BiliarysystemAnatomyandandphysiologyofBiliarySystem1MethodsofInvestigation2DisordersofGallbladder3DisordersofBileDuct4Casediscussion5AnatomyandphysiologyofBiliarySystem1Bilecomefrom?Howbilewastransported?Pre-TestSecretionofBile75%25%About75%bilewassecretedfromhepatocyteand25%wasproducedbybiliaryepithelial.Composition：water、bileacid、bilesaltandbilepigmentFunction：helpdigestionandabsorptionoffatCompositionandfunctionofbileIntrahepaticBiliaryTract

CapillaryBileductLefthepaticBileductRighthepaticbileductAnatomyofBiliarySystemExtrahepaticBiliaryTract

BifurcationCommonhepaticductCommonbileductCysticductGallbladderAnatomyofBiliarySystemTheliversecretebile,bileflowfromlivertorightandlefthepaticducts.Theseductsdrainintothecommonhepaticduct.Thecommonhepaticductthenjoinswiththecysticducttoformthecommonbileduct.TransportationofBileAbout50percentofthebileproducedbyliverisfirststoredandconcentratedingallbladder.Whenfoodistaken,thegallbladdercontractsandreleasestoredbileintotheduodeumtohelpdigestthefood.TransportationofBileRegulationofbilesecretionCalot

triangleThetriangleisboundedbythecysticduct,thecommonhepaticduct,andtheinferiorborderoftheliver.

Importantstructuresincluding:thecysticartery,therighthepaticartery,andthecysticductlymphnode.

TheimportanceofBiliarysystemInGreekmythology,whenAchilleswasababy,itwasforetoldthathewoulddieyoungTopreventhisdeath,hismotherThetistookAchillestotheRiverStyx,whichwassupposedtoofferpowersofinvulnerability,anddippedhisbodyintothewaterButasThetisheldAchillesbytheheel,hisheelwasnotwashedoverbythewaterofthemagicalriverAchilles’heelAchilles’heelrighthepaticarteryretroduodenalartery9:00arterylefthepaticarteryproperhepaticartery3:00arterycommonhepaticarterygastroduodenalarteryTheimportanceofBiliarysystemPapillaofVaterTheopeningofthebileductandpanceaticductinthedescendingpartoftheduodenum.Throughthepapilla,bileandpancreaticjuicepasstobowel.obstructivejaundiceorpancreatitiswillhappenwhenpapillaofVaterwasblockedbystonesandtumors,NormalgallbladderAgenesisofthegallbladderisextremelyrare,withaprevalenceof0.03-0.07percent.Doublegallbladderoccursinabout0.03percent,usuallywithasharedcycticduct,andtheaccessorygallbladderisoftendiseased.GallbladderAnatomicalVariantsVariationsofbiliarybranchingATypicalanatomyoftheconfluence.BTrifurcationofleft,rightanterior,andrightposteriorhepaticducts.CAberrantdrainageofarightanterior(C1)orposterior(C2)sectoralhepaticductintothecommonhepaticduct.MethodsofInvestigation2Ultrasonography(B-US)CT,ComputedTomographicMagneticResonanceCholangiopancreatographyEndoscopicRetrogradeCholangiopancreatographyPercutaneousTranshepaticCholangiographyT-tubecholangiographyRadiographsIntraoperativecholangiographyEndoscopicultrasound……MethodsofinvestigationFast,real-time,non-invasive,andnoionizingradiation,cheapandcouldbeavailableevenincountryside.95%sensitivityfordetectionofcholelithiasis.

--Foundamobile,hyperechoicwithacousticshadowing>90%sensitivityfordetectionofacutecholecystitis.

--Gallbladderwallthickening,pericholecysticfluidB-USNormalGallbladderGallbladder,withsludgeandstonepresentGallstonescanbeseenonCT,butitisnotusedprimarilyforthispurpose.(Moreexpensive,ionizingradiation)CTcanbeusedinsituationswhereultrasoundisdifficult--suchasinobesepatients.Itcanalsobeusediftheultrasoundisnotdefinitive.

CTscanPlainCTshowsmultiplegallstones.Multiplestoneswerefoundintheleftintrahepaticbileduct.BecomingamoreviableimagingtechniqueNewtoolfornon-invasiveevaluationofthepancreaticandbiliaryductalsystems.GraduallyreplacingPTCandERCPfordiagnosticpurposes.MRCPMRCPshowedslightdilationofCBD

PancreaticductCommonbileductStoneswasdetectedinthebileductbyMRCP.StonesinCBDERCPistheprimarymethodofdirectcholangiography,andhastherapeuticpotential.ItalsoallowsforexaminationoftheupperGItract,thepapillaofVater,andthepancreaticduct.ERCPLeft:TheendoscopewasintroducedtothepapillaofVaterandcontrastmediumwasinjectedintocommonbileduct.Right:RadiographicresultafterthecontrastmediumwasinjectedintotheCBD.ERCP:Instrumentscanalsobeinsertedthroughthescopetoremovestones,insertstent,tissuebiopsy,andothertreatments.ERCP:showingslightlydilatedcommonbileductwithcalculusandnormalpancreaticduct.StonesinCBDEndoscopePancreaticductLargestonewasdrawingoutfromCBDduringERCPwasperforming.Showtheprocedureofremovalthestonesusingendoscope.PTCThecatheterwasplacedintotheintrahepaticbileductthroughpatient’sskinguidingbyB-USandfixedontheskin.Theradiographicimagewastaken.Obstructivelesioncanbeseeninthispicture.ObstructivelesionLeft:Afterinjectionofdye,showingalargestonetrappedintheduct.Right:Afterremovalofthestonethroughthedrainagecatheter.BeforeAfterPostoperativelyInjectionofcontrastmediumthroughaT-tubecatheterplacedintheCBD

EasywaytoshowwhetherthereareremainingstonesoranystrictureT-tubecholangiographyT-tubegraphyOldtechniqueusedinthepast,widelyreplacedbytheultrasoundandMRCP.Canbeusedtovisualizecalcifiedstonesbyabdominalx-rayfilm.RadiographsAbdominalx-raydemonstratingstonesinthegallbladderStonesStonesStonesDisordersofGallbladder3AcutecholecystitisGallbladderstonesandsludgeAdenomyomatoushyperplasiaGallbladderpolypsGallbladdercarcinoma……DisordersofGallbladderCalculouscholecystitis:over90%Clinicalmanifestation:

--Paininrightupperquadrant--Radiatetorightshoulder&back

--Nausea&vomiting--Chilland/orfever

--Abdominaltenderness--Murphy'ssign(+)AcuteCholecystitisAcuteCholecystitis:B-USThegallbladdercontainssmallstonesintheneckanditswallshowsedematousthickening(>5mmthickness).OtherB-USsignsare:--Gallbladderoverdistension--Pericholecysticfluid--GBwallthickening--……LessaccuratethanB-USTheCTfindings:

--Gallbladderwallthickening--Subserosaledema--Gallbladderdistension--Pericholecysticfluid--GallstonesAcuteCholecystitis:CTFine,nonshadowingdependentechoes.Composedofcalciumbilirubinategranules,cholesterolcrystals.Gallstoneswilldevelopin5-15percent.SludgeGallbladder,withsludgeandstonepresentStoneSludgeGallbladderpolypsThemajorityofpolypsarecholesterolCholesterolpolypsareusually2-10mminsizeTheyappearassmallechogenicnonshadowingfociadherenttothegallbladderwallLackofmobilityindicatespolypTheaffectedsegmentoftencontainsbrightechoesOftenassociatedwith‘comet-tail’Gallbladder-AdenomyomatosisCommonhepaticductobstructioncausedbyanextrinsiccompressionfromanimpactedstoneinthecysticduct.MayresultinbiliaryobstructionandjaundiceIfnotrecognizedpreoperatively,itcanresultinsignificantmorbidityandmortality

MirrizzisyndromeSymptomaticcholelithiasisNon-functioninggallbladders(Fullofstones)Malignantconsidered:GBpolyps(>1.0cm)orothersIndicationforCholecystectomyThefirstcasewasperformedin1882OnesafeandeffectivemethodDirectvisualizationandpalpationOpenCholecystectomyAlessinvasivewaytoremovethegallbladderSmallerincisionsandlesspainShorterhospitalstayandashorterrecoverytimeLaparoscopicCholecystectomyLaparoscopicCholecystectomyGallbladderCarcinomaGallbladdercarcinomaisassociatedwithstonesinover90%ofpatientsThereisafemaletomaleratioof3:1FewpatientwasdiagnosedpriortosurgeryGallbladderCarcinomaCancerGallbladderCarcinomaGallbladderCarcinomaNodalMetastasisTNMclassificationTNMclassificationNevinStagingSystemDirectinvasionoftheliverbygallbladdercancerina66-year-oldwomanShoulddifferentiategallbladdercancerfromacutecholecystitisT?N?M?QuizTreatmentT1aN0M0:cholecystectomyT1bN0M0:radicalsurgeryincludingsegmentliverresection,bileductresectionandextensivelymphadenectomyT3,T4:radicalcholecystectomy,resectionofcommonhepaticductandcommonbileductPoorprognosisinpatientswithunresectabletumorExternalradiationtherapymayprovidepalliativebenefit5-FuandGemcitabinecanbeusedaschemotherapyDisordersofBileDuct4DisordersofBileDuctAOSCCholedocholithiasis/HepatolithiasisCholedochalcystCholangiocarcinomaPancreaticandampullarytumorAcuteobstructivesuppurativeCholangitis(AOSC)EmergencydiseasecarrieshighmortalityCommonobstructingfactors:stones,tumorCompleteobstructionandsuppurativeinfectionMayresultinsepticemia&septicshock;MSOF(multiplesystemicorganfailure)AOSCAbruptonsetof

paininupperquadrantChill,highfever,maynauseaandvomitingJaundiceMayshockandalteredmentalstatus(Reynoldspentad)ClinicalmanifestationCharcottriadCorrectthefluidandacid-basebalanceSystemicadministrationofantibioticsAnti-shocktreatmentDrainthebiliarytract:ERCPorPTCDEmergencyoperationTreatmentCholedocholithiasis/HepatolithiasisSmallshadowingstone(Arrow)indilatedbileduct.CTshowmultiplestonesinhepaticbileductCholedocholithiasis/HepatolithiasisERCP:demonstratingstoneintheduct(arrow)StonesCholedocholithiasis/HepatolithiasisCysticdilatationoftheextrahepaticbileductsFemaletomaleisaboutration4:1ThemajorityarenowdiagnosedinchildhoodClassifiedintofivetypesAssociatedwithvariousbiliarytumorsCholedochalcystsTypeITypeIITypeIIITypeIVTypeVCholedochalcystsCTSlidesMRCPSlidesTreatmentofCholedochalcystsConservativetreatmentisnotrecommended：

recurrentcholangitis,ruptureofcyst,cancerationetc.Surgicaltreatmentisrecommended：

cystectomyandcholedochojejunostomyCholangiocarcinomaPancreaticandampullarytumours……BileDuctCancerMostcommonlyatthehepaticductbifurcation(Klatskintumor)PresentwithjaundiceClinicalPresentation:--Jaundice(around90%)--Pruritus--fever--mildabdominalpain--fatigue--……Surgicalresectionofferachanceforlong-termdisease-freesurvivalCholangiocarcinomaB-US:nodulesorfocalbileductwallthickeningCT:nodulesareusuallyisodenseorslightlyhypodenseMRCP:showtheproximalextentofthestricturingCholangiocarcinomaBismuthClassificationTypeItumorsaredistaltothehepaticductconfluence(HDC)whiletypeIIneoplasmsextendtoandinvolvetheHDC.TypeIIItumorsinvolvetheHDCandeithertheproximalrighthepaticduct(typeIIIA)orproximallefthepaticduct(typeIIIB).TypeIVtumorsextendintothebilateralproximalhepaticductsuptothesegmentalbileducts.Type?QuizDistallesionsareusuallytreatedwithWhippleIntrahepaticlesionsaretreatedbyhepaticresectionPerihilar(Klatskin)tumor:--TypeIandII:Resectionoftheextrahepaticbileductsandgallbladder--TypeIIIandIV:Curativeresectionisdifficult

Radiationtherapyimprovessurvivalforpatients

TreatmentResectionoftheextrahepaticbileductsandgallbladderwith5-10mmbileductmargins,andregionallymphadenectomywithRoux-en-Yhepaticojejunostomy.

TypicaloperationI:Roux-en-YTypicaloperationII:WhippleBeforeAfterTheheadofthepancreas,theentireduodenum,aportionofthejejunum,thedistalthirdofthestomach,andthelowerhalfofthecommonbileductareexcised.Continuityisreestablishedbetweenthebiliary,pancreatic,andGIsystems.Casediscussion542-year-oldwomanpatientwasadmittedtoouremergencydepartmentbecauseofrepeatedupperabdominalpainfor2yearsandaggravatedforthreedays.Withnausea,vomiting,chillandfever.Thehighesttemperaturereachedto39.5℃.Shealsofounddarkurineandskinturnedyellow.PE:

BP85/52mmHg.Yellowstainedwasfoundintheskinandsclera.CaseI:

ClinicalmanifestationWhichexaminationshouldbeperformedfordiagnosis?Laboratorytes