012B - Gallbladder.pdf

GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEM KHRISTINE S. OLITA, MD OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma...

GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEM KHRISTINE S. OLITA, MD OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ULTRASOUND Sorrentino S, Grano I, Weerakkody Y, et al. Gallstones. Reference article, Radiopaedia.org (Accessed on 31 Jan 2023) https://doi.org/10.53347/rID- 20125 MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) Hacking C, Normal MRCP. Case study, Radiopaedia.org (Accessed on 31 Jan 2023) https://doi.org/10.53347/rID-41966 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) Knipe H, El-Feky M, Worsley C, et al. Endoscopic retrograde cholangiopancreatography. Reference article, Radiopaedia.org (Accessed on 31 Jan 2023) https://doi.org/10.53347/rID-35490  T-TUBE CHOLANGIOGRAM Hamidi H, Normal T tube cholangiogram. Case study, Radiopaedia.org (Accessed on 31 Jan 2023) https://doi.org/10.53347/rID-50937 HEPATOBILIRY SCINTIGRAPHY/ HEPATOBILIARY IMINODIACETIC ACID (HIDA) SCAN Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ENDOSCOPIC CHOLEDOCHOSCOPY Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York.  Endoscopic Ultrasound CT Scan of the abdomen Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLSTONE DISEASE (CHOLELITHIASIS) Most are asymptomatic despite the high prevalence Biliary colic o Postprandial RUQ or epigastric pain Cholesterol stones (80%) Pigment stones (15-20%) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLSTONE DISEASE (CHOLELITHIASIS) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures GALLSTONE DISEASE SYMPTOMATIC CHOLELITHIASIS Biliary colic o Radiating to right upper back or between scapulae o Postprandial Hydrops of the gallbladder o During night or after a fatty meal o Impacted stone on the cystic duct without cholecystitis Nausea and vomiting o Clear-white mucinous material Recurrent attacks Bloating and belching Ultrasound of the abdomen (standard) Management: o Cholecystectomy Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures GALLSTONE DISEASE ACUTE CHOLECYSTITIS Infection of the gallbladder Mirizzi Syndrome 90-95% associated with gallstones o Severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct Pain does not subside Fever Ultrasound of the abdomen Anorexia, nausea and vomiting HIDA Scan (>90% sensitivity) PE: o RUQ tenderness Management: o Murphy’s Sign § Inspiratory arrest on deep o Laparoscopic cholecystectomy palpation of the RUQ (definitive treatment) o IV fluids and antibiotics Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLSTONE DISEASE ACUTE CHOLECYSTITIS GALLSTONE DISEASE ACUTE CHOLECYSTITIS Okamoto, K., Suzuki, K., Takada, T., Strasberg, S.M., Asbun, H.J., Endo, I., Iwashita, Y., Hibi, T., Pitt, H.A., Umezawa, A., Asai, K., Han, H.-S., Hwang, T.-L., Mori, Y., Yoon, Y.-S., Huang, W.S.-W., Belli, G., Dervenis, C., Yokoe, M., Kiriyama, S., Itoi, T., Jagannath, P., Garden, O.J., Miura, F., Nakamura, M., Horiguchi, A., Wakabayashi, G., Cherqui, D., de Santibañes, E., Shikata, S., Noguchi, Y., Ukai, T., Higuchi, R., Wada, K., Honda, G., Supe, A.N., Yoshida, M., Mayumi, T., Gouma, D.J., Deziel, D.J., Liau, K.-H., Chen, M.-F., Shibao, K., Liu, K.-H., Su, C.-H., Chan, A.C.W., Yoon, D.-S., Choi, I.-S., Jonas, E., Chen, X.-P., Fan, S.T., Ker, C.-G., Giménez, M.E., Kitano, S., Inomata, M., Hirata, K., Inui, K., Sumiyama, Y. and Yamamoto, M. (2018), Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci, 25: 55- 72. https://doi.org/10.1002/jhbp.516 Okamoto, K., Suzuki, K., Takada, T., Strasberg, S.M., Asbun, H.J., Endo, I., Iwashita, Y., Hibi, T., Pitt, H.A., Umezawa, A., Asai, K., Han, H.-S., Hwang, T.-L., Mori, Y., Yoon, Y.-S., Huang, W.S.-W., Belli, G., Dervenis, C., Yokoe, M., Kiriyama, S., Itoi, T., Jagannath, P., Garden, O.J., Miura, F., Nakamura, M., Horiguchi, A., Wakabayashi, G., Cherqui, D., de Santibañes, E., Shikata, S., Noguchi, Y., Ukai, T., Higuchi, R., Wada, K., Honda, G., Supe, A.N., Yoshida, M., Mayumi, T., Gouma, D.J., Deziel, D.J., Liau, K.-H., Chen, M.-F., Shibao, K., Liu, K.-H., Su, C.-H., Chan, A.C.W., Yoon, D.-S., Choi, I.-S., Jonas, E., Chen, X.-P., Fan, S.T., Ker, C.-G., Giménez, M.E., Kitano, S., Inomata, M., Hirata, K., Inui, K., Sumiyama, Y. and Yamamoto, M. (2018), Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci, 25: 55- 72. https://doi.org/10.1002/jhbp.516 Okamoto, K., Suzuki, K., Takada, T., Strasberg, S.M., Asbun, H.J., Endo, I., Iwashita, Y., Hibi, T., Pitt, H.A., Umezawa, A., Asai, K., Han, H.-S., Hwang, T.-L., Mori, Y., Yoon, Y.-S., Huang, W.S.-W., Belli, G., Dervenis, C., Yokoe, M., Kiriyama, S., Itoi, T., Jagannath, P., Garden, O.J., Miura, F., Nakamura, M., Horiguchi, A., Wakabayashi, G., Cherqui, D., de Santibañes, E., Shikata, S., Noguchi, Y., Ukai, T., Higuchi, R., Wada, K., Honda, G., Supe, A.N., Yoshida, M., Mayumi, T., Gouma, D.J., Deziel, D.J., Liau, K.-H., Chen, M.-F., Shibao, K., Liu, K.-H., Su, C.-H., Chan, A.C.W., Yoon, D.-S., Choi, I.-S., Jonas, E., Chen, X.-P., Fan, S.T., Ker, C.-G., Giménez, M.E., Kitano, S., Inomata, M., Hirata, K., Inui, K., Sumiyama, Y. and Yamamoto, M. (2018), Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci, 25: 55- 72. https://doi.org/10.1002/jhbp.516 OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures  Elevated serum bilirubin, ALP, GALLSTONE DISEASE transaminase CHOLEDOCHOLITHIASIS Ultrasound of the abdomen MRCP Common bile duct stones ERCP Incidental, incomplete or complete obstruction Management: 1. ERCP + Laparoscopic cholecystectomy Biliary colic Jaundice (in complete obstruction) 2. Lap cholecystectomy, intraoperative Nausea, and vomiting cholangiogram, bile duct exploration, with or without T-tube insertion PE: o Jaundice and icterisia 3. Open cholecystectomy, intraoperative o RUQ tenderness cholangiogram, bile duct exploration, with or without T-tube insertion Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLSTONE DISEASE CHOLEDOCHOLITHIASIS Retained stone – stone left in place at the time of surgery Recurrent stone – months or years after the surgery Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLSTONE DISEASE CHOLEDOCHOLITHIASIS Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures  Charcot’s Triad: GALLSTONE DISEASE ü Fever CHOLANGITIS ü Epigastric or RUQ ü Jaundice Ascending bacterial infection associated Reynolds’ Pentad: with partial or complete obstruction of the ü Fever bile ducts ü Epigastric or RUQ o Gallstones (most common) ü Jaundice o PCS, strictures, parasites, ü Septic shock instrumentation, indwelling stents ü Mental status changes E. coli, Klebsiella pneumoniae, DIAGNOSTICS: Streptococcus faecalis, Enterobacter, and Elevated bilirubin, ALP, transaminases Bacteroides fragilis Ultrasound – obstructing stone, dilated duct CT/MR – Periampullary/pancreatic mass Initial diagnosis made clinically Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLSTONE DISEASE CHOLANGITIS MANAGEMENT: Rapid deterioration in patients with ü Broad-spectrum antibiotics cholangitis, necessitating ICU monitoring ü Fluid resuscitation and vasopressor support ü Rapid biliary decompression: o ERCP (first-line) Most respond to biliary decompression and o PTC supportive measures o Surgical drainage 5% Overall Mortality Higher risk of mortality if associated with end-organ damage Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures GALLSTONE DISEASE GALLSTONE PANCREATITIS Gallstone in the CBD with acute Management: pancreatitis ü Supportive (first-line) o Transient obstruction of pancreatic o Admission for bowel rest ducts o IV hydration o Stone passing through or impacted in o Pain control the ampulla ü ERCP with sphincterotomy* Ultrasound, CT, or MRCP o If with obstructing stone (Confirmatory) Elevated amylase, lipase Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures GALLSTONE DISEASE GALLSTONE ILEUS Large gallstone erodes through the wall of Abdominal pain, nausea and vomiting, the gallbladder directly into the intestine via obstipation a choledochoenteric fistula Plain radiograph (obstructing gas pattern) Bouveret syndrome Ultrasound (limited study) o Proximal stones, impacted in the CT Scan (confirm location of obstruction) pylorus or proximal duodenum causing gastric outlet obstruction Management: ü Endoscopic removal of stone Small bowel obstruction: (proximal obstruction) o Surgical anastomoses ü Enterolithotomy (Distal obstruction) o Ileocecal valve Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures CHOLEDOCHAL CYST Congenital cystic dilatations of the Clinical triad: extrahepatic and/or intrahepatic biliary ü Abdominal pain, jaundice, palpable tree mass ERCP or MRCP (Assess biliary tract) 1:100,000 to 1:150,000 3-8x common in Females > Males 20-30% risk for malignancy Excision is recommended Weakness of the bile duct wall o Increased pressure due to partial biliary obstruction o Biliary cyst formation Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures PRIMARY SCLEROSING CHOLANGITIS Inflammatory strictures involving the ERCP (Confirmatory) intrahepatic and extrahepatic biliary o Multiple dilatations and strictures tree (beading) of the intra- and extrahepatic biliary tree Progressive, cause secondary cirrhosis 10-15% will develop 30-45 years (mean age) cholangiocarcinoma 2:1 Males > Females Conservative management Intermittent jaundice, fatigue, weight Resection of extrahepatic biliary tree loss, pruritus, or abdominal pain and hepaticojejunostomy* Some incidental finding Liver transplantation* Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures  Signs and symptoms of recurrent BILE DUCT STRICTURES cholangitis, jaundice Elevated bilirubin, ALP, transaminases Operative injury (most common) MRCP – outline biliary tree Chronic pancreatitis ERCP – diagnostic and therapeutic Common bile duct stones Acute cholangitis Management depends on the location Biliary obstruction due to and cause of stricture ü Percutaneous/ endoscopic dilatation cholecystolithiasis (Mirizzi’s syndrome) and stent placement Sclerosing cholangitis ü Surgical resection and reconstruction Cholangiohepatitis with Roux-en-Y choledochojejunostomy or Strictures of a biliary-enteric hepaticojejunostomy anastomosis Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures GALLBLADDER CARCINOMA Rare type of cancer in the elderly Cholelithiasis – most important risk factor Aggressive, poor prognosis o >3cm (large stones) with 10-fold Median survival – 6 months increased risk in cancer 5% = 5-year survival rate Factors Risk of malignancy Early gallbladder cancer Cholelithiasis 10-fold increased risk o 80-100% 5-year survival rate Polyps >1cm 25% risk Porcelain gallbladder 10% risk Cholelithiasis – most important risk factor o >3cm (large stones) with 10-fold increased risk in cancer Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLBLADDER CARCINOMA Gallbladder veins drain to adjacent liver (Segment IVB and V), where tumor invasion is common Ultrasound (70-100% sensitivity) CT Scan (Identify nodal and distant spread) MRCP assess biliary tract Image-guided biopsy Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. GALLBLADDER CARCINOMA Jayaraman, S., & Jarnagin, W.R. (2010). Management of gallbladder cancer. Gastroenterology clinics of North America, 39 2, 331-42. OUTLINE GALLSTONE DISEASE MALIGNANT NEOPLASMS OF THE BILIARY TRACT Symptomatic Cholelithiasis Gallbladder Carcinoma Acute Cholecystitis Cholangiocarcinoma Choledocholithiasis Cholangitis Gallstone Pancreatitis Gallstone Ileus BILIARY TRACT Choledochal Cyst Primary Sclerosing Cholangitis Bile Duct Strictures CHOLANGIOCARCINOMA Rare tumor arising from biliary epithelium and occur along the biliary tract Klatskin tumor (hepatic bifurcation) 50% - hilar 40% - distal 10% - intrahepatic Male predominance 50-70 years of age Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. CHOLANGIOCARCINOMA Etiology: Painless jaundice (most common) Idiopathic (most common) Usually PE is normal PCS (5-10% risk) Elevated CEA, CA 125, CA 19-9 Choledochal cyst (>129U/mL) Ulcerative colitis Biliary-enteric anastomosis Ultrasound (initial) Hepatitis B and C Chlonorchis (liver fluke) CT or MRCP (Biliary tract mapping) Typhoid carriers ERCP Nitrosamines Choledochoscopy with direct visualization and sampling of mass Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. CHOLANGIOCARCINOMA Management: q Surgical excision (potentially curative) q Location and extent of tumor dictates the approach: ü Pancreaticoduodenectomy (Whipple Procedure) (distal tumor) ü Roux-en-Y hepaticojejunostomy, cholecystectomy, gastrojejunostomy (If unresectable) ü Local tumor excision with portal lymphadenectomy, cholecystectomy, CBD excision, and bilateral Roux-en-Y hepaticojejunostomies (Type I, II) ü Liver transplantation (Type IV) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York.  ü Local tumor excision ü Portal lymphadenectomy, ü Cholecystectomy ü CBD excision ü Bilateral Roux-en-Y hepaticojejunostomies Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York.  ü Tumor resection ü Right or left hepatic lobectomy and reconstruction Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York.  ü Unresectable ü Liver transplantation Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. THANK YOU