochal cyst
100% overall 5-year ● Ulcerative colitis
survival rate ● Hepatolithiasis
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 ● Biliary–enteric anastomosis
● Biliary tract infections
○ Clonorchis sinensis infection &
Typhoid carriers
● Exposure to dietary nitrosamines,
Thorotrast, dioxin
● Primary Sclerosing Cholangitis
Morphological classification
● Nodular
○ Common type
○ Firm mass seen in the ductal wall
growing in the ductal lumen
● Cirrhous
○ Occurs in the proximal ducts causing
fibrosis
● Papillary
○ Soft polypoid lesion occurs distally
with intraluminal growth
● Diffusely infiltrating
Bismuth-Corlette classification
● Type I
○ Tumors are confined to the common
hepatic duct
● Type II
○ Tumors involve the bifurcation
without involvement of the
secondary intrahepatic ducts.
● Type IIIa and IIIb
○ Tumors extend into the right and left
secondary intrahepatic ducts,
respectively.
● Type IV
○ Tumors involve both the right and
left secondary intrahepatic ducts.
Clinical presentation:
● Painless jaundice is usually severe
○ Most common
● Pruritus
● Cholangitis
○ Presenting symptom of 10% of
patients
● Weight loss
● Fatigue
● Mild RUQ pain
Diagnostics
● Tumor marker
○ CA 19-9
■ sensitivity of 79% and
specificity of 98% if the
serum value is >129 U/mL
● Ultrasound or CT scan
○ dilatation of the intrahepatic biliary
tree
○ normal or collapsed gallbladder and
extrahepatic bile ducts distal to the
tumor
● Cholangiography
○ MRCP, ERCP, PTC
Treatment
● Surgical excision is the only potentially
curative treatment for cholangiocarcinoma
● Distal bile duct tumors
○ Pancreaticoduodenectomy (Whipple
procedure)
● Perihilar tumors
○ Bismuth- Corlette type I or II
■ Local tumor excision with
portal lymphadenectomy,
cholecystectomy, common
bile duct excision, and
bilateral Roux-en-Y
hepaticojejunostomies
○ Bismuth- Corlette type IIIa or IIIb
■ right or left hepatic lobectomy
○ Bismuth- Corlette type IV
■ considered unresectable
■ treatable with liver
transplantation
● Adjuvant Chemotherapy
○ No proven role in treatment
● Adjuvant radiation therapy
○ has also not been shown to increase
either quality of life or survival in
resected patients
● Combination of Radiation and
Chemotherapy
○ may be more effective than either
treatment alone for unresectable
disease
Prognosis
● Resectable Perihilar Cholangiocarcinoma:
○ 5 year survival: 10-30%
○ Negative margin : 40%
● Resectable Distal Perihilar
Cholangiocarcinoma:
○ 5 year survival: 30 - 50%
○ median survival is 32 to 38 month
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● liver transplantation for cholangiocarcinoma
○ 5-year disease free survival rates as
high as 68%
● MOST COMMON cause of death
○ Hepatic failure
○ Cholangitis

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