disease-of-biliary-disease-of-biliary-tracttractAnatomy extrahepatic ductCalot triangle Anatomyintrahepatic ductStructure of Oddis sphincterPhysiology Bile secretion : hepatocyte Gallbladder: storage, concentration, secretion Systolic pressure of Oddis: 1.181.47kPa (1215cmH2O) Intra-CBD pressure: 1.18kPa Intra-gallbladder pressure: 0.98kPa Secretory pressure threshold : 2.94 kPa(30cmH2O) Daily output of bile: 8001200mlImaging investigations1. Abdominal plain film Gall stonePositive rate: 10%Imaging investigations2.2. ultrasound ultrasoundA convenient, low-cost, accurate, A convenient, low-cost, accurate, non-traumatic methodnon-traumatic methodTumor of the gallbladderIntrahepatic stones3 3. Computer tomography, CT. Computer tomography, CT Imaging investigationsTumor of the gallbladderIntrahepatic stoneProviding a two-dimensions informationImaging investigations4. Manegtic resonance imiging, MRI, MRCPMRCPEnlarged gallbladderDilated pncreaticductDilated CBDProviding a completed figureOf biliary systemNon-traumatic Imaging investigationsPTCERCP5. PTC: percutanous transhepatic cholangiography ERCP: endoscopic retrograde choloangiopancreatographyImaging investigations6. Choledochoscopy: intraoperative postoperative Residual stone extractionCongenital cystic dilatation of bile duct (Carolis disease)Cystic dilatation of the intrahepatic or/ and extraheptic bile ductClinical manifestations:A congenital disease, onset initially at the childhood Right upper quadrant painJaundice Chill, feverAbdominal massclinical classificationsTadonis classificationsDiagnosisB-us, CT, MRCP, PTCTreatmentCompleted excision of the dilated bile ductRoux-en-Y hepatojejunostomyCholelithiasisclassificationsCholesterol stone Pigment stone Mixed stone Sludge stonelocationcomponentGallstoneManifestation and diagnosisAsymptomatic symptomatic right upper quadrant pain, radiate to right backChill, feverBiliary colicMirizzi syndromeAbdominal massB-usTreatmentSurgery: CholecystectomyLaparoscopic cholecystectomy, LC: gold standard procedure for benign gall disease Open cholecystectomy, OC Mini-lap cholecystetomy, MCIndications of surgery Symptomatic gall stone strangulated gall stone, acute pyogenic or gangrenous cholecystitis Chronic atrophic cholecystitis Stack gall stone or diameter 2 cmGallstoneTreatmentConservative treatmentAsymptomatic sludge gall stoneCDCA: chenodeoxycholic acidUDCA :Ursodeoxycholic acidPostcholecystectomy syndrome Residual stone Stricture of the Oddis sphincter muscle Residual of the cyst ductGallstoneExtrahepatic stoneManifestationsCharcot s triad Abdominal pain, colic pain Chill, fever jaundiceLab investigation and imagingALT , TBIL, DBIL,ALPB-US, first choice. PTC/ ERCPExtrahepatic stoneTreatmentPrinciples Complete clearance of stone Removal of bile duct stricture Reconstruction of bile drainageProcedures:Cholecystectomy, choledolithoctomy T tube drainageHepatojejunostomyEST: endoscopic sphincteroctomy, stone removal for single CBD stone (mini-invasive)choledolithoctomy T tube drainageExtrahepatic stoneExtrahepatic stoneIndications of T tube removal 2 weeks after operation Choledochography showed no residual stone No abdominal pain when T tube clampedCholedochoscopic manipulation6 weeks after surgery when residual stone was found by choledochographyIntrahepatic stonePathology Biliary infection and bile duct stricture Atrophy biliary cirrhosis carcinogenesisIntrahepatic stoneManifestations:AsymptomaticAbdominal pain , or Charcot triadAcute obstructive suppurative cholangitisBiliary cirrhosisDiagnosisB-US, CT, PTCTreatmentA challenge for hepatobiliary surgeon Principle for selective surgery Complete clearance of stone Removal of bile duct stricture Reconstruction of bile drainageIntrahepatic stoneProceduresHepatectomyCholedocholithiaoctomycholedochojejunostomyIntrahepatic stoneResidual stonePostoperative choledochoscopic lithotripsy 6 weeks after operation Acute cholecystitisetiologyGall stoneBacterial infectionpathologyAcute simple cholecystitisAcute suppurative cholecystitisAcute gangrenous cholecystitisClinical manifestationsRight upper quadrant colic pain radiate to right shoulder FeverJaundice, Mirizzi syndrome Ultrasound findingstreatmentsConservative therapyOpen cholecystectomyLCcholecystostomySurgical indications illness deteriorating after Conservative therapy Perforation of gallbladder Complicated with acute suppurative cholangitis Acute severe pancreatitis Onset within 4872 hours Chronic cholecystitis Repeated attack of acute cholecystitis 90% with gallstone Mild abdominal pain, dyspepsia Acute attack similar with acute cholecystitis Ultrasound: atrophy of gallbladder, thickness of the wall Cholecystectomy is the optimal treatmentAcute obstructive suppurative cholangitis Acute severe cholangitis EtiologyIntrahepatolithiasis Biliary ascariasis Biliary stricture Sclerosing cholangitisPathology Obstruction of biliary tractinfectionManifestations Abdominal pain Chill, high fever Jaundice Shock psychological symptoms WBC20109/L Impairment of liver functions Acidosis Electrolytes disturbanceReynold pentadDiagnosisTypical manifestationsUltrasoundCTPTCTreatmentPrinciplesEliminating biliary obstruction as soon as possiblePreoperative preparations Volume expansion for patient with shock Correct acidosis. Water/electrolytes disturbance Antibiotics cortisol SurgeryOnce the vital signs are stable, surgery should be doneCBD exploration T tube drainageoperating time: the shorter the betterNon-surgical interventionsPTCDENBD: endoscopic nasobiliary drainageBiliary ascariasisChildhood Rapid onset with severe upper abdominal colic pain Upset, groaning, sweatiness Mild abdominal signs The symptoms do not correlate with the signs Ultrasound, ERCP Symptomatic treatments: relieve Oddis spasm, Analgesia helminthic drugs Surgical treatment Complications of biliary tract Perforation of gallbladder Hemobilia Biliary stricture Biliary liver abscessSevere right upper quadrant painChill, fever and jaundicehematochezia，hematemesisPeriodical attack with 12 weeks Manifestations Of hemobiliaSecondary to choledocholithiasis, biliary infectionPolypoid lesions of gallbladder Cholesterol polyps Inflammatory polyps Adenomyohyperplasia of gallbladder adenomaB-usSurgical indicationsSymptomatic polyps Polyps 1.0cm Polyps complicated with gallstone Polyps located in the neck of gallbladderGallbladder carcinomaEtiologyGallstone, chronic cholecystitis, porcelain gallbladder Adenoma, adenomyoplasia of gallbladderHigh malignancy, early metastasisLymph node, direct invasion Early stage: no symptomsLate stage: jaundice, abdominal mass, emaciation B-us, CTGallbladder carcinomaCurative resection: the only hope to cure the disease Palliative surgery: relieve jaundice and gastrointestinal obstructionChemotherapy is not sensitiveIntraoperative radiation: relieve symptomsPrognosisCurative resectability is low(2040%)5-year survival is very low (5%)CholangiocarcinomaExtrahepatic ductHilar cholangiocarcinoma: 5075% (klatskin tumor)Middle cholangiocarcinoma:1020%Lower cholangiocarcinoma: 1020%Painless progressive jaundice is the key featureB-us, E-us, CT, PTC, MRCPCurative operationPalliative surgeryTumor growth is slow than Gallbladder carcinomaPrognosis is relatively good than Gallbladder carcinomaBile duct injuryEtiologyTraumatic bile duct injury: Abdominal injury Iatrogenic bile duct injury:Cholecystectomy, gastrectomyDiagnosisIntraoperative findingPostoperative: fever, jaundice, bile leakagePTC, ERCPBile duct injuryTreatmentSide-to-side anastomosisHepatojejunostomyIntracholedochal stentPrimary sclerosing cholangitisLocalizing or diffuse bile duct fibrosis , strictureRelated to autoimmune disease, viral infectionUlcerative colitis, Crohns diseaseJaundice: intermittent progressiveCharcot triadBiliary cirrhosis, portal hypertensionDiagnosis: PTC, ERCP Treatment:Immunosuppressive drugsSurgery: internal drainageLiver transplantation The endThanks for your listening! 结束结束