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Hepatobilliary surgery billary tract
Anatomy of gallbladder
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Gallbladder is a pear shaped, hallow structure located just beneath
the right lobe of the liver and on the right side of the abdomen
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In adult the, the gallbladder is approximately 8 cm in length and 4
cm in diameter. Angel of gallbladder is located between the costal
margin and the lateral margin of the rectus abdomens muscle.
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The gallbladder is divided into three sections: the funds, body and
neck:
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Fundus—> is a rounded end that faces the front of the body
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Body—> is in contact with the liver, lying in the gallbladder
fossa, a depression at the bottom of the liver
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Neck—> tapers and is continuous with the cystic duct, part of
the biliary tree.
physiology of gallbladder
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Gallbladder is made up of layers of tissue:
mucosa ( the inner layer of epithelial cells and lamina propria
loose connective tissue)
muscular layer ( a layer of smooth muscle)
perimuscular layer ( connective tissue that covers the muscular
layer)
serosa (the outer covering of the gallbladder)
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The cystic duct units with the common hepatic duct to
become the common bile duct. Junction of the neck of the
gallbladder and the cystic duct, has a an opening patching to
the gallbladder wall forming a mucosal fold known as
Hartmanns pouch, where gallstones commonly get stuck
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The primary function of gallbladder is to store and
concentrate bile ( yellow-brown digestive enzyme produced
by the liver)
physiology of gallbladder
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Gallbladder serves as a reservoir for bile while its not used
for digestion. The absorbent lining concentrates the stored
bile.
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When food enters the small intestine a hormone called
cholecystokinin is released, signaling the gallbladder to
concentrate and secrete bile into the small intestine through
the common bile duct
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Bile—> helps the digestive process by breaking up fats, and
it also drains waste products from the liver into the
duodenum.
Blood supply
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The celiac trunk branches from the abdominal aorta and splits
into three major branches, one of which, the common hepatic
artery, supplies blood to the liver and gallbladder along with the
stomach, small intestine, and pancreas.
•
common hepatic artery further divides into three more branches,
with the proper hepatic artery supplying blood to the liver,
gallbladder, and part of the stomach.
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common hepatic artery further bifurcates into the left and right
hepatic arteries to deliver blood the left and right sides of the
liver. As the right hepatic artery approaches the gallbladder, it
branches off to form the cystic artery, which supplies the
gallbladder and cystic duct with oxygenated blood.
•
These arteries further branch off into many smaller arteries and
arterioles and, finally, capillaries to provide oxygen and nutrients
to all of the tissues of the liver and gallbladder.
Anatomy and physiology of the biliary tree
•
The biliary tract refers to the liver, gallbladder and bile duct,
and how they work together to make store and secrete bile
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Bile consist of water, electrolytes, bile acid, cholesterol,
phospholipids and conjugated bilirubin.
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Bile is secreted by the liver into small ducts that join to form
the common hepatic duct. between meals, secreted bile is
stored in the gallbladder, where 80-90 % of the water and
electrolyte can be absorbed, leaving the bile acids and
cholesterol.
•
During a meal, the smooth muscles in gallbladder wall
contract, leading to the bile begin secreted into the
duodenum.
Anatomy and physiology of the biliary tree
•
Biliary tract is often referred as the tree, because it begins
with many small branches which end in the common bile
duct, and sometimes as the trunk of the biliary tree. the duct,
the branches of the hepatic artery and the portal vein form
the central axis of the portal triad.
•
The term hepatobiliary is used to refer just to the liver and
bile ducts.
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Path of flow: Liver cells (hepatocytes) excrete bile into >>
Bile canaliculi>> canals of hering>> intrahepatic bile
ductule >> interlobular bile duct ( from gallbladder) >>
forming>> common bile duct>> joins with >> pancreatic
duct>> forming>> ampulla of vater>> enters duodenum.
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Biliary system main function: to drain waste products from
the liver into the duodenum. To help in digestion with the
controlled release of bile.
Cholelithiasis (Gallstones)
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There are two main types of gallstones: cholesterol stones, containing crystalline
cholesterol monohydrate ( 80 % of stone in west), and pigmented stones, made of
bilirubin calcium salts.
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Bile formation is the only significant pathway to eliminate excess of cholesterol from
the body, as free cholesterol or as bile salts.
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Cholesterol is rendered water-soluble by aggregation with bile salt and lecithins. When
cholesterol concentrate exceed the solubilizing capacity of bile, cholesterol can no
longer remain dispersed and crystalizing out of solution.
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Cholesterol gallstone formation is enhanced by hypomobility of the gallbladder, which
promotes nucleation and by mucus hypersecretion with trapping of crystals thereby
enhancing their aggregation into stones.
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Cholesterol stones consist of 50- 100 % cholesterol. Pure cholesterol stones are pale
yellow increasing proportions of calcium carbonate, phosphate, and bilirubin. They
can occur single, but most often several.
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Formation of pigment stones is more likely in the presence of unconjugated bilirubin
in the biliary tree. The precipitates are primarily insoluble calcium bilirubinated salts.
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They can arise anywhere in the biliary tree and classified into black and brown stones.
Black pigmented stones are found in sterile gallbladder bile, whereas brown stones are
found in infected intrahepatic or extra hepatic duct.
Risk factor to develop gallstones are
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- Age and gender: the prevalence of gallstones increases throughout
life. In USA less then 5-6 % of population younger then 40 has stones.
and 25-30 % of those older then 80 years. Prevalence in women of all
age is about twice as high as in men.
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Ethnic and geographic: cholesterol gallstones approaches 50- 70% in
certain Native American population. Whereas pigment stones are rare.
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Heredity: positive family history increases the risk, as do a variety of
inborn error of metabolism like impair bile salt synthesis and secretion.
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Environment: oral contraceptives and pregnancy increases hepatic
cholesterol uptake and synthesis, leading to excess biliary.
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High blood cholesterol level, rapid weight loss, diabetes and pregnancy,
old age, gender= risk to develop cholesterol gallstones.
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Disorders that lead to destruction of red blood cells such as sickle cell
anemia are associated with the development of pigmented or bilirubin
stones
symptoms
• 70-80 % of individual with gallstones remain
asymptomatic throughout life.
• . Some of the symptoms are pain, typically
localized to the right upper quadrant or
epigastric region and can be constant or less
commonly spasmodic.
• Pain like this is usually caused by biliary tree
or gallbladder obstruction or inflammation
of the gallbladder.
• Severe complication
empysema, perforation, fistula, inflammation of biliary tree,
or obstructive cholestasis or pancreatitis.
Diagnosis of Cholelithiasis
•
is suspected when symptoms of right upper quadrant abdominal
pain, nausea or vomiting occur. Location, duration and character
(stabbing,cramping) of the pain help to determine the likelihood
of gallstone disease. Patient with uncomplicated cholelithiasis
typically have normal laboratory test result. Blood test when its
indicated includes, complete blood count, liver function panel,
amylase, lipase.
•
Abdominal ultrasound examination is a quick, sensitive and
relatively inexpensive method to detect gallstones in the
gallbladder or common bile duct.
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Abdominal radiography upright and supine(used to exclude other
cause of abdominal pain), ultrasonography, CT ( more expensive
and less sensitive than ultrasound for detecting gallbladder stones)
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Scintigraphy ( highly accurate for the diagnosis of cystic duct
obstruction)
Treatment of Cholelithiasis
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treatment of gallstones depend on the stage of the disease. However
obstruct gallstones to the common bile duct is ERCP or surgery .
ERCP involves a thin flexible scope through the mouth and into
duodenum where it is used to evaluate the common bile duct or
pancreatic duct.
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Gallbladder surgery is performed if there is stones found in the
gallbladder itself, as these cannot be removed by ERCP so the surgery
performed is cholecystectomy which is frequently done by laparoscopy.
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Lithogenic state- interventions are currently limited to a few special
circumstances.
•
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Asymptomatic gallstones- expectant management
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The medical treatments used individually or in combination are: oral
bile salt therapy, contact dissolution, extracorporeal shockwave
lithotripsy
Symptomatic gallstones- usually definitive surgical intervention like
cholecystectomy.
Gallbladder polyps
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Gallbladder polyps are growths or lesions in the wall of the
gallbladder.
•
Affects around 5 % of the adult population. causes are uncertain,
but there is a correlation with increasing age and the presence of
gallstones. Higher prevalence among women
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The main types of polypoid growths of the gallbladder are:
cholesterol polyp/cholesterosis, cholesterosis with fibrous
dysplasia of gallbladder, adenomyomastosis, hyperplastic
cholecystosis and adenocarcinoma.
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Most of small polyps (less than 1 cm) are not cancerous and may
remain unchanged for years. About 95 % of gallbladder polyps
are benign. However, when small polyps occur with other
conditions, like primary sclerosing cholangitis, they are less likely
to be benign.
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larger polyps are more likely to develop into adenocarcinoma.
Cholesterolosis
• is characterized by an outgrowth of
the mucosal lining of the gallbladder
into fingerlike projections due to
excessive accumulation of cholesterol
and triglycerides within macrophages
in the epithelial lining.
• This type of cholesterol polyps
accounts for most benign gallbladder
polyps
Adenomyomatosis
• describes a disease state of gallbladder
in which the gallbladder wall is
excessively thick, due to proliferation
of subsurface cellular layer.
• it is characterized by deep folds into
muscular propria.
• ultrasonography can reveal the
thickened gallbladder wall with
intramural diverticula, called
Rokitansky- Aschoff sinuses.
Gallbladder polyps
• Most affected individuals do not have symptoms. They
are usually detected during abdominal ultrasonography
performed for other reasons.
• Small gallbladder polyps are common and does not
require any treatment, however recommended follow up
of small polyps varies from author to author.
• a commonly accepted strategy includes: <5 mm (no
further follow up necessary.) 6-9mm ( follow-up to
ensure no interval growth; follow-up interval varies from
3 to 6 months. > 10 mm (surgical consultation) usually
warrant cholecystectomy, if no cholecystectomy, annual
follow up is warranted.
Gallbladder cancer
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Gallbladder cancer is relatively uncommon. Carcinoma of
gallbladder is the most frequent malignant tumor of the biliary
tract.
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Carcinoma of gallbladder is more frequent in the populations of
Mexico and Chile, due to higher incidence of gallbladder stones
disease in these region. The mean 5- years survival rate is dismal 5
%, and gallstones are present in 50- 60 % of cases.
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Gallbladder containing stones or infectious agents develops
cancer as a result of recurrent trauma and chronic inflammation.
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Cancer may exhibit exophytic or infiltrating growth patterns.
infiltrating—> is more common and usually appears as a poorly
defined area of diffuse thickening and induration of the
gallbladder wall that may cover several square cm or involve the
entire gallbladder, these tumor are scirrhous and very firm.
Exophytic—> grows into the lumen as an irregular, cauliflower
like mass but at the same time also invades the underlying wall.
Gallbladder cancer
• By the time gallbladder cancers are discovered, most have
invaded the liver or have spread to the bile ducts or to
the portal hepatic lymph nodes.
•
If its detected early enough it can be cured by removing
the gallbladder, part of the liver and associated lymph
nodes.
•
Gallbladder cancer is most often found after symptoms
such as
• abdominal pain, jaundice, lump in the abdomen,
fever, bloating and vomiting.
• The risk factors are: Gender 2:1 women 7-8 decades,
obesity, chronic cholecystitis and cholelithiasis, chronic
typhoid infection of gallbladder ( chronic salmonella).
Diagnosis Gallbladder cancer
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for gallbladder cancer is difficult to detect and diagnose. signs and
symptoms are not usually seen in the early stage of the disease
and often overlap with the symptoms of gallstones and biliary
colic.
•
Some tests that might be helpful in the diagnosing gallbladder
cancer include: Liver function test, CA 19-9 assay,
carcinoembryonic antigen assay (CEA)
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Image studies: Ultrasound is the standard initial study in patient
with right upper quadrant pain. A mass can be identified in 50-70
% of patient with gallbladder cancer.
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CT- might be useful in patients with upper abdominal pain and
can demonstrate tumor invasion outside of the gallbladder and
identify metastatic disease elsewhere in the abdomen or pelvis.
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staging for gallbladder cancer:
Treatment Gallbladder cancer
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•
•
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surgery,
radiation therapy,
chemotherapy
palliative therapy.
Cholangiocarcinoma
• Is adenocarcinoma that arise from cholangiocytes lining
the intrahepatic and extrahepatic biliary ducts.
• Extrahepatic cholangiocarcinomas constitute
approximately two third of these tumors and may
develop at the hilum (known as Klatskin tumor) or more
distally in the biliary tree.
• It occur mostly in person at 50-70 year of age. the
prognosis is poor and most patients has unresectable
tumor.
• Both intra and extrahepatic cholangiocarcinoma are
generally asymptomatic until they reach an advanced
stage. Intraheptatic tumor might show symptom only
when much of the liver is replaced by tumor, whereas
extraheaptic might spread to sites as regional lymph
nodes, lungs, bones, and adrenal gland.
Risk factors
• primary sclerosing cholangitis, fibropolycystic
disease of the biliary tree, and infestation by
clonorchis sinensis(chinese liver fluke).
• All the risk factors of cholangiocarcinoma cause
chronic cholestasis and inflammation, which
promote the occurence of somatic mutations in
cholangiocytes.
• There are several genetic changes that have been
noted in these tumors, including activating
mutation in the KRAS and BRAF oncogenes and
loss of function mutation in the TP53 tumor
suppressor gene.
Clinical features
• Intrahepatic cholangiocarcinoma may be
manifested by the presence of a liver mass
and nonspecific signs and symptoms such
as wight loss, pain, anorexia, and ascites.
• Symptom and sign from extrahepatic:
jaundice,wight loss, nausea, and vomiting,
result from biliary obstruction.
• Common finding includes elevated alkaline
phosphatase, and aminotransferases
Treatment
• Surgical resection, which is not curative in large majority
of cases. Transplantation is contraindication. The mean
survival time ranges from 6-18 months regardless of
aggressive resection or palliative surgery is performed.
• Chemotherapy or radiation may be given after surgery to
decrease the risk of the cancer returning.
• Endoscopic therapy with stent placement can
temporarily relive blockages in the biliary duct and relieve
jaundice in the patient when the tumor can not be
removed.
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Laser therapy combined with high activated
chemotherapy medications is another treatment option
for those with blockage of the bile duct.
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