Gall Bladder & Bile ducts(4.5) (SGT)

DR.CHRIS ANTHONY

Gall bladder & bile Ducts Outline of talk



Anatomy



Bile duct strictures



Physiology + Bilirubin



GB polyps



Imaging



Carcinoma GB



Cholangiocarcinoma



Periampullary carcinoma



Cholecystectomy

Part 1



Gallstone



Acute cholecystitis



Chronic cholecystitis



Choledocholithiasis/



Indications



Cholangitis



Surgery



Complications

Part 2

Part 3

Part 4

Anatomy of Gall Bladder & Bile Ducts

(R & L) CHD HP

B

N

F

Surgical anatomy

CD

1.GB – Fundus,body,neck,Hartman pouch Cystic Duct

2.Bile ducts – R&L hepatic ducts ,CHD,CBD

D2

CBD

Surface Anatomy of Gall Bladder 

1.Right hypochondrium



2.Transpyloric plane :

3

Horizontal plane at level of lower border of L1 vertebral body 1 

3.Mid-clavicular line



4.Angle between right costal margin & lateral border of rectus abdominis muscle



Normally not palpable

2

Calot’s Triangle 

3

Boundaries :

2

1.Lateral : cystic duct, GB bladder 2.Medial : common hepatic duct 3.Superior : inferior surface of right lobe of liver 

Contents :

Right hepatic artery Cystic artery Cystic lymph node of Lund

1

CysticCystic LN Lund LN Lund

Anatomy of CBD 

About 7.5 cm long, about 6 mm in diameter



4 parts :

1.Supraduodenal : 2.5 cm long, on free edge of lesser omentum 2.Retroduodenal : behind first part of duodenum

1

3.Infraduodenal : on posterior surface or 2

3

through part of the pancreas 4.Intraduodenal : opens in second part of duodenum as ampulla of Vater

5.Ends on summit of the called papilla 4

Sphincter of Oddi 

Muscular valve that controls the flow of digestive juices (bile and pancreatic juice)



Through the ampulla of Vater into the



Second part of the duodenum at the papilla.



Importance : ERCP & sphincterotomy

D2 Ampulla Vater Papilla

1.At Liver : 

Bile production : 97% water, 1 to 2% bile salts,



1% bile pigments, cholesterol, calcium & fatty acids



Excretion : about 40 mls/ hour (about 1 L/ 24 hours)

2.At Gall Bladder : 3 main functions

Physiology



Reservoir for bile : during fasting



Concentration of bile : 5 to 10 times, by active absorption of water



Mucin secretion : about 20 ml/hr

3.Neuroendocrine control

Vagus & Cholecystokinin (CCK) GB contraction + sphincter of Oddi relaxation

bile excreted

Bilirubin metabolism(Normal) spleen

A Pre-hepatic

Pre-hepatic/Blood Unconjugated bilirubin

B Intra-hepatic D

Liver

Intrahepatic/Liver Conjugated bilirubin

CB Enterohepatic circulation

C Post-hepatic (Trace)

(stercobilirubin)

Post-hepatic/Bile ducts/ intestine Urobilinogen/Stercobilirubin EH circulation

Imaging of Gall Bladder & Bile ducts 

Plain Xray - CXR & AXR



Ultrasonography (USG)





Most useful Initial Ix

Computerised Tomogram(CT scan)

Magnetic Resonance CholangioPancreaticography (MRCP)



Endoscopic Retrograde CholangioPancreaticogram (ERCP)



Endoscopic Ultrasound (EUS) + biopsy

Others 

Oral Cholecystogram; Intravenous Cholangiogram



Percutaneous Transhepatic Cholangiogram (PTC)



Per-operative Cholangiogram Xrays(OTC)



Radio-isotope scan(HIDA) - hepatobiliary iminodiacetic acid



cholescintigraphy and hepatobiliary scintigraphy



Indocyanine Green(ICG) fluorescent scan

Plain Xray Abdomen 

Only 10% of gall stones are radio-opaque



Some gall bladders may be calcified (porcelain)



Gas in bile ducts (aerobilia) – ERCP/infection

Gallstones

Porcelain GB

Aerobilia

Ultrasonography (USG) 

Most important initial imaging for GB & BD



Safe, painless, accurate, convenient, cost-effective,readily available & no radiation



Gallstones, gall bladder, thickness of gall bladder wall & surrounding inflammation



Size of bile ducts – diameter of CBD 6-8mm



sometimes stones in common bile duct & growth in pancreas

GS

Ac.cholecystitis Posterior shadow

CT & MRI Scans 1.Computed Tomography (CT) 

Useful for detecting liver & pancreas lesion(mass lesion)



Staging of liver, bile duct, pancreatic cancers;



Enlarged lymph nodes



Only 75% gallstones seen on CT, not for screening

CT scan Mass lesion Tumour

2.Magnetic Resonance Cholangio-Pancreaticogram (MRCP) 

Imaging of gall-bladder & bile ducts



Can show bile duct obstruction, stricture



& other intra-ductal abnormalities like tumour

3.Endoscopic Retrograde Cholangio-Pancreaticography (ERCP) 

Imaging of bile ducts &



Removal of CBD stones & stenting of CBD



Minimally invasive, radiation & sedation( day case)

MRCP Solely diagnostic

ERCP Diagnostic & Therapeutic

Endoscopic Retrograde Cholangio-Pancreaticography (ERCP)

GB 1&2

IHD

CBD

papilla

Heavy sedation/day case

GB

CD

PD

Diseases of biliary system Gallstone 80%

Bilary ducts

Gallbladder 

Cholelithiasis



Biliary colic



Acute Cholecystitis



Chronic cholecystitis



Empyema



Gangrene & perforation



Gall bladder polyps



Carcinoma GB

Common

Complications GS



Choledocholithiasis



Cholangitis



Stricture CBD



Biliary atresia



Choledochal cyst



Sclerosing cholangitis



Ca head of pancreas Cholangiocarcinoma



Periampullary carcinoma

Common

congenital

Gallstones (Cholelithiasis)



80% are asymptomatic



Every year about 1 to 2% of asymptomatic cases develop symptoms requiring surgery



Female 4 : 1 male

Causes/aetiology Classical teaching : Female Fertile Fat Forty Flatulent Family history

4+2

Stone Formation  

Bile salts & Lecithin Keep cholesterol in solution

When stability is lost due to excess cholesterol Gallstones reduced bile salts form Reduced lecithin 

Lithogenic

Safe zone

(lithogenic bile)

Gallstones

Black(H) & brown(I) >80%