胆道疾病上海交大瑞金英.pptx

DepartmentofSurgeryRuijinClinicalMedicalCollegeShanghaiJiaoTongUniversityAnatomyandPathophysiologyDiagnostictechniquesStonesofBiliarytractInfectionofBiliarytractBiliaryTumorsAnatomhy of biliary tract Intrahepatic bile duct:Intrahepatic bile duct:Biliary tract extrahepatic bile duct:extrahepatic bile duct:Left hepatic duct Left hepatic duct Right hepatic duct Right hepatic duct Common hepatic common bile ductCommon hepatic common bile ductGallbladder cystic ductGallbladder cystic ductCalot trangle:Calot trangle:Liver :Liver :upper borderupper border Common hepatic duct diameter=0.4-0.6cmCommon hepatic duct diameter=0.4-0.6cmCystic duct Cystic duct lower borderlower border length 3cm length 3cmThe cystic artery runs in this triangle The cystic artery runs in this triangle Common bile ductDiameter0.6-0.8cm1cmabnormalLength7-9cmsupraduodenalsegmentretroduodenalsegmentretropancreaticsegmentduodenalwallsegmentThe papilla of VaterpancreaticsphinctercommonsphincterbiliarysphincterThe sphincter of oddiGallbladderLength:8-12cmwidth:3-5cmvariablesize:40-60mlshape:pearshapedfundusbodytheneckThe physiological function of GallbladderStoreandconcentratehepaticbileSecretionofwaterandelectrolytesEmptybileintothecommonbileductBile secretionHepatocytessecretebile800-1200mlBilecomposition:bileacids,bilepigments,cholesterol,phospholipids,inorganicelectrolytes,waterDiagnostic techniquesAbdominal ultrasonography1.untraumal2.lowcost3.flexibicity4.firstchoiceAbdominal ultrasonographyDiagnosebiliarystoneIdentifythecauseofjaundicePTCDby-ultrasoundguidedDopplerbloodflowPercutaneous Transhepatic CholangiographyShowthedilatedbileductaboveobstructionsiteDrainageofbilebyPTCDTraumaticmethodsComplications BileleakageHaemorrhageSepsisEndoscopic Retrograde Cholangiopancreatography ERCPDirectlyobservepapillalesionandbiopsyShowtheentirebiliarytractShowthebiliarytractproximaltoobstructionsiteDrainbileComplications acutepancreatitispostprocedurecholangitisOthercomplicationsOperative and postoperative direct cholangiographyShowtheentirebiliarytractDisplaythestoneandstenosisTubecholangiographydonebeforebiliarydraingewithdrawnCT and MRIHighresolutionMoreaccurateExpensiveShowthestone,tumor,dilatedductMRCPshowtheentirebiliarytreePlain radiographsshowradio-opaquecalcuiairinthebiliarytreecalcificationofthegallbladderOral cholecystographyShowthefunctionofgallbladderShowthestonespolypsandtumorcontraindicationsSensitivitytoiodineLiverandrenaldiseasepregnancyCholedochoscopeIntraoperativeuse:ExploretheCBDstoneTumor,stenosisReduceretainedstonerateRemovestonebiopsyOther examinationIntravenouscholangiogramAngiographyIsotopicstudiesHow to choose1.Bultrasound2.MRCPandCT3.ERCPandPTCInfections of biliary tract1.Cholecystitis2.CholangitisobstructionstoneinfectioncoreAcute cholecystitisAcutecalculouscholecystitis95%Acuteacalculouscholecystitis5%Etiology1.CysticductobstructedbyagallstoneimpactinginHartmannspouch2.BacteialinfectionofthestagnantbileAerobicenteric-derivedorganismsEscherichiacoli,klebsiellapneumoniae,streptococcusfaecalisgallstoneimpactionmucosaldamageLecithinlysolecithinphospholipasesPathologyCysticductobstructiongallbladderEdemasuppurategangrenepericholecysticabscessperforationCholecyst-entericfitulaPeritonitisintestinalobstructionAcutechronicatrophyClinical features1.Suddenandseverepainmainlyintherighthypochondriumradiatetotherightscapularregionfattyfoods2.Nauseaandvomiting3.Fever4.Tendernessandrigidityintherightupperquadrant5.PositiveMurphyssign6.Jaundice7.Apalpablegallbladdermass(1/4)Mirrizzis SyndromeThecommonhepaticisobstructedduetostonesimpactedinorextrudedfromHartmanspouchofthegallbldderorthecysticduct.Cholecystobiliaryorcholecystoentericfistulaearecommoncomplication.Differential DiagnsisPerforatedpepticulcerAcutepancreatitisRetrocaecelappendicitisRightlowlobepneumoniaHepaticabscessAcuteviralhepatitisLaboratory TestLeukocytosisintherangeofl0000-15000SerumbilirubinornormalAlkalinephosphataseornormalTransaminaseornormalSerumamylaseornormalTreatmentConservativetreatment1.Intravenonsfluidandelectrolytereplacement2.Nasogastricsuction3.Systemicantibiotics4.Parenteralanalgesia5.fastSurgical Treatment1.Attackwithin48-72hofdiagnosis2.Deteriorationinpatientsgeneralcondition3.ComplicationsarepresentPerforationPeritonitisAcuteobstructivesuppurativecholangitisAcutepancreatitisSurgical methodsOpencholecystectomyLaparoscopiccholecystectomyAcalculous CholecystitisComplicationsofmajortrauma,burnsandsepsisComplicationsofparenteralfeedingNoteasytomakeacleardiagnosisNeedpromptsurgicalinterventionover70%withatherosccleroticcardiovasculardiseaseBiliaryscintiscanninghelpfulfordiagnosisAcute cholangitis and acute obstructive suppurative cholangitisEtiologyCholedocholithiasis80%BenignstricturesObstructedbiliaryanastomoticstricturesMalignantobstructionAscaridPathophysiologyBiliaryobstructionintraductalpressure20mH20biliarystagnationbacteremia,bacteriaproliferationrefluxintohepaticveinsandperihepaticlymphaticssystemicsignsofcholangitisClinical presentationFeverandchillJaundicecharcotstriad)Rightupper-quadrantpainHypotensionMentalobtundationReynoldsPhysical examinationTendernessAbdominalguardingSwollengallbladderHepatomegalyLaboratory TestLeukocytosisHyperbilirubinemiaAlkalinephosphataseAminotransferasesLeukopeniaProfoundgram-negativesepsisandimmunosuppressionlmmunosuppressionSerumamylaseRadiological EvaluationUltrasonographyCTMRCPPTCERCPGeneral supportCessationoforalintake,fastAntibioticsKeepliquidandelectrolytebalanceIntravenousfluidsTreatmentBiliary decompressionPercutanecustranshepaticbiliarydrainageEndoscopicdrainagepapillotomyandplacementofanasobiliarytubeOperativedecompressionCBDexplorationandTtubedrainageCholelithiasis Classification of gallstoneCholesterolstones:lightbrown,smoothorfaceted,singleormultiplecross-sectionlaminated/crystallineappearancePigmentstone:small,blackorbrown,irregularcross-sectionamorphous/crystallineMixedstoneLocationGallbladderstonesCommonbileductstoneIntrahepaticbileductstoneExtrahepaticbileductstoneClinical presentationDyspepsiaRightupperquadrantabdominalpaininassociationwithorshortlyafteraheavyorfattymealAfeelingofgaseousbloatingBiliarycolicPhysical examinationUsuallynormalChronichydropsofgallbladdermassSometimestendernessRadiological TestAplainabdominalroentgenogramOralcholecystographyUltrasonographytheinitialdiagnosticstudyCTMRIComplicationsAcutecholecystitisJaundiceCholangitisPancreatitisMtrizzisyndromecancerSurgical IndicationAcceleratingsymptomsPoorvisualizationornon-visulizationonoralcholecystographyDiabetasPorcelaingallbladderstone2-3cmLaparoscopic CholecystectomyIndications:Chronic,uncomplicatedcholecystitisCholelithiasisGBpolypsBenefits:ReducinghospitalizationandassociatedcostsDecreasingpainImprovedcosmeticoutcomeReducedpost-operativerecoveryOther treatmentDietarytherapyalow-fatdiet,avoidanceofheavymealsAntispasmodicmedicationChenodeoxycholicacidandursodeoxycholicacidExtracorporealshockwavelithotripsyCarcinoma of GallbladderIncidenceThecommonestformofbiliarytractmalignancythefifthmostcommongastrointestinalcancerEncounteredin1-2%ofcholecystectomyspecimensPredominantlyoccursinelderlyfemalesOver90%ofpatientsarewere50yearsofageThepeakageofincidenceis70-75%yearsAmaletofemaleratioof1:3Etiology CholelithiasisBenignadenomaPolypoidgallbladderlesions(polypgreaterthan1cm)AnomalouspancreaticbiliaryjunctionChronicinflammatoryboweldiseasePathologyAdenocarcinoma80%carcinoidtumoursUndifferentiatedcarcinoma6%sarcomaSquamouscarcinoma3%melanomaMixedtumororacanthoma1%lymphomaUICCstage:mucosaandmuscularstage:totallayerofthegallbladderstage:invasionintoliver2cmBstage:spreadtodistalorganandlymphnodeClinical FeaturesThediagnosisofgallbladdercancerisusuallymadewhenthediseaseiswelladvanced.TherearenocharacteristicfeaturesatanearlyandcurativestageLaboratory invesitigationsCantprovidediagnosticinformationProvidesomehelpfulcluesAnaemiaSerumalkalinephosphataseCEACA19-9CA125Radiological DiagnosisPlainabdominalradiographyOralcholecystographyPTCERCPCTMRIMRCPOther methods for diagnosisFNACultrasoundTreatmentUICCUICCUICCIVAUICCB cholecystectomyCurativeexcisionprocednreextendedcurativeexcisionPalliativeproceduresBilliaryorduodenalbypass PrognosisPiehlerandcrichlowReportof6000patients:1yearsurvivialrate11.8%5yearsurvivalrate4.1%Palliative procedure1.ExcrabiledraingeTtubeUtubePTCD2.Intra-draingeBiliary-entericbypassorintubationNon-operativeendoprostheticinsertionThankyou