Biliary Tract Disease

Dr.Lydia B.
 Overview
Anatomy & physiology of biliary system
Cholelithiasis
Acute cholecystitis
Chledocholithiasis
Cholangitis
Cholecystectomy
Choledocal Cysts
Biliary strictures
 Biliary Tract

Part of the digestive system.

Made up of:
Intra hepatic ducts
Exta hepatic ducts
Gallbladder
Common Bile Duct
 The Gallbladder

The GB- concentrates and stores bile.

Bile: Secreted by the liver
cholesterol, bile pigments and phospholipids

Digestion & absorption -fatty foods and

fat-soluble vitamins
 Gallstones – Pathophysiology

Altered Ratio of cholesterol, phospholipids, and bile salts >

cholesterol crystals
Gallstone formation :
Cholesterol supersaturation
Mucin hypersecretion
Bile stasis
 Gallstones – Types
Two main types:
Cholesterol stones (85%):
pure (90-100% cholesterol
solitary, whitish, and larger than 2.5 cm in diameter.
mixed (50-90% cholesterol).
smaller, multiple in number, and occur in various
shapes and colors.
Pigment stones (15%)
Brown stones - calcium bilirubinate and calcium-soaps.
Bacteria - beta glucuronidase and phospholipase
Black stones - excess bilirubin - calcium bilirubinate
Eg. chronic hemolysis)
 Epidemiology
Common (20% population)
Cholesterol stones
Risk factors
Sex (F:M=3:1)
Age
Genetic
Obesity
Estrogen
Hypercholesterolaemia
5 F’s
Disruption :Enterohepatic circulation- bile salt
Biliary stasis
Biliary infections
 Gallstones – Natural History

80% of patients, gallstones are clinically

silent
20% of patients develop symptoms over
15-20 years
About 1% per year
Almost all become symptomatic before
complications develop
 Clinical manifestation
Asymptomatic
Biliary colic
Dyspepsia
Complications
Cholecystitis
Choledocholithiasis
Pancreatitis
Mirizzi syndrome
Cholangitis
Gallstone ileus
Carcinoma of gallbladder
Complications of Gallstones
In the gallbladder
Biliary colic
Acute and chronic cholecystitis
Empyema
Mucocoele
Carcinoma
In the bile ducts
Obstructive jaundice
Pancreatitis
Cholangitis
In the Gut
Gallstone ileus
 INVESTIGATIONS

ULTRASOUND
TREATMENT
Cholesystectomy
-Symptomatic patients
-Fit for surgery
-Laparascopic
Acute Cholecystitis

Acute inflammation of the gallbladder

Usually associated with calculi (stones)
obstruction at Hartmann's pouch or cystic
duct
Less commonly with biliary sludge
A-calculus (no-stone) cholecystitis rare
Bacterial infection < 50%
Recurrent attacks - fibrosed thickened
gallbladder (chronic cholecystitis)
 Clinical manifestation
Symptoms
Right upper quadrant pain – continuous, >4-6 hrs
Signs
Tachycardia, fever
RUQ tenderness
Murphy’s sign
Investigations
Leucocytosis, CRP, LFT
Ultrasound of abdomen
Thickened gallbladder wall, pericholecystic fluid and stones
Treatment
Nil by mouth
Analgesia
Intravenous antibiotics
Cholecystectomy
Murphy’s Sign
 Complications of Acute cholecystitis
Empyema
Mucocele/hydropis
Emphysematous cholecystitis
Gangrenous
Perforation
Localized(Abscess)
Generalized Peritonitis
Fistula –Biliary enteric
-cholecysto choledochal
 CHOLEDOCHOLITHIASIS
Presence of Stone –Bile duct
Most – secondary stones (GB)
Primary stones- causes
CLINICAL MANIFESTATION
Asymptomatic
Biliary colic
Obstructive jaundice
Cholangitis
Investigations
LFT- ALP, Bilirubin (T&D), GGT
Ultrasound of abdomen
MRCP, ERCP
Treatment
Endoscopic Retrograde CholangioPancreatogram
Open Choledocholithotomy
 Ascending Cholangitis
Infection of the obstructed biliary system
Symptoms
Charcot’s triad : fever, RUQ pain, jaundice (50%)
Vomiting
Abnormal mentation
Signs
Sepsis (Fever, tachycardia, low BP), Jaundice & RUQ tenderness
Investigations
Leucocytosis
LFT- Abnormal
Ultrasound of abdomen
Treatment
IV fluid resuscitation
Intravenous antibiotics
-Gm Negatives , Anaerobes
Persistent sepsis- Emergency biliary decompression
Cholesystectomy & CBD exploration / ERCP with bile duct clearance
-Done during the same admission
 Complications (Cholesystectomy)
Trauma
dBile duct Biliary peritonitis
Intestine
Liver
Haemorrhage
Vessel injury
Liver injury
Cystic artery clips
Infection
Hernia
 Choledochal cysts
Consist of cystic dilatations of the extra-hepatic biliary tree
Uncommon abnormality
50% present with combination of jaundice, abdominal pain,
and an abdominal mass.
? Due to anomalous union of the pancreatic and biliary
ductal system.
Complications
-Ascending cholangitis (Recurrent)
-Cholangiocarcinoma
-Biliary cirrhosis
Treatment - surgical (excision of the cyst with construction).
Biliary Stricture

CAUSES:
Malignant strictures (90%)
Pancreatic cancer
Cholangiocarcinoma
HCC
Benign Strictures
Iatrogenic (Most)
-Cholesystectomy
Stones (Mrizzi synd)
Abdominal Trauma
Pancreatitis
Primary sclerosing cholangiti
Clinical presentation

• Asymptomatic (Lab. Abnormalities)

• Abdominal pain
• Obstructive Jaundice
• Complications
-Cholangitis (Recurrent)
-Biliary stones (extrahepatic & intrahepatic)
-Biliary cirrhosis & PHN
 DIAGNOSIS
LFT (Cholestatic)
ULTRASOUND
MRCP
CHOLANGIOGRAPHY
-ERCP
-PTC
CT-SCAN
BILIARY SCINTIGRAPHY
MANAGEMENT
Individualized

Tumour resection & reconstruction

-Post cholesystecomy strict.
Biliary-Enteric Bypass
Biliary stents
Reference
• Schwartz's principles of surgery 10th edition.
• Bailey’s and love’s
Thank you