SURGERY_1.6 Gallbladder and the HBT.docx

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

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

CYSTIC ARTERY AND THE HEPATOCYSTIC TRIANGLE  Liver bed  Cystic duct  CHD

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

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

GALLBLADDER

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

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

Suzie, Patsu, Dayle, Gemmy

LUND’S NODE & MASCAGNI NODE

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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

 >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

EFFECT OF CHOLECYSTOKININ

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

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM AND DRAINAGE For Obstructing Proximal CholangioCA

 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

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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%. I.6 Gallbladder and the Extrahepatic Biliary System

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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)

PIGMENT STONES  contain chronic cholecystitis

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

LAPAROSCOPIC CHOLECYSTECTOMY

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

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

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

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MAGNETIC RESONANCE CHOLANGIOGRAPHY excellent anatomic detail 95% sensitivity 89% specificity detecting choledocholithiasis >5 mm

ENDOSCOPIC CHOLANGIOGRAPHY  gold standard for diagnosing CBD stones

Take not of the thick walls of GB and edema GALLBLADDER WALL  grossly thickened  reddish with subserosal hemorrhages PERICHOLECYSTIC  fluid often is present I.6 Gallbladder and the Extrahepatic Biliary System

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)

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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

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