胆道疾病上海交大瑞金英

DiseasesofBiliaryTractAnatomyandPathophysiology

Diagnostictechniques

StonesofBiliarytract

InfectionofBiliarytract

BiliaryTumorsAnatomhyofbiliarytract

Intrahepaticbileduct:

Biliarytract

extrahepaticbileduct:LefthepaticductRighthepaticduct

Commonhepatic→commonbileductGallbladder→cysticductCalottrangle:Liver:upperborder

Cysticductlowerborderlength3cmThecysticarteryrunsinthistriangleCommonbileductDiameter0.6-0.8cm>1cmabnormalLength7-9cmsupraduodenalsegmentretroduodenalsegmentretropancreaticsegmentduodenalwallsegment

ThepapillaofVater

pancreaticsphincter

commonsphincter

biliarysphincterThesphincterofoddiGallbladderLength:8-12cm

width:3-5cmvariable

size:40-60ml

shape:pearshaped

fundus

body

theneck

ThephysiologicalfunctionofGallbladderStoreandconcentratehepaticbile

SecretionofwaterandelectrolytesEmptybileintothecommonbileductBilesecretionHepatocytessecretebile800-1200mlBilecomposition:bileacids,bilepigments,cholesterol,phospholipids,inorganicelectrolytes,waterDiagnostictechniques

Abdominalultrasonography

1.untraumal

2.lowcost

3.flexibicity

4.firstchoice

AbdominalultrasonographyDiagnosebiliarystoneIdentifythecauseofjaundicePTCDbyβ-ultrasoundguidedDopplerbloodflowPercutaneousTranshepaticCholangiographyShowthedilatedbileductaboveobstructionsiteDrainageofbilebyPTCDTraumaticmethods

ComplicationsBileleakageHaemorrhageSepsisEndoscopicRetrogradeCholangiopancreatographyERCPDirectlyobservepapillalesionandbiopsyShowtheentirebiliarytractShowthebiliarytractproximaltoobstructionsiteDrainbile

Complicationsacutepancreatitis

postprocedurecholangitisOthercomplicationsOperativeandpostoperativedirectcholangiographyShowtheentirebiliarytractDisplaythestoneandstenosisTubecholangiographydonebeforebiliarydraingewithdrawnCTandMRIHighresolutionMoreaccurateExpensiveShowthestone,tumor,dilatedductMRCPshowtheentirebiliarytreePlainradiographsshowradio-opaquecalcuiairinthebiliarytreecalcificationofthegallbladderOralcholecystographyShowthefunctionofgallbladderShowthestonespolypsandtumorcontraindicationsSensitivitytoiodineLiverandrenaldiseasepregnancyCholedochoscopeIntraoperativeuse:ExploretheCBDstoneTumor,stenosisReduceretainedstonerateRemovestonebiopsyOtherexaminationIntravenouscholangiogramAngiographyIsotopicstudiesHowtochoose1.Bultrasound2.MRCPandCT3.ERCPandPTCInfectionsofbiliarytract1.Cholecystitis2.CholangitisobstructionstoneinfectioncoreAcutecholecystitisAcutecalculouscholecystitis95%Acuteacalculouscholecystitis5%Etiology1.CysticductobstructedbyagallstoneimpactinginHartmann’spouch2.BacteialinfectionofthestagnantbileAerobicenteric-derivedorganisms

Escherichiacoli,klebsiellapneumoniae,streptococcusfaecalis

gallstoneimpaction→mucosaldamage

Lecithin→lysolecithin↑phospholipasesPathologyCysticductobstruction→gallbladder→Edema→suppurate→gangrene→pericholecysticabscess→perforationCholecyst-entericfitulaPeritonitisintestinalobstructionAcute→chronic→atrophyClinicalfeatures1.Suddenandseverepainmainlyintherighthypochondriumradiatetotherightscapularregionfattyfoods2.Nauseaandvomiting3.Fever4.Tendernessandrigidityintherightupperquadrant5.PositiveMurphy’ssign6.Jaundice7.Apalpablegallbladdermass(1/4)Mirrizzi’sSyndromeThecommonhepaticisobstructedduetostonesimpactedinorextrudedfromHartman’spouchofthegallbldderorthecysticduct.Cholecystobiliaryorcholecystoentericfistulaearecommoncomplication.DifferentialDiagnsisPerforatedpepticulcerAcutepancreatitisRetrocaecelappendicitisRightlowlobepneumoniaHepaticabscessAcuteviralhepatitisLaboratoryTestLeukocytosisintherangeofl0000-15000Serumbilirubin↑ornormalAlkalinephosphatase↑ornormalTransaminase↑ornormalSerumamylase↑ornormalTreatmentConservativetreatment1.Intravenonsfluidandelectrolytereplacement2.Nasogastricsuction3.Systemicantibiotics4.Parenteralanalgesia5.fastSurgicalTreatment1.Attackwithin48-72hofdiagnosis2.Deteriorationinpatient’sgeneralcondition3.ComplicationsarepresentPerforationPeritonitisAcuteobstructivesuppurativecholangitisAcutepancreatitisSurgicalmethodsOpencholecystectomyLaparoscopiccholecystectomyAcalculousCholecystitisComplicationsofmajortrauma,burnsandsepsisComplicationsofparenteralfeedingNoteasytomakeacleardiagnosisNeedpromptsurgicalinterventionover70%withatherosccleroticcardiovasculardiseaseBiliaryscintiscanninghelpfulfordiagnosisAcutecholangitisandacuteobstructivesuppurativecholangitisEtiologyCholedocholithiasis80%BenignstricturesObstructedbiliaryanastomoticstricturesMalignantobstructionAscaridPathophysiologyBiliaryobstruction→intraductalpressure>20mH20→biliarystagnation→bacteremia,bacteriaproliferation→refluxintohepaticveinsandperihepaticlymphatics→systemicsignsofcholangitisClinicalpresentationFeverandchillJaundicecharcot’striad)Rightupper-quadrantpainHypotensionMentalobtundationReynold’sPhysicalexaminationTendernessAbdominalguardingSwollengallbladderHepatomegalyLaboratoryTestLeukocytosisHyperbilirubinemiaAlkalinephosphatase↑Aminotransferases↑LeukopeniaProfoundgram-negativesepsisandimmunosuppressionlmmunosuppressionSerumamylase↑RadiologicalEvaluationUltrasonographyCTMRCPPTCERCPGeneralsupportCessationoforalintake,fastAntibioticsKeepliquidandelectrolytebalanceIntravenousfluidsTreatmentBiliarydecompressionPercutanecustranshepaticbiliarydrainageEndoscopicdrainagepapillotomyandplacementofanasobiliarytubeOperativedecompressionCBDexplorationandTtubedrainageCholelithiasisClassificationofgallstoneCholesterolstones:lightbrown,smoothorfaceted,singleormultiplecross-sectionlaminated/crystallineappearancePigmentstone:small,blackorbrown,irregularcross-sectionamorphous/crystallineMixedstoneLocationGallbladderstonesCommonbileductstoneIntrahepaticbileductstoneExtrahepaticbileductstoneClinicalpresentationDyspepsiaRightupperquadrantabdominalpaininassociationwithorshortlyafteraheavyorfattymealAfeelingofgaseousbloatingBiliarycolicPhysicalexaminationUsuallynormalChronichydropsofgallbladder→massSometimestendernessRadiologicalTestAplainabdominalroentgenogramOralcholecystographyUltrasonographytheinitialdiagnosticstudyCTMRIComplicationsAcutecholecystitisJaundiceCholangitisPancreatitisMtrizzisyndromecancerSurgicalIndicationAcceleratingsymptomsPoorvisualizationornon-visulizationonoralcholecystographyDiabetasPorcelaingallbladderstone>2-3cmLaparoscopicCholecystectomyIndications:Chronic,uncomplicatedcholecystitisCholelithiasisGBpolyps

Benefits:ReducinghospitalizationandassociatedcostsDecreasingpainImprovedcosmeticoutcomeReducedpost-operativerecoveryOthertreatmentDietarytherapyalow-fatdiet,avoidanceofheavymealsAntispasmodicmedicationChenodeoxycholicacidandursodeoxycholicacidExtracorporealshockwavelithotripsyCarcinomaofGallbladderIncidenceThecommonestformofbiliarytractmalignancythefifthmostcommongastrointestinalcancerEncounteredin1-2%ofcholecystectomyspecimensPredominantlyoccursinelderlyfemalesOver90%ofpatientsarewere50yearsofageThepeakageofincidenceis70-75%yearsAmaletofemaleratioof1:3EtiologyCholelithiasisBenignadenomaPolypoidgallbladderlesions(polypgreaterthan1cm)AnomalouspancreaticbiliaryjunctionChronicinflammatoryboweldiseasePathologyAdenocarcinoma80%carcinoidtumoursUndifferentiatedcarcinoma6%sarcomaSquamouscarcinoma3%melanomaMixedtumororacanthoma1%lymphomaUICCⅠstage:mucosaandmuscularⅡstage:totallayerofthegallbladderⅢstage:invasionintoliver<2cmorregionallyphaticspreadⅣAstage:invasionintoliver>2cmⅣBstage:spreadtodistalorganandlymphnodeClinicalFeaturesThediagnosisofgallbladdercancerisusuallymadewhenthediseaseiswelladvanced.TherearenocharacteristicfeaturesatanearlyandcurativestageLaboratoryinvesitigationsCan’tprovidediagnosticinformationProvid