Biliary system Prof. Weilin Wang wam@zju.edu.cn Good morning everybody. I am Wang weilin from Department of Hapatobiliary Pancreatic Surgery, the first affiliated hospital. I major in HBP surgery, specialized in hepatobiliary and pancreatic diseases and liver transplantation. If you have any question about my field, please contact with me by E-mail: Wam@zju.edu.cn. Today I am going to present the biliary system. Next…. Prof. Weilin Wang wam@zju.edu.cn Department of Hepatobiliary Pancreatic Surgery The First Affiliated Hospital

Anatomy of Biliary System 1 Methods of Investigation 2 Disorders of Gallbladder 3 Four parts of content will be presented including the anatomy of biliary system, the common methods of investigation. Then we will move to disorders of gallbladder and bile duct. I you have any question, please don not hesitate to interrupt me and I will give you explain as possible. Next…. Disorders of Bile Duct 4 Case discussion 5

Anatomy of Biliary System 1 Firstly, we are going to talk about the anatomy of biliary system. Next…

Extrahepatic Biliary Tract Bifurcation Common hepatic duct Common bile duct Cystic duct Gallbladder The extrahepatic biliary tract consists of the bifurcation of the left and right hepatic ducts, the common hepatic duct, the common bile duct, and the cystic duct and gallbladder Next….

Transportation of Bile The liver secrete bile, bile flow from liver to right and left hepatic ducts. These ducts drain into the common hepatic duct. The common hepatic duct then joins with the cystic duct to form the common bile duct. The transportation of bile follows this sequence: The liver cells secrete bile, then bile flow from liver to right and left hepatic ducts. These ducts drain into the common hepatic duct. The common hepatic duct then joins with the cystic duct to form the common bile duct. About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder. When food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help digest the fats. Next….

Transportation of Bile About 50 percent of the bile produced by liver is first stored and concentrated in gallbladder. When food is taken, the gallbladder contracts and release stored bile into the duodeum to help digest the fats.

Calot triangle The triangle is bounded by the cystic duct, the common hepatic duct, and the inferior border of the liver. Important structures including: the cystic artery, the right hepatic artery, and the cystic duct lymph node. The common hepatic duct, the liver, and the cystic duct define the boundaries of Calot's triangle. Located within this triangle are important structures: the cystic artery, the right hepatic artery, and the cystic duct lymph node.

Papilla of Vater Tthe opening of the bile duct and panceatic duct in the descending part of the duodenum. Through the papilla, bile and pancreatic juice pass to to bowel. obstructive jaundice or pancreatitis will happen when papilla of Vater was blocked by stones and tumors,

Normal gallbladder

Gallbladder Anatomical Variants Agenesis of the gallbladder is extremely rare, with a prevalence of 0.03-0.07 percent. Double gallbladder occurs in about 0.03 per cent, usually with a shared cyctic duct, and the accessory gallbladder is often diseased. In this slide, we will talk about the anatomical variants about gallbladder. Double gallbladder occurs in about 0.03 per cent, usually with a shared cystic duct, and the accessory gallbladder is often diseased.

B unltrosound picture shows double gallbladder.

Variations of biliary branching A Typical anatomy of the confluence. B Trifurcation of left, right anterior, and right posterior hepatic ducts. C Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct. c A, Typical anatomy of the confluence. B, Trifurcation of left, right anterior, and right posterior hepatic ducts. C, Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct. D-F, Less common variations in hepatic ductal anatomy.

Methods of Investigation 2

Methods of investigation Ultrasonography (B-US) CT, Computed Tomographic Magnetic Resonance Cholangiopancreatography Endoscopic Retrograde Cholangopancreatography Percutaneous Transhepatic Cholangiography T-tube cholangiography Radiographs Intraoperative cholangiography Endoscopic ultrasound ……

B-US Fast, real-time, non-invasive, and no ionizing radiation, cheap and could be available even in countryside. 95% sensitivity for detection of cholelithiasis. --Found a mobile, hyperechoic with acoustic shadowing >90% sensitivity for detection of acute cholecystitis. --Gallbladder wall thickening, pericholecystic fluid

Gallbladder, with sludge and stone present Normal Gallbladder Gallbladder, with sludge and stone present

CT scan Gallstones can be seen on CT, but it is not used primarily for this purpose. CT can be used in situations where ultrasound is difficult --such as in obese patients. It can also be used if the ultrasound is not definitive.

Plain CT shows multiple gallstones.

Multiple stones were found in the left intrahepatic bile duct.

MRCP Becoming a more viable imaging technique New tool for non-invasive evaluation of the pancreatic and biliary ductal systems. Gradually replacing PTC and ERCP for diagnostic purposes. MRCP becoming a more viable imaging technique, as MRI technology improves. However, CT and ultrasound are faster, easier, and more readily available, so they are used more frequently than MRCP. MRCP is emerging as a new tool for non-invasive evaluation of the pancreatic and biliary ductal systems. MRCP is gradually replacing PTC and ERCP for diagnostic purposes.

MRCP showed slight dilation of CBD Pancreatic duct Common bile duct MRCP showed slight dilation of CBD

Stones was detected in the bile duct by MRCP. Stones in CBD Stones was detected in the bile duct by MRCP.

ERCP Left: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct. Right: Radiographic result after the contrast medium was injected into the CBD. ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct. Left picture showed anatomy of upper GI: The endoscope was introduced to the papilla of Vater and contrast medium was injected into common bile duct. Right picture shows the radiographic result after the contrast medium was injected into the CBD. ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct.

Otherwise the instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments. ERCP: Instruments can also be inserted through the scope to remove stones, insert stent, tissue biopsy, and other treatments.

Endoscope Stones in CBD Pancreatic duct ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct. ERCP: showing slightly dilated common bile duct with calculus and normal pancreatic duct.

Large stone was drawing out from CBD during ERCP was performing.

Show the procedure of removal the stones using endoscope . Next case I am going to show you the procedure of removal the stones using endoscope. The mucosal layer of duodenum is cut and coagulated. We can see that the stone is released. Show the procedure of removal the stones using endoscope .

ERCP.wmv

PTC The catheter was placed into the intrahepatic bile duct through patient’s skin guiding by B-US and fixed on the skin. The radiographic image was taken. Obstructive lesion can be seen in this picture. The catheter was placed into intrahepatic bile duct through patient’s skin guiding by B-ultrasound. PTC is indicated when ERCP is not suitable or has failed. It can be used to drain biliary obstructions.

Obstructive lesion Obstructive lesion

Before After Left : After injection of dye, showing a large gallstone trapped in the duct. Right: After removal of the stone through the drainage catheter.

T-tube cholangiography Postoperatively Injection of contrast medium through a T-tube catheter placed in the CBD Easy way to show whether there are remaining stones or any stricture

T-tube graphy I will show you one case of T-tube radiography. Two months ago, this patient received side-side choledo-jejunostomy. After that operation, he did not feel well because of the liver function was abnormal. So T-tube radiography was suggested and the result showed that the contrast medium could pass through the anastomotic site.

Radiographs Old technique used in the past, widely replaced by the ultrasound and MRCP. Can be used to visualize calcified stones by abdominal x-ray film. This was an imaging technique used in the past, but has been widely replaced by the ultrasound. Can be used to visualize calcified stones, emphysematous cholecystitis (gas within the wall of the gallbladder), biliary fistula (gas within the biliary system), or a porcelain gallbladder.

Abdominal x-ray demonstrating stones in the gallbladder

Disorders of Gallbladder 3

Disorders of Gallbladder Acute cholecystitis Gallbladder stones and sludge Adenomyomatous hyperplasia Gallbladder polyps Gallbladder carcinoma ……

Acute Cholecystitis Calculous cholecystitis: over 90% Clinical manifestation: --Pain in right upper quadrant --Radiates to right shoulder & back --Nausea & vomiting --Chill and/or fever --Abdominal tenderness --Murphy's sign (+)

Acute Cholecystitis: B-US The gallbladder contains small stones in the neck and its wall shows oedematous thickening (>5 mm thickness).

--Gallbladder over distension Other B-US signs are: --Gallbladder over distension --Pericholecystic fluid --GB wall thickening -- …… Other B-US signs includes gallbladder over distension, pericholecystic fluid, GB Wall thickening.

Acute Cholecystitis: CT Less accurate than B-US The CT findings : --Gallbladder wall thickening --Subserosal oedema --Gallbladder distension --Pericholecystic fluid --Gallstones CT is less accurate that B-US for acute cholecystitis. That is mean that B-US is the first choice for acute Cholecystitis. The CT findings in acute cholecystitis include: Gallbladder wall thickening, Subserosal oedema, Gallbladder distension, pericholecystic fluid, Gallstones and gallbladder wall enhancement.

Sludge Fine, nonshadowing dependent echoes. Sludge on B-US appears as fine, nonshadowing dependent echoes. It is composed of calcium bilirubinate granules, cholesterol crystals et al. It is more commonly seen in chronic fasting states. Gallstones will develop in 5-15 percent. Fine, nonshadowing dependent echoes. Composed of calcium bilirubinate granules, cholesterol crystals. Gallstones will develop in 5-15 percent.

Gallbladder, with sludge and stone present

Gallbladder polyps The majority of polyps are cholesterol Cholesterol polyps are usually 2-10mm in size They appear as small echogenic nonshadowing foci adherent to the gallbladder wall Lack of mobility indicates polyp The majority of polyps are cholesterol and less often adenomatous Cholesterol polyps are usually 2–10mm in size whereas adenomas can be up to 2 cm They appear as small echogenic nonshadowing foci adherent to the gallbladder wall Lack of mobility favours a polyp

Gallbladder-Adenomyomatosis The affected segment often contains bright echoes Often associated with ‘comet-tail’

Mirrizzi syndrome Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct. May result in biliary obstruction and jaundice If not recognized preoperatively, it can result in significant morbidity and mortality

Indication for Cholecystectomy Symptomatic cholelithiasis Non-functioning gallbladders (Full of stones) Malignant considered: GB polyps (>1.2cm) or others

Open Cholecystectomy The first case was performed in 1882 One safe and effective method Direct visualization and palpation

Laparoscopic Cholecystectomy A less invasive way to remove the gallbladder Smaller incisions and less pain Shorter hospital stay and a shorter recovery time

Laparoscopic Cholecystectomy

Gallbladder Carcinoma Gallbladder carcinoma is associated with stones in over 90% of patients There is a female to male ratio of 3:1 Few patient was diagnosed prior to surgery

Gallbladder Carcinoma

Gallbladder Carcinoma Left picture showed B-US result for gallbladder carcinoma. Polypoidal growth with breach of continuity of the underlying wall (arrow). Right CT result show us the advanced carcinoma extending outside the fundus, with a nodal metastasis posterior to the pancreatic head (arrow)

TNM classification

TNM classification

Quiz Direct invasion of the liver by gallbladder cancer in a 66-year-old woman Should differentiate gallbladder cancer from acute cholecystitis T?N?M?

Treatment Radical surgery including segment liver resection, bile duct resection and extensive lymphadenectomy Poor prognosis in patients with unresectable tumor External radiation therapy may provide palliative benefit. 5-Fu and Gemcitabine can be used as chemotherapy.

Gall-Bladder.mp4 LC.mp4

Disorders of Bile Duct 4

Disorders of Bile Duct AOSC Choledocholithiasis/Hepatolithiasis Choledochal cyst Cholangiocarcinoma Pancreatic and ampullary tumor

AOSC Acute obstructive suppurative Cholangitis (AOSC) Emergency disease carries high mortality Common obstructing factors: stones, tumor Complete obstruction and suppurative infection May result in septicemia & septic shock; MSOF

Clinical manifestation Charcot triad Abrupt onset of pain in upper quadrant Chill, high fever, may nausea and vomiting Jaundice May shock, and/or Acute renal failure and ARDS

Treatment Correct the fluid and acid-base balance Systemic administration of antibiotics Anti-shock treatment Drain the biliary tract: ERCP or PTCD Emergency operation

Small shadowing stone (Arrow) in dilated bile duct. Choledocholithiasis/Hepatolithiasis Small shadowing stone (Arrow) in dilated bile duct.

CT show multiple stones in hepatic bile duct Choledocholithiasis/Hepatolithiasis CT show multiple stones in hepatic bile duct

ERCP: demonstrating stone in the duct (arrow) Choledocholithiasis/Hepatolithiasis Stones ERCP: demonstrating stone in the duct (arrow)

Choledochal cysts Cystic dilatation of the extrahepatic bile ducts Female to male is about ration 4:1 The majority are now diagnosed in childhood Classified into five types Associated with various biliary tumors

Type I

Type II

Type III

Type IV

Type V

Choledochal cysts CT MRCP

Pancreatic and ampullary tumours …… Bile Duct Cancer Cholangiocarcinoma Pancreatic and ampullary tumours …… Cholangiocarcinoma Pancreatic and ampullary tumours Biliary cyctadenoma

Cholangiocarcinoma Most commonly at the hepatic duct bifurcation (Klatskin tumor) Present with jaundice Clinical Presentation: --Jaundice (around 90% ) --Pruritus --fever --mild abdominal pain --fatigue --…… Surgical resection offer a chance for long-term disease-free survival

Cholangiocarcinoma B-US: nodules or focal bile duct wall thickening CT: nodules are usually isodense or slightly hypodense MRCP: show the proximal extent of the stricturing

Small hilar cholangiocarcinoma (Arrowhead) producing obstruction of the right posteral sectoral duct (Short arrow). Right anterior sectoral duct (long arrow) and left hepatic duct. (A) Thick oblique coronal MRCP. (B) Axial portal phase CT (C) Longitudinal US. (D) Transverse color Doppler US (Open arrow, normal left portal vein).

Bismuth Classification Type I: confined to the common hepatic duct type II: involve the bifurcation Type IIIa and IIIb: extend into either the right or left secondary intrahepatic ducts, respectively Type IV: involve the secondary intrahepatic ducts on both sides I I I I I I I II II II II II II Type I tumors (upper, left) are confined to the common hepatic duct, and type II tumors (upper, right) involve the bifurcation without involvement of secondary intrahepatic ducts. Type IIIa and IIIb tumors (lower, left) extend into either the right or left secondary intrahepatic ducts, respectively. Type IV tumors (lower, right) involve the secondary intrahepatic ducts on both sides. III III III III III IV IV IV IV IV IV IV IV

Quiz Type?

Treatment Distal lesions are usually treated with Whipple Intrahepatic lesions are treated by hepatic resection Perihilar (Klatskin) tumor: --Type I and II: Resection of the extrahepatic bile ducts and gallbladder --Type III and IV: Curative resection is difficult Radiation therapy improves survival for patients

Typical operation I Resection of the extrahepatic bile ducts and gallbladder with 5-10 mm bile duct margins, and regional lymphadenectomy with Roux-en-Y hepaticojejunostomy.

Typical operation II: Whipple The head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct are excised, usually to relieve obstruction caused by tumors. Continuity is reestablished between the biliary, pancreatic, and GI systems. Before After

Case discussion 5

Case: Clinical manifestation 42-year-old woman patient was admitted to our emergency department because of repeated upper abdominal pain for 2 years and aggravated for three days. With nausea, vomiting, chill and fever. The highest temperature reached to 39.5℃. She also found dark urine and skin turned yellow. PE: BP 85/52 mmHg. Yellow stained was found in the skin and sclera. Which examination should be performed for diagnosis?

Laboratory test: --Blood routine test Imaging test: Examination needed --Liver function and serum electrolyte --Serum Amylase Imaging test: --B-US (First choice. Why?) --MRCP --CT

--BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l Imaging test: Examination finding Laboratory test: --BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l --Liver function: ALT 154 U/l TB/DB 194/153 mmol/l --Serum Amylase : Normal Imaging test: --MRCP

Gallstone pancreatitis? Diagnosis Acute Cholecystitis? No Gallstone pancreatitis? No Cholangitis? Yes AOSC, Septic shock

Treatment Anti-shock treatment Most important!! Antibiotic drug Drainage: Emergency ERCP was performed and ENBD was placed …….

CT scan show multiple stone in CBD and hepatic duct CT scan show multiple stone in CBD and hepatic duct. The catheter can be seen.

Treatment When the general condition is stable and the TB level declined to 50mmol/l, choledocholithotomy was carried out and stones were removed. The patient recovery very well without any episode.

Questions?

Thank You !