I.

6 Gallbladder and the Extrahepatic Biliary System

Dr. HAZEL Z. TURINGAN, MD, FPCS, FPSGS, DPBTCVS, DMCC July 16, 2013
ANATOMY GALLBLADDER FUNCTION concentrate and store hepatic bile deliver bile into the duodenum in response to a meal FASTING STATE 80% of the bile secreted by the liver stored in the gallbladder gradual relaxation emptying of the gallbladder role in maintaining a relatively low intraluminal pressure in the biliary tree H ion transport bile pH acidification promotes calcium solubility Prevents precipitation as calcium salts CYSTIC ARTERY AND THE HEPATOCYSTIC TRIANGLE Liver bed Cystic duct CHD

a = right hepatic duct b = left hepatic duct c = common hepatic duct h = common bile duct i = fundus of the gallbladder j = body of gallbladder k = infundibulum l = cystic duct d. portal vein e. hepatic artery f. gastroduodenal art g. left gastric artery m. cystic artery n. superior pancreaticoduodenal artery What connects to gallbladder? Cystic duct Right hepatic duct + Left hepatic duct forms the common hepatic duct common bile duct goes all the way to meet pancreatic duct Duct of Wirsung major duct Duct of Santorini small, accessory duct Gallbladder stores bile until you need it Sphincter of Oddi important in regulating flow of bile Contracts if it does NOT need bile Relaxes if it does need bile H+ - acidifies bile; helps develop stone Ca2+ in presence of acid no stone formation Ca2+ in presence of alkali with stone formation GALLBLADDER

Relevance : this is where you find the cystic artery Not seen in cadavers In living bodies, covered by mesentery. Hence, you have to be careful baka ma-ligate ang Right Hepatic Artery CALOT TRIANGLE Cystic artery Cystic duct CHD

Important for surgeons: CHD diameter is important (usually 4mm). You want to know if the stone can pass the duct CBD there must be a stone inside for it to dilate LUNDS NODE & MASCAGNI NODE

pear-shaped sac 7 to 10 cm long 30 - 50 ml capacity 300 ml obstructed

Suzie, Patsu, Dayle, Gemmy

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COMMON HEPATIC DUCT 1 - 4 cm length 4 mm diameter COMMON BILE DUCT 7 - 11 cm length 5 - 10 mm diameter CYSTIC DUCT 2-5 mm diameter 1-6 cm length

SPHINCTER OF ODDI thick coat of circular smooth muscle surrounds the common bile duct at the ampulla of Vater Controls the flow of bile, and in some cases pancreatic juice, into the duodenum. VARIATIONS IN CYSTIC DUCT

Small ducts (of Luschka) may drain directly from the liver into the body of the gallbladder [FAVORITE EXAM QUESTION!] Unrecognized post cholecystectomy causes BILOMA(accumulation of bile in the peritoneal fluid) Spiral valves of Heister Not really clinically significant undulating folds or valves in the proximal mucosa of the cystic duct

CBD & PD UNITES 70% outside the duodenal wall and traverse the duodenal wall as a single duct 20% join within the duodenal wall and have a short or no common duct, but open through the same opening into the duodenum. 10% exit via separate openings into the duodenum.

liver produces bile excreted bile canaliculi 500 to 1000 ml/day average diet produced within the liver Vagal stimulation - bile secretion Splanchnic nerve stimulation - bile flow Memorize the FLOW of BILE! Liver R&L hepatic duct common hepatic duct cystic duct common bile duct duodenum DUODENUM Hydrochloric acid partly digested proteins fatty acids stimulate release Secretin bile production bile flow

I.6 Gallbladder and the Extrahepatic Biliary System

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HBT ULTRASONOGRAPHY HBT hepatobiliary tree

Liver bile flow hepatic duct common hepatic duct common bile duct Duodenum Intact sphincter of Oddi - bile flow is directed into the gallbladder EFFECT OF CHOLECYSTOKININ

>90% sensitivity & specificity Post-acoustic shadowing = stone Also notes thickness of the GB wall = inflammation STONES acoustically dense reflect the ultrasound waves back to the ultrasonic transducer block the passage of sound waves to the region behind them they also produce an acoustic shadow PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM AND DRAINAGE For Obstructing Proximal CholangioCA

response to a meal gallbladder contraction sphincter of Oddi relaxation gallbladder empties CHOLECYSTOKININ (CCK) stimulus for galbladder emptying released endogenously from the duodenal mucosa in response to a meal After a meal GB empties 30-40 mins 50 -70% of contents GB refills 60-90 mins correlated with a reduced CCK level acts directly on GB smooth muscle receptors stimulates gallbladder contraction relaxes terminal bile duct sphincter of Oddi duodenum Vasoactive intestinal polypeptide inhibits contraction and causes gallbladder relaxation. Somatostatin and its analogues are potent inhibitors of gallbladder contraction. high incidence of gallstones, presumably due to the inhibition of gallbladder contraction and emptying. Somatostatin is given when there is spastic pain because of the stones

bile duct strictures and tumors, defines the anatomy of the biliary tree proximal to the affected segment ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY (ERC) & ENDOSCOPIC ULTRASOUND CBD cannulated cholangiogram using fluoroscopy Diagnostic and treatment procedure of choice for CBD stones ADVANTAGES OF ERC direct visualization of the ampullary region direct access to the distal CBD possibility of therapeutic DIAGNOSTIC & THERAPEUTIC PROCEDURE OF CHOICE stones in the CBD associated with obstructive jaundice cholangitis gallstone pancreatitis endoscopic cholangiogram (+) ductal stones sphincterotomy stone extraction (-) CBD stones CBD cannulation and cholangiography success rate >90%.

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ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY (ERC) & ENDOSCOPIC ULTRASOUND

DEFINITION OF TERMS Cholecystitis GB + inflammation Cholecystolithiasis GB + stone Choledocholithiasis CBD + stone Cholelithiasis GB / BD + stone Cholangitis bile duct + inflammation Cholecystectomy GB + removal Cholecystostomy GB + tube Choledochostomy CBD + tube Choledochotomy CBD + incise CHOLECYST - Gall bladder CHOLEDOCHO Common Bile Duct LITHIASIS - Stone TECTOMY Removal OSTOMY Tube insertion CHOLELITHIASIS Over a 20-year period, 2/3 asymptomatic patients with gallstones remain symptom free GALLSTONE FORMATION Major organic solutes in bile: bilirubin bile salts phospholipids cholesterol Cholesterol solubility depends on the relative concentration of: cholesterol bile salts lecithin (the main phospholipid in bile) SUPERSATURATION cholesterol hypersecretion > reduced secretion of phospholipid or bile salts CHOLESTEROL

PIGMENT STONES contain <20% cholesterol dark due to presence of calcium bilirubinate supersaturation calcium bilirubinate carbonate phosphate most often 2ndry to: hemolytic disorders cirrhosis almost always form in the gallbladder Unconjugated bilirubin is much less soluble than conjugated bilirubin in bile BROWN STONES <1 cm in diameter brownish-yellow soft, and often mushy form either in the gallbladder or in the bile ducts, usually secondary to bacterial infection caused by bile stasis Precipitated calcium bilirubinate and bacterial cell bodies compose the major part of the stone CHRONIC CHOLECYSTITIS About two thirds of patients with gallstone disease present with chronic cholecystitis characterized by recurrent attacks of pain pain develops when a stone obstructs the cystic duct, resulting in a progressive increase of tension in the gallbladder wall (distention of GB causes pain) pain is constant and increases in severity over the first half hour or so and typically lasts 1 to 5 hours. located in the epigastrium or right upper quadrant frequently radiates to the right upper back or between the scapulae severe and comes on abruptly, typically during the night or after a fatty meal. often associated with nausea and vomiting. Ddx: history of ulcer

LECITHIN

BILE SALTS

Cholesterol is secreted into bile as cholesterolphospholipid vesicles Cholesterol is held in solution by micelles, a conjugated bile salt-phospholipid-cholesterol complex, as well as by the cholesterol-phospholipid vesicles
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DIAGNOTICS HBT USG

ACUTE ACALCULOUS CHOLESCTITIS typically occurs in patients with other acute systemic diseases TREATMENT LAPAROSCOPIC CHOLECYSTECTOMY Procedure of Choice You can give antibiotics first before lap conversion rate to open cholecystectomy 10-15% higher acute cholecystitis > chronic cholecystitis

MANAGEMENT Lap cholecystectomy treatment of choice Open cholecystectomy LAPAROSCOPIC CHOLECYSTECTOMY

ANTIBIOTICS + LAPAROSCOPIC CHOLECYSTECTOMY 2 MONTHS LATER Late presentation > 3-4 days of illness unfit for surgery

Ginagawa ito sa mga cases na inoperable pa dahil inflamed ba ang GB (increased morbidity). So you give antibiotics first for the inflammation. Pag wala nang inflammation (2months later), you can operate na.

PERCUTANEOUS CHOLECYSTOSTOMY/ OPEN CHOLECYSTOSTOMY UNDER LA Unfit for surgery Poke it and drain fluid (pang-alleviate lang ng symptoms) CHOLEDOCHOLITHIASIS Common bile duct stones small or large single or multiple 6 to 12% (+) GB stones INCIDENCE increases with age 20-25% age 60 - (+) stones in GB & CBD DIAGNOSTIC HBT USG document GB stone size CBD (normal 5-10mm) HIGHLY SUGGESTIVE OF CBD STONE dilated CBD (>8 mm in diameter) (+) GB stone, jaundice biliary pain MAGNETIC RESONANCE CHOLANGIOGRAPHY excellent anatomic detail 95% sensitivity 89% specificity detecting choledocholithiasis >5 mm

ACUTE CHOLECYSTITIS 90-95% 2ndry to gallstones No stones sometimes due to systemic diseases GALLSTONE gallbladder distention inflammation edema of the gallbladder wall

ENDOSCOPIC CHOLANGIOGRAPHY gold standard for diagnosing CBD stones TREATMENT FOR CBD STONES Laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting Open common bile duct exploration choledochotomy with T-tube (for small stones to help them pass)

Take not of the thick walls of GB and edema GALLBLADDER WALL grossly thickened reddish with subserosal hemorrhages PERICHOLECYSTIC fluid often is present
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 the problem with small stones, they are easily friable, so not all of them are taken out

CHOLEDOCHODUODENOSTOMY OR ROUX-EN-Y CHOLEDOCHOJEJUNOSTOMY Stones impacted in the ampulla CBD STONES COMPLICATION Cholangitis inflammation of GB Gallstone pancreatitis CHOLANGITIS ascending bacterial infection in association with partial or complete obstruction of the bile ducts Hepatic bile is sterile bile in the bile ducts is kept sterile by continuous bile flow (stasis causes bacterial infection) presence of antibacterial substances in bile, such as immunoglobulin Mechanical hindrance to bile flow facilitates bacterial contamination Most common cause of Obstruction in cholangitis Gallstones most common benign and malignant strictures parasites instrumentation of the ducts indwelling stents Most common organisms cultured from bile E. coli Klebsiella pneumoniae Streptococcus faecalis Enterobacter Bacteroides fragilis PRESENTATION Charcot's triad fever epigastric or right upper quadrant pain jaundice (present in 2/3 of patients) patients with Charcots triad go straight to OR! Reynolds pentad fever jaundice right upper quadrant pain septic shock mental status changes DIAGNOSTIC ERC definitive diagnostic test PTC ERC not available PTC is indicated Both ERC and PTC show the level & reason for the obstruction, allow culture of the bile allow the removal of stones if present drainage of the bile ducts with drainage catheters or stents CT scanning and MRI show pancreatic and periampullary masses ductal dilatation TREATMENT Initial treatment IV antibiotics and fluid resuscitation Biliary decompression endoscopically percutaneous transhepatic route surgically
I.6 Gallbladder and the Extrahepatic Biliary System

BILIARY PANCREATITIS Obstruction of the pancreatic duct by an impacted stone Temporary obstruction by a stone passing through the ampulla may lead to pancreatitis ERC with sphincterotomy and stone extraction may abort the episode of pancreatitis Once the pancreatitis has subsided GB (GB stone) removed during same admission Treatment: cholecystectomy + IOC preoperative ERC OPERATIVE INTERVENTION CHOLECYSTOSTOMY decompresses and drains the distended, inflamed, hydropic, or purulent gallbladder. applicable if the patient is not fit to tolerate an abdominal operation. Ultrasound-guided percutaneous drainage with a pigtail catheter is the procedure of choice. LAPAROSCOPIC CHOLECYSTOSTOMY Absolute contraindications uncontrolled coagulopathy end-stage liver disease Rarely severe obstructive pulmonary disease CHF (EF <20%) may not tolerate pneumoperitoneum with C02 INTRAOPERATIVE CHOLANGIOGRAM

CHOLEDOCHAL EXPLORATION common bile duct exploration (CBDE)

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 CHOLEDOCHAL DRAINAGE PROCEDURE pallative esp for cancer patients

GALLBLADDER CARCINOMA rare malignancy predominantly in the elderly an aggressive tumor poor prognosis overall 5-year survival rate 5% Cholelithiasis is the most important risk factor for gallbladder carcinoma 95% of patients with carcinoma of the gallbladder have gallstone Polypoid lesions of the gallbladder increased risk of cancer polyps >10 mm Calcified "Porcelain" Gallbladder >20% incidence of gallbladder carcinoma cholecystectomy even if asymptomatic Choledochal Cysts highest in gallbladder Sclerosing cholangitis anomalous pancreaticobiliary duct junction exposure to carcinogens (azotoluene, nitrosamines) Most common GB CA: 80-90% adenocarcinomas spreads through: a. the lymphatics (Calots node) b. venous drainage c. direct liver parenchyma invasion When diagnosed 25% localized to the gallbladder wall, 35% have regional nodal involvement and/or extension into adjacent liver 40% have distant metastasis CT scan staging identify a gallbladder mass local invasion into adjacent organs cannot identify nodal spread

CHOLEDOCHAL CYSTS

In jaundiced patients: percutaneous transhepatic endoscopic cholangiogram delineate the extent of biliary tree involvement TREATMENT: Surgery - only curative option Palliation unresectable disease at the time of diagnosis 5-year survival rate <5%, median survival of 6 months T1 disease treated with cholecystectomy excellent prognosis (85 -100% 5-year survival rate) advanced but resectable gallbladder cancer o 5-year survival rates 20 -50% distant metastasis o median survival 1 - 3 months

Treatment Cholecystectomy Hepaticojejunostomy 15% risk of chalangioca

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I.6 Gallbladder and the Extrahepatic Biliary System