Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 14 Common Bile Duct Stones Stricture PPT-Powerpoint Presentations and lecture notes
CBD Stones, Stricture
Carcinoma Gal Bladder
Cholangiocarcinoma
Common Bile Duct Stones
(Choledocholithiasis)
? May be small or large
? Single or multiple
? Found in 6 to 12% of patients with stones in the gallbladder
? Incidence increases with age
? Secondary stones:
? Formed within the gallbladder and migrate down the cystic
duct to the common bile duct
? Cholesterol stones
? Primary stones : form in the bile ducts
? Brown pigment type
? Associated with biliary stasis and infection
Clinical Manifestations
? Silent and often are discovered incidentally
? May cause obstruction, complete or incomplete
? Cholangitis or gallstone pancreatitis
? Pain
? Mild epigastric or right upper quadrant tenderness
Clinical Manifestations
? Mild icterus
? Symptoms may also be intermittent
? Elevation of serum bilirubin, alkaline phosphatase, and
transaminases are commonly seen in patients with
bile duct stones
? However, in about one third of patients with common
bile duct stones, the liver chemistries are normal
Diagnosis
Investigation
Sensitivity
Specificity
US
25-82%
56-100%
EUS
95 %
95-98 %
MRCP
95 %
97 %
CT
87 %
97 %
Ultrasound shows a normal or mildly dilated common bile
duct with a stone
ERCP shows multiple stones in the common bile duct
? Dilated CBD (>8 mm in diameter) on ultrasonography
in a patient with gallstones, jaundice, and biliary pain is
highly suggestive
? Magnetic resonance cholangiography (MRC) provides
excellent anatomic detail
? Endoscopic cholangiography is the gold standard for
diagnosing common bile duct stones.
Management Options? CBD Stones
? Open cholecystectomy + CBD exploration
? ERCP + Endoscopic Sphincterotomy (followed by
cholecystectomy ? most frequently used).
? Laparoscopic cholecystectomy + Laparoscopic CBD exploration
? in specialized centers.
? Choledochoscopy at laparoscopy or percutaneous
choleydochoscopy or choleydochoscopy through T tube.
? ERCP has become a popular technique to clear CBD stones.
? Currently in the laparoscopic era studies have shown that
laparoscopic treatment of CBD stones is possible and is
potential y as effective as ERCP.
? This is most commonly done by a transcystic approach,
though evidence of success in large volume cohorts with a
more technical y demanding laparoscopic Choledochotomy
is emerging .
Common Bile Duct Stricture
Causes
? operative injury MC by lap. cholecystectomy
? fibrosis due to:
?chronic pancreatitis
?common bile duct stones
?acute cholangitis
biliary obstruction:
? cholecystolithiasis (Mirizzi's syndrome)
? sclerosing cholangitis
? Cholangiohepatitis
? strictures of a biliary-enteric anastomosis
Clinical presentation
? Episodes of cholangitis
? Jaundice
? Liver function tests usually show evidence of
cholestasis
Diagnosis
? Ultrasound / CT scan will show dilated bile ducts
proximal to the stricture
? MRC : anatomic information about the location
and the degree of dilatation
? Endoscopic cholangiogram will outline the distal
bile duct
ERC showing stricture of the common hepatic duct
Management
Depends on the location and the cause of the stricture
? Percutaneous or endoscopic dilatation and/or stent placement
give good results in more than one half of patients
? Surgery with Roux-en-Y choledochojejunostomy or
hepaticojejunostomy is the standard of care with good or
excellent results in 80 to 90% of patients
? Choledochoduodenostomy may be a choice for strictures in the
distal-most part of the common bile duct
Carcinoma Gal bladder
Etiology
? Accounts for 2 to 4% of malignant GI tumors
? 2-3 times more common in females than males
? 90% of patients have gallstones
? Larger stones (3 cm) are associated with tenfold
increased risk of cancer
? Polypoid lesions of the gallbladder (>10 mm)
? Calcified "porcelain" gallbladder >20% incidence
? Choledochal cysts
? Sclerosing cholangitis
? Anomalous pancreaticobiliary duct junction
? Exposure to carcinogens (azotoluene, nitrosamines)
Pathology
? 80 and 90% of the tumors are adenocarcinomas
? papillary, nodular, and tubular
Squamous cell
Adenosquamous
Oat cell
Cancer of the gallbladder spreads through:
? lymphatics
? venous drainage
? direct invasion into the liver parenchyma
Clinical Manifestation
? Abdominal discomfort
? Right upper quadrant pain
? Nausea & vomiting
? Jaundice
? Weight loss
? Anorexia
? Ascites
? Abdominal mass
Diagnosis
? FNAC /Biopsy (guided)
? Ultrasonography
? CT scan
? Percutaneous transhepatic or endoscopic cholangiogram
(in jaundiced pt)
? MRCP
CT scan of a patient with gal bladder cancer
Staging:
(AJCC 7th Edition)
Treatment
? Surgery :
? Radical Cholecystectomy, Liver resection with
regional lymphadenectomy
? Radiotherapy
? Adjuvant (pT1b onwards)
? Chemotherapy
? Concurrent
? Adjuvant
? Palliative
Prognosis
? 5-year survival rate of al patients <less than 5%
? Median survival: 6 months
? T1 disease treated with cholecystectomy have an excel ent prognosis
(85 - 100% 5-year survival rate)
? 5-year survival rate for T2 lesions treated with an extended
cholecystectomy and lymphadenectomy compared with simple
cholecystectomy is over 70% versus 25 to 40%, respectively
? Patients with advanced but resectable gal bladder cancer are
reported to have 5-year survival rates of 20 to 50%
? Median survival for patients with distant metastasis at the time of
presentation is only 1 to 3 months
Cholangiocarci
noma
? Rare tumor arising from the biliary epithelium
? May occur anywhere along the biliary tree
? About 2/3rd are located at the hepatic duct bifurcation
? Male to female ratio is 1.3:1
? Average age of presentation is between 50 to 70 years
Etiology
Ulcerative Colitis
Thorotrast Exposure
Sclerosing Cholangitis
Typhoid Carrier
Choledochal Cysts
Adult Polycystic Kidney
Disease
Hepatolithiasis
Liver Flukes
Papil omatosis of Bile Ducts
Distribution
? Right or left hepatic duct = 10%
? Bifurcation = 20%
? Proximal CBD = 30%
? Distal CBD = 30%
Pathology
? Over 95% of bile duct cancers are adenocarcinomas.
? Anatomical y they are divided into distal, proximal, or
perihilar tumors.
? Intrahepatic cholangiocarcinomas are treated like
hepatocel ular carcinoma, with hepatectomy when
possible.
? About two-thirds of cholangiocarcinomas are located
in the perihilar location
? Perihilar cholangiocarcinomas, also referred to as
Klatskin tumors, are further classified based on
anatomic location by the Bismuth-Corlette
classification
Bismuth-Corlette classification
? Type I: confined to the common hepatic duct
? Type II: involve the bifurcation without involvement
of the secondary intrahepatic ducts
? Type II A &I IB: extend into the right and left
secondary intrahepatic ducts, respectively
? Type IV: involve both the right and left secondary
intrahepatic ducts
Clinical Presentation
? Painless jaundice
? Pruritus
? Mild right upper quadrant pain
? Anorexia
? Fatigue
? Weight loss
? Cholangitis
? Elevated ALK PO4 and GGT levels
Intra and Extra-hepatic Cholangiocarcinoma
Diagnosis
? Ultrasound abdomen
? CT scan
? Cholangiography : biliary anatomy is defined
? PTC
Defines the proximal extent of the tumor, which is the most
important factor in determining resectability.
? ERC: evaluation of distal bile duct tumors
? Celiac angiography: evaluation of vascular involvement
? MRI: has the potential of evaluating the biliary anatomy,
lymph nodes, vascular involvement, tumor growth
ERCP: Distal CBD Cancer
MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation
Klatskin tumor
Treatment
? Surgical excision is the only potentially
curative treatment
? Location and local extension of the tumor
dictates the extent of the resection
Bismuth-Corlette type I or II with no signs of
vascular involvement:
? local tumor excision with portal lymphadenectomy,
cholecystectomy, common bile duct excision, and
bilateral Roux-en-Y hepaticojejunostomies
Bismuth-Corlette type II a or II b:
? right or left hepatic lobectomy respectively should
also be performed
Distal bile duct tumors:
? pylorus-preserving pancreatoduodenectomy
(Whipple procedure)
Unresectable distal bile duct cancer:
? Roux-en-Y hepaticojejunostomy, cholecystectomy
and gastrojejunostomy
Roux-en-Y Hepaticojejunostomy
Cholangiocarcinoma
Extra-hepatic Disease: Positive Margins or
Unresectable
? Stent and Chemo/Radiation Therapy
? 5-FU based or Gemcitabine or Clinical Trial
? Survival with surgery and chemo/radiation is 24 to
36 m
? With chemo/radiation alone survival is 12 to 18 m.
Cholangiocarcinoma
Extra-hepatic Disease: Unstentable
? Bypass if possible
? If not use proximal decompression and
feeding jejunostomy
? Chemotherapy/Radiation
Therapy/Brachy therapy as tolerated or
clinical trial.
Prognosis
? Best Result are with distal CBD tumors completely excised.
Cure = 40%
? Incomplete resection plus radiation gives a median
survival of 30 m.
? Stenting plus chemo/radiation gives a median survival of
17 to 27m
? Those stented alone live only a few months
This post was last modified on 08 April 2022