Disease of The Biliary Tract

Abdifatah Osman Nur,MBBS,Mmed(General Surgery)

 Anatomy Review
• Biliary tract
– Intra-hepatic bile duct
– Extra-hepatic bile duct
– Gallbladder
– Oddi sphincter
From bile canaliculi to the ampulla of Vater.
 Intra-hepatic Bile Duct
• Bile canaliculi.
• Segmental bile duct
• Lobal bile duct
• Hepatic part of left and right hepatic duct
 Extra-hepatic Bile Duct
• Left and right hepatic duct
• The common hepatic duct
-Diameter :0.4-0.6 cm ,
- length: less than 2cm
• Common bile duct(4 parts).
-Diameter:0.6-0.8cm
-length:2.5cm
• Gallbladder:
- Body, Fundus and Neck
• Cyst duct
Calot triangle:
• The triangle bounded by the common hepatic duct
medially, the cystic duct lateraly and the inferior
surface of the right liver superiorly is known as
Calot triangle.

• The fact that cystic artery ,right hepatic artery &

para-right hepatic duct run within the triangle
makes an important area of dissection during
cholecytectomy.
• The sphincter of Oddi:
• The distal bile and pancreatic ducts and the
common channel are surrounded by circular
and longitudinal smooth muscle, this muscle
complex is known as the sphincter of Oddi.
CONGENITAL Abnormalities
 Extrahepatic biliary atresia
• Biliary atresia presents in 1 per 12 000 live
births.
• Affects both gender equally.
• Aetiology is unclear.
• Untreated, death from the consequences of
liver failure occurs before the age of 3 years.
• About 20% of cases there will be associated
anomalies.
 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
 Clinical features
• Obstructive jaundice features
• Biliary rickets.
• Clubbing and skin xanthomas(raised serum
cholesterol).
 Treatment
• Surgery
-A direct Roux-en-Y hepaticojejunostomy(type1).
- Kasai procedure( type 2 and 3).
• Liver transplantation(liver failure or unsuccessful
of kasai procedure) .
 Caroli’s disease
• Multiple irregular saccular dilatations of the
intrahepatic ducts, separated by segments of
normal or stenotic ducts, with a normal
extrahepatic biliary system.
• The majority of patients present before the age of
30.
• Sex distribution is equal.
• The biliary dilatation is associated with congenital
hepatic fibrosis.
• Hepatic resection is indicated in limited disease.
• liver transplantation for diffuse disease and
concomitant hepatic fibrosis.
• long-term surveillance is required.
 Choledochal cyst
• Choledochal cysts are congenital dilations of the
intra and/or extrahepatic biliary system.

• Classification of cystic disease of the biliary tract

- Type I:Diffuse cystic.
- Type II: Diverticulum of common bile duct.
- Type III Diverticulum within pancreas.
- Type IV: extension into the liver.
• Type V: cystic dilatation only of the
intrahepatic ducts(caroli disease).
• Type I cysts are the most common and account for
approximately 75% of patients.
• jaundice, fever, abdominal pain and a right upper
quadrant mass on examination.
• U/S will confirm the presence of cyst.
• (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.
• 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.
 Special Investigation of
the biliary Tract
Ultrasound
• Non-invasive
• painless
• Easily performed
• First choice for biliary tract disease
• Bile duct stones
• Stones in gallbladder
- High echo which cast an acoustic shadow
and which move with changes in posture
• Jaundice differential diagnosis:
-Dilatation of the ducts
-CBD: diameter > 1.0cm
• Other disease: Cholecytitis, tumor ect.
• Computed tomography(CT)
• Endoscopic retrograde cholangio-
pancreatography(ERCP)
-Outline the biliary tree and pancreatic duct
-Inspect the ampulla of Vater
-Exam of the fluid of duodenum ,bile, pancreatic
fluid.
• Magnetic resonance cholangio-pancreatography
(MRCP)
Percutaneous transhepatic cholangiography
(PTC)
• T-tube Cholangiography during &
postoperation
• Choledochoscopy
– Operation
– Post operation
• Thank you.