1、膽道疾病類型和診斷Anatomy and Pathophysiology Diagnostic techniques Stones of Biliary tract Infection of Biliary tract Biliary TumorsAnatomhy of biliary tract Intrahepatic bile duct: Biliary tract extrahepatic bile duct: Left hepatic duct Right hepatic duct Common hepatic common bile ductGallbladder cystic d

2、uctCalot trangle:Liver : upper border Cystic duct lower border length 3cmThe cystic artery runs in this triangle Common bile ductDiameter 0.6-0.8cm 1cm abnormalLength 7-9cmsupraduodenal segmentretro duodenal segmentretro pancreatic segmentduodenal wall segmentThe papilla of Vater pancreatic sphincte

3、r common sphincter biliary sphincterThe sphincter of oddiGallbladderLength:8-12cmwidth:3-5cm variablesize:40-60mlshape: pearshaped fundus body the neck The physiological function of GallbladderStore and concentrate hepatic bile Secretion of water and electrolytesEmpty bile into the common bile ductB

4、ile secretionHepatocytes secrete bile 800-1200mlBile composition: bile acids, bile pigments,cholesterol, phospholipids,inorganic electrolytes ,waterDiagnostic techniquesAbdominal ultrasonography1.untraumal2.low cost3.flexibicity4.first choiceAbdominal ultrasonographyDiagnose biliary stoneIdentify th

5、e cause of jaundice PTCD by -ultrasound guidedDoppler blood flowPercutaneous Transhepatic CholangiographyShow the dilated bile duct above obstruction siteDrainage of bile by PTCDTraumatic methodsComplications Bile leakageHaemorrhage Sepsis Endoscopic Retrograde Cholangiopancreatography ERCPDirectly

6、observe papilla lesion and biopsyShow the entire biliary tractShow the biliary tract proximal to obstruction site Drain bile Complications acute pancreatitis postprocedure cholangitisOther complicationsOperative and postoperative direct cholangiographyShow the entire biliary tractDisplay the stone a

7、nd stenosisTube cholangiography done before biliary drainge with drawnCT and MRIHigh resolutionMore accurateExpensiveShow the stone ,tumor, dilated ductMRCP show the entire biliary treePlain radiographsshow radio-opaque calcuiair in the biliary treecalcification of the gallbladderOral cholecystograp

8、hy Show the function of gallbladder Show the stones polyps and tumor contraindicationsSensitivity to iodineLiver and renal disease pregnancyCholedochoscopeIntraoperative use:Explore the CBD stone Tumor,stenosisReduce retained stone rate Remove stone biopsyOther examinationIntravenous cholangiogramAn

9、giographyIsotopic studiesHow to choose1.B ultrasound2.MRCP and CT3.ERCP and PTCInfections of biliary tract obstruction stone infection coreAcute cholecystitisAcute calculous cholecystitis 95%Acute acalculous cholecystitis 5%Etiology1.Cystic duct obstructed by a gallstone impacting in Hartmanns pouch

10、2.Bacteial infection of the stagnant bile Aerobic enteric-derived organisms Escherichia coli, klebsiella pneumoniae, streptococcus faecalis gallstone impaction mucosal damage Lecithin lysolecithin phospholipasesPathologyCystic duct obstruction gallbladder Edema suppurate gangrene pericholecystic abs

11、cess perforation Cholecyst-enteric fitula Peritonitis intestinal obstruction Acute chronic atrophyClinical features1.Sudden and severe pain mainly in the right hypochondrium radiate to the right scapular region fatty foods2.Nausea and vomiting4.Tenderness and rigidity in the right upper quadrant5.Po

12、sitive Murphys sign7.A palpable gallbladder mass (1/4)Mirrizzis Syndrome The common hepatic is obstructed due to stones impacted in or extruded from Hartmans pouch of the gallbldder or the cystic duct.Cholecystobiliary or cholecystoenteric fistulae are common complication.Differential DiagnsisPerfor

13、ated peptic ulcerAcute pancreatitisRetrocaecel appendicitisRight low lobe pneumoniaHepatic abscessAcute viral hepatitisLaboratory TestLeukocytosis in the range of l0000-15000Serum bilirubin or normalAlkaline phosphatase or normalTransaminase or normalSerum amylase or normalTreatmentConservative trea

14、tment1.Intravenons fluid and electrolyte replacement2.Nasogastric suction3.Systemic antibiotics4.Parenteral analgesiaSurgical Treatment1.Attack within 48-72 h of diagnosis2.Deterioration in patients general condition3.Complications are present Perforation Peritonitis Acute obstructive suppurative ch

15、olangitis Acute pancreatitisSurgical methodsOpen cholecystectomyLaparoscopic cholecystectomy Acalculous CholecystitisComplications of major trauma, burns and sepsisComplications of parenteral feedingNot easy to make a clear diagnosisNeed prompt surgical interventionover 70% with atheroscclerotic car

16、diovascular diseaseBiliary scintiscanning helpful for diagnosisAcute cholangitis and acute obstructive suppurative cholangitisEtiologyCholedocholithiasis 80%Benign stricturesObstructed biliary anastomotic stricturesMalignant obstructionAscarid PathophysiologyBiliary obstruction intraductal pressure

17、20mH20biliary stagnation bacteremia,bacteria proliferationreflux into hepatic veins and perihepatic lymphaticssystemic signs of cholangitis Clinical presentationFever and chillJaundice charcots triad)Right upper-quadrant painHypotensionMental obtundation Reynolds Physical examinationTendernessAbdomi

18、nal guardingSwollen gallbladderHepatomegalyLaboratory TestLeukocytosisHyperbilirubinemiaAlkaline phosphatase Aminotransferases LeukopeniaProfound gram-negative sepsis and immunosuppression lmmunosuppressionSerum amylase Radiological EvaluationUltrasonographyCTMRCPPTC ERCPGeneral supportCessation of

19、oral intake ,fastAntibiotics Keep liquid and electrolyte balanceIntravenous fluidsTreatmentBiliary decompressionPercutanecus transhepatic biliary drainageEndoscopic drainage papillotomy and placement of a nasobiliary tubeOperative decompressionCBD exploration and T tube drainageCholelithiasis Classi

20、fication of gallstoneCholesterol stones: light brown, smooth or faceted, single or multiple cross-section laminated/crystallineappearancePigment stone: small, black or brown, irregular cross- section a morphous/crystallineMixed stoneLocationGallbladder stonesCommon bile duct stoneIntrahepatic bile d

21、uct stoneExtrahepatic bile duct stoneClinical presentationDyspepsia Right upper quadrant abdominal pain in association with or shortly after a heavy or fatty mealA feeling of gaseous bloatingBiliary colic Physical examinationUsually normalChronic hydrops of gallbladdermassSome times tendernessRadiol

22、ogical TestA plain abdominal roentgenogramOral cholecystography Ultrasonography the initial diagnostic studyCTMRIComplicationsAcute cholecystitisJaundiceCholangitisPancreatitisMtrizzi syndromecancerSurgical IndicationAccelerating symptomsPoor visualization or non-visulization on oral cholecystograph

23、yDiabetasPorcelain gallbladderstone2-3cmLaparoscopic CholecystectomyIndications:Chronic, uncomplicated cholecystitisCholelithiasisGB polypsBenefits:Reducing hospitalization and associated costsDecreasing painImproved cosmetic outcomeReduced post-operative recoveryOther treatmentDietary therapy a low

24、-fat diet, avoidance of heavy mealsAntispasmodic medicationChenodeoxycholic acid and ursodeoxycholic acid Extracorporeal shock wave lithotripsyCarcinoma of GallbladderIncidenceThe commonest form of biliary tract malignancy the fifth most common gastrointestinal cancerEncountered in 1-2% of cholecyst

25、ectomy specimensPredominantly occurs in elderly femalesOver 90% of patients are were 50 years of ageThe peak age of incidence is 70-75% yearsA male to female ratio of 1:3Etiology CholelithiasisBenign adenomaPolypoid gallbladder lesions (polyp greater than 1cm)Anomalous pancreaticbiliary junctionChronic inflammatory bowel diseasePathologyAdenocarcinoma 80% carcinoid tumoursUndifferentiated carcinoma 6% sarcomaSquamous carcinoma 3% melanomaMixed tumor or acanthoma 1% lymphomaUICC stage: mucosa and muscular stage: total layer of the gallbladder stage: invasion into liver 2cm B stage: spr