THE BILIARY TREE AND BILIARY THE BILIARY TREE AND BILIARY TRACT DISEASESTRACT DISEASES

Presented By:Presented By:Rhile M. Arcenio, M.D.Rhile M. Arcenio, M.D.

OUTLINEOUTLINE

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGY DuctsDucts Gall BladderGall Bladder PancreasPancreas

COMMON BILIARY TRACT COMMON BILIARY TRACT DISEASESDISEASES

Cholelithiasis ( Gall stones)Cholelithiasis ( Gall stones) Acute CholecystitisAcute Cholecystitis Acute CholangitisAcute Cholangitis

ANATOMY: The DuctsANATOMY: The Ducts

THE DUCTS:THE DUCTS:

1.1. Right Hepatic Right Hepatic Duct (RHD)Duct (RHD)

2.2. Left Hepatic Left Hepatic Duct (LHD)Duct (LHD)

3.3. Common Common Hepatic Duct Hepatic Duct (CHD)(CHD)

4.4. Common Bile Common Bile Duct (CBD)Duct (CBD)

THE DUCTS:THE DUCTS:

The Hepatic Ducts:The Hepatic Ducts:- R and L Hepatic R and L Hepatic

ducts emerge from ducts emerge from the liver via the the liver via the Porta HepatisPorta Hepatis

- R and L unite to R and L unite to form the form the Common Common Hepatic DuctHepatic Duct

- The Common The Common Hepatic Duct Hepatic Duct

- descends and is descends and is joined on the R side joined on the R side by the cystic duct by the cystic duct from the gall from the gall bladder to form the bladder to form the Common Bile Common Bile DuctDuct

The Common The Common Bile DuctBile Duct 3 inches long3 inches long Pierces the Pierces the

duodenum and duodenum and joined by the joined by the main pancreatic main pancreatic ductduct

Opens into the Opens into the Ampulla of Ampulla of VaterVater

ANATOMY: The Gall ANATOMY: The Gall BladderBladder

Pear shaped sac Pear shaped sac lying on the lying on the visceral side of visceral side of the liverthe liver

Approx 8 cm longApprox 8 cm long

FUNCTIONS:FUNCTIONS: Reservoir for Reservoir for

bile~ 50 mLbile~ 50 mL Concentrates bileConcentrates bile

3 MAIN ANATOMIC 3 MAIN ANATOMIC PARTS:PARTS:

1.1. NeckNeck

2.2. Corpus/ BodyCorpus/ Body

3.3. FundusFundus

Blood Supply:Blood Supply: Cystic ArteryCystic Artery

Drainage:Drainage: Cystic VeinCystic Vein

Nerve Supply:Nerve Supply: Celiac PlexusCeliac Plexus

THE CYSTIC THE CYSTIC DUCTDUCT 1.5 cm 1.5 cm Connects the Connects the

neck of the GB to neck of the GB to the Common the Common Hepatic Duct to Hepatic Duct to form the form the Common Bile Common Bile DuctDuct

THE PANCREAS:THE PANCREAS: Exocrine- produce Exocrine- produce

secretions with secretions with enzymes that are enzymes that are capable of capable of hydrolyzing fats, hydrolyzing fats, proteins and proteins and carbohydratescarbohydrates

Endocrine- ( Islet of Endocrine- ( Islet of Langerhans) Langerhans) produce Insulin & produce Insulin & GlucagonGlucagon

HEADHEAD Disc shapedDisc shaped Lies in the Lies in the

concavity of the concavity of the duodenumduodenum

Part of the head Part of the head extends to the extends to the leftleft UNCINATE UNCINATE PROCESSPROCESS

NECKNECK Connects the Connects the

head to the bodyhead to the body BODYBODY

Runs upward and Runs upward and to the L across to the L across the midlinethe midline

TAILTAIL

SUMMARY:SUMMARY:

GALL BLADDERGALL BLADDER An 8cm sac stuck to the An 8cm sac stuck to the

undersurface of the liver. undersurface of the liver. Store and concentrate the bileStore and concentrate the bile Deliver Bile into the gut Deliver Bile into the gut Mixes with the food and aids in Mixes with the food and aids in

the absorption of fats and certain the absorption of fats and certain vitaminsvitamins

BILIARY TRACT BILIARY TRACT PROCEDURESPROCEDURES

22ndnd most common procedure most common procedure next to Appendectomynext to Appendectomy

CHOLELITHIASIS:CHOLELITHIASIS:

Also known as Gall StonesAlso known as Gall Stones Formed when bile acids are Formed when bile acids are

overwhelmed by increased overwhelmed by increased cholesterolcholesterol

RISK FACTORS: (5 F’s)RISK FACTORS: (5 F’s) FemaleFemale FatFat FertileFertile Forty Forty FlatulentFlatulent

CHOLELITHIASISCHOLELITHIASIS

TYPES OF GALL TYPES OF GALL STONES:STONES:

Cholesterol StonesCholesterol Stones RadioluscentRadioluscent Grossly yellow in Grossly yellow in

colorcolor Mixed StonesMixed Stones

Has both cholesterol Has both cholesterol and pigment and pigment componentscomponents

Most common typeMost common type Pigment StonesPigment Stones

Seen in patients with Seen in patients with alcoholic cirrhosis, alcoholic cirrhosis, advanced age and advanced age and biliary infectionbiliary infection

CHOLELITHIASISCHOLELITHIASIS

Diagnostics:Diagnostics: Abdominal Ultrasound- detect Abdominal Ultrasound- detect

gallstones within the bladdergallstones within the bladder Radionuclide Biliary Scan- most Radionuclide Biliary Scan- most

sensitivesensitive Abdominal Radiograph is of little Abdominal Radiograph is of little

valuevalue

CHOLELITHIASISCHOLELITHIASIS

Treatment:Treatment: Cholecystectomy- definitive and Cholecystectomy- definitive and

curativecurative may be done on an elective basismay be done on an elective basis

ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS

Inflammation of the gall bladder Inflammation of the gall bladder secondary to prolonged blockage of secondary to prolonged blockage of the cystic ductthe cystic duct

Most commonly due to an impacted Most commonly due to an impacted gall stonegall stone

Crampy epigastric or RUQ pain, Crampy epigastric or RUQ pain, postprandialpostprandial

Fever, Nausea and VomitingFever, Nausea and Vomiting (+) Murphy’s sign- RUQ tendernes on (+) Murphy’s sign- RUQ tendernes on

inspirationinspiration Jaundice if it impacts the CBDJaundice if it impacts the CBD

ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS

TREATMENT:TREATMENT: IV AntibioticsIV Antibiotics Early Cholecystectomy ( within 72 Early Cholecystectomy ( within 72

hrs of onset of symptoms)hrs of onset of symptoms) For patients with significant medical For patients with significant medical

problems , delay cholecystectomy problems , delay cholecystectomy until acute inflammation resolvesuntil acute inflammation resolves

ACUTE CHOLANGITIS:ACUTE CHOLANGITIS:

Acute bacterial infection of the Acute bacterial infection of the biliary tree usually secondary to biliary tree usually secondary to obstructionobstruction

Fever, jaundice & RUQ pain Fever, jaundice & RUQ pain

( Charcot’s Triad)( Charcot’s Triad) Reynaud’s Pentad ( Charcot’s Reynaud’s Pentad ( Charcot’s

triad + shock+ altered mental triad + shock+ altered mental status)status)

ACUTE CHOLANGITISACUTE CHOLANGITIS

DIAGNOSTICS:DIAGNOSTICS: LeukocytosisLeukocytosis Elevated bilirubinElevated bilirubin Elevated Alkaline PhosphataseElevated Alkaline Phosphatase Culture to rule out sepsisCulture to rule out sepsis ERCP ( biliary drainage) ERCP ( biliary drainage)

ACUTE CHOLANGITISACUTE CHOLANGITIS

TREATMENT:TREATMENT: Serious & Life threateningSerious & Life threatening Requires ICU admissionRequires ICU admission Aggressive IV antibiotic Aggressive IV antibiotic

treatmenttreatment Patients with Acute Suppurative Patients with Acute Suppurative

Cholangitis require emergent bile Cholangitis require emergent bile duct decompressionduct decompression

SUMMARYSUMMARY

Biliary Tract Procedures are the 2Biliary Tract Procedures are the 2ndnd most most common surgical procedure next to common surgical procedure next to AppendectomyAppendectomy

Most Common Cause- gall stone formationMost Common Cause- gall stone formation 3 types of Gall stones3 types of Gall stones

CholesterolCholesterol MixedMixed PigmentPigment

Stones that lodge and obstruct into the CBD will Stones that lodge and obstruct into the CBD will cause jaundice and bile stasis which may super cause jaundice and bile stasis which may super infect and cause Cholecystitis/ Cholangitisinfect and cause Cholecystitis/ Cholangitis

Best Diagnosed by Radionucleotide Biliary Scan,Best Diagnosed by Radionucleotide Biliary Scan, Ultrasound remains the diagnostic procedure of Ultrasound remains the diagnostic procedure of

choice choice

Treatment – Cholecystectomy Treatment – Cholecystectomy For patients with significant For patients with significant

medical illness, delay medical illness, delay cholecystectomy until cholecystectomy until inflammation resolvesinflammation resolves

THANK YOUTHANK YOU