Ch. 54 – Biliary System

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1552 Section X Abdomen Suspect common bile duct stones Lap cholecystectomy with IOC and lap CDBE or ERCP with stone extraction, papillotomy; lap cholecystectomy sphincter pressure relaxes in coordination with gallbladder contraction, thereby allowing the passive fl ow of bile into the duodenum. During fasting, high-pressure phasic contractions of the sphincter of Oddi persist through all phases of the MMC. Sphincter of Oddi activity appears to be coordinated with the partial gallbladder emptying and increases in the bile fl ow that occur during phase III of the MMC. This activity may be a preventive mechanism against the accumulation of biliary crystals during fasting. GENERAL CONSIDERATIONS IN BILIARY TRACT PATHOPHYSIOLOGY Suspect extrahepatic biliary obstruction Ultrasound Symptoms Symptoms attributable to biliary tract pathology are usually the result of obstruction, infection, or both. Obstruction can be extramural (e.g., pancreatic cancer), intramural (cholangiocarcinoma), or intraluminal (cho- Jaundice History and physical Dilated ducts Normal ducts Proximal obstruction Palliative PTC Suspect malignant obstruction 3-phase CT scan with venous delay Operation Suspect intrahepatic disease CT scan to rule out liver mass Hepatitis screen Possible liver biopsy Distal obstruction Palliative ERCP Figure 54-6 Diagnostic algorithm for patients presenting with jaundice. CBDE, common bile duct exploration; CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; IOC, intraoperative cholangiogram; lap, laparoscopic; PTC, percutaneous transhepatic cholangiography. ledocholithiasis). Similar to infections in other parts of the body, biliary infections are usually due to three factors: a susceptible host, suffi cient inoculum, and stasis. The most common symptoms related to biliary tract disease are abdominal pain, jaundice, fever, and nausea and vomiting. Abdominal Pain Gallstones and infl ammation of the gallbladder are the most frequent causes of abdominal pain from biliary tract disease. Acute obstruction of the gallbladder by calculi results in biliary colic, a common misnomer because the pain is not colicky in the epigastrium or right upper quadrant. Biliary colic is a constant pain that builds in intensity, and can radiate to the back, interscapular region, or right shoulder. The pain is described as a bandlike tightness of the upper abdomen that may be associated with nausea and vomiting. This is due to a normal gallbladder contracting against a luminal obstruction, such as a gallstone impacted in the neck of the gallbladder, the cystic duct, or the common bile duct.
The pain is most commonly triggered by fatty foods, but it can also be initiated by other types of food or even occur spontaneously. An association with meals is present in only 50% of patients, and in these patients, the pain often develops more than 1 hour after eating. The pain of biliary colic is distinct from that associated with acute cholecystitis. Although biliary colic can also be localized to the right upper quadrant, the pain of acute cholecystitis is exacerbated by touch, is somatic in nature, and is often associated with fever and leukocytosis. Irritation of the visceral and parietal peritoneum due to transmural infl ammation from cholecystitis results in a positive Murphy’s sign. This physical exam fi nding (in a patient abruptly arresting his or her inspiratory effort because of pain as the examiner palpates under the right costal margin) is indicative of acute cholecystitis. Jaundice When the serum concentration of bilirubin exceeds about 2.5 mg/dL, a yellowish discoloration of the sclera becomes evident (scleral icterus). Jaundice represents a similar discoloration of the skin, with serum bilirubin levels in excess of 5 mg/dL. The changes in color represent deposition of bile pigments in the affected tissues. The presence of conjugated bilirubin in the urine is one of the fi rst changes noted by patients. Workup and diagnosis of the jaundiced patient require an algorithm similar that in to Figure 54-6. Disorders resulting in jaundice can be divided into those causing “medical” jaundice, such as increased production, decreased hepatocyte transport or conjugation, or impaired excretion of bilirubin, and those causing “surgical” jaundice through impaired delivery of bilirubin into the intestine. Common causes of increased bilirubin production include the hemolytic anemias and acquired causes of hemolysis, including sepsis, burns, transfusion reactions, and medications. Impaired excretion of bilirubin leads to intrahepatic cholestasis and conjugated hyperbilirubinemia and can be due to conditions like viral or alcoholic hepatitis, cirrhosis, and drug-induced cholestasis. Chapter 54 Biliary System 1553 Table 54-1 Accuracy of Preferred Imaging Modalities for Different Biliary Tract Diagnoses Causing Right Upper Quadrant Pain SUSPECTED DIAGNOSIS IMAGING MODALITY SENSITIVITY (%) SPECIFICITY (%) Cholelithiasis Ultrasound 95 99 Acute calculous cholecystitis Ultrasound 88 80 HIDA 95 95 Acute acalculous cholecystitis Ultrasound 36-93 17-89 HIDA 70-80 90-100 Choledocholithiasis ERCP 95 89 MRC 95 98 I/OP cholangiogram 78 97 Lap ultrasound 80 99 Biliary dyskinesia HIDA 94 80 ERCP, endoscopic retrograde cholangiopancreatography; HIDA, cholecystokinin hepatobiliary 2,6-dimethyl-iminodiacetic acid scan; I/OP, intraoperative; Lap, laparoscopic; MRC, magnetic resonance cholangiography. From Trowbridge RL, Rutkowski NK, Shojania KG: Does this patient have acute cholecystitis? JAMA 289:80-86, 2003. Fever Signifi cant elevations in body temperature (≥38.0°C) represent a systemic manifestation of an initially localized infl ammatory process. Bacterial contamination of the biliary system is a common feature of acute cholecystitis or choledocholithiasis with obstruction, and can be expected following percutaneous or endoscopic cholangiography. The combination of right upper quadrant abdominal pain, jaundice, and fever, known as Charcot’s triad, signifi es an active infection of the biliary system termed acute cholangitis. The addition of an altered mental status and hypotension to the above fi ndings represents severe cholangitis and is termed pentad of Reynolds. Laboratory Tests Biliary colic, in the absence of gallbladder wall pathology or common bile duct obstruction, does not produce abnormal laboratory test values. On the other hand, obstructive choledocholithiasis is commonly associated with both liver dysfunction and acute cellular injury with resultant elevations in liver function tests. Hepatocellular injury results in increased levels of unconjugated or indirect reacting bilirubin due to an increase in bilirubin production or a decrease in hepatocyte uptake with conjugation. Conjugated or direct hyperbilirubinemia is due to defects in bilirubin excretion (intrahepatic cholestasis) or extrahepatic biliary obstruction. In addition to hyperbilirubinemia, an increased alkaline phosphatase level is virtually pathognomonic of bile duct obstruction. In patients with a high clinical suspicion of cholecystitis, but with associated elevations of bilirubin, alkaline phosphatase, and aminotransferase, cholangitis should be suspected. Serum transaminase (aspartate and alanine) levels can also be mildly elevated in biliary system disease, either because of direct injury of the liver adjacent to an infl amed gallbladder or from the effect of biliary sepsis on hepatocellular membrane integrity. Leukocytosis, composed primarily of neutrophils, is often present with acute cholecystitis or cholangitis, but is a nonspecifi c
Page 1 and 2: Biliary System Ravi S. Chari, MD an
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Page 9 and 10: Cholangiography Cholangiography fun
Page 11 and 12: Cholesterol Gallstones The pathogen
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Page 17 and 18: Surgery for Calculous Biliary Disea
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Page 21 and 22: transduodenal approach may be feasi
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Page 31 and 32: Box 54-6 Todani Modifi cation of Al
Page 33 and 34: Figure 54-31 Operative photography
Page 35 and 36: ant abdominal pain. A heterogeneous
Page 37 and 38: Figure 54-35 Bismuth classifi catio
Page 39 and 40: sectable disease; however, intraope
Page 41 and 42: tion and mimic either pancreatic ca

Ch. 54 – Biliary System

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