Surgery

Hepatobiliary Tract Part 1: Gallbladder & Hepatobiliary Tree

Michael June C. Perez, MD
August 31, 2020

OUTLINE o Because stone block the passage of soundwaves to the

region behind them, they produce acoustic shadows. As
LABORATORY AND RADIOLOGIC INVESTIGATION ....................................... 1 shown in this picture:
Blood Test ..................................................................................................................................... 1
Transabdominal Ultrasonography............................................................................................. 1
Computed Tomography .............................................................................................................. 1
Hepatobiliary Scintigraphy or Hepatobiliary Iminodiacetic Acid (HIDA) Scanning ........... 2
Magnetic Resonance Imaging (MRI) ......................................................................................... 2
Endoscopic Retrograde Cholangiopancreatography (ERCP) ............................................... 2
Endoscopic Choledochoscopy .................................................................................................. 2
Endoscopic Ultrasound ............................................................................................................... 2
Percutaneous Transhepatic Cholangiography ........................................................................ 2

BENIGN LESIONS AND MALIGNANT TUMORS OF THE LIVER ....................... 3

Benign Liver Lesions ................................................................................................................... 3
Hepatic .......................................................................................................................................... 3
Malignant Liver Tumors .............................................................................................................. 3

Source: Schwart’z Principles of Surgery 11th edition

- Sonographic Murphy’s sign

LABORATORY AND RADIOLOGIC INVESTIGATION
o Thickened gallbladder wall, pericholecystic fluid, and local
- In the 1924, the diagnosis of gallstones was revolutionized by the
tenderness with direct pressure by the ultrasound probe
introduction of oral cholecystography by Graham and Cole
over the fundus of the gallbladder.
- In the later half of the 20th century, biliary imaging improved
o This may indicate acute cholecystitis.
dramatically
o When a stone obstructs the neck of the gallbladder, the
gallbladder may become very large or thin-walled.
Blood Test - Contracted, thick-walled gallbladder → Indicative of chronic
- As part for an evaluation of suspected diseases of the gallbladder cholecystitis.
and hepatobiliary tree, CBC and liver function test are routinely o The extrahepatic bile ducts are also well-visualized by
requested transabdominal ultrasound with no exception of the
retroduodenal portion.
Complete Blood Count - Dilation of the biliary tree in a patient with jaundice
- Increase in WBC count indicate or raise suspicion of acute o Suggests an extrahepatic obstruction as cause of jaundice
cholecystitis (infection within the gallbladder) ▪ Frequently, the site and sometimes the cause of the
obstruction can be determined by the ultrasound.
▪ Small stones in the CBD frequently get lodged at the
Liver Function Tests
distal end of it, behind the duodenum and are
- Elevated WBC count associated with other increases in the liver
therefore difficult to detect.
function such as: o A dilated CBD in ultrasound, small stones in the gallbladder
o Elevation of bilirubin, alkaline phosphatase, and and a classic clinical presentation allows one to assume
transaminases, cholangitis (infection within the biliary tree) that a stone or stones are causing the obstruction.
should be suspected. - Periampullary tumors can be difficult to diagnose on ultrasound,
o Elevation of conjugated bilirubin and a rise in alkaline but above the retroduodenal portion, the level of obstruction and
phosphatase with no transaminitis are suggestive of a the cause may be visualized quite well.
choledocholithiasis, a stricture or any distal CBD mass. - Helpful in evaluating tumor invasion and flow in the portal vein.
▪ They all present as Cholestasis (obstruction to the bile o An important guideline for adaptability of the periampullary
flow) tumor.

Transabdominal Ultrasonography Computed Tomography

- Needed for initial investigation of any patient suspected to have - Abdominal CT scan are frequently used in the work-up of
disease of the biliary tree. undifferentiated abdominal pain and thus often diagnose
o Non-invasive, painless, does not submit patients to radiation gallbladder disease.
and can be performed in critically ill patients. - Inferior to ultrasonography in diagnosing gallstones.
o Reliability and interpretation are dependent upon the skills o However, Similar in sensitivity for acute cholecystitis.
and experience of the operator. - Major application: Define the course and status of the extrahepatic
- Sensitivity and specificity of >90% in detecting gallstones. biliary tree and adjacent structures and to evaluate the
o Can also reliably detect other pathologies in the biliary tree. alternative causes of a patient’s clinical presentations.
- STONES move with changes in position while POLYPS on the other - Initial test of choice in evaluating patients with suspected
hand do not. malignancy of the gallbladder, the extrahepatic biliary system, or
o Stones are acoustically dense and reflect the ultrasound nearby organs such as the head of the pancreas.
waves back to the ultrasound transducer.

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 Surgery | Hepatobiliary Tract Part 1: Gallbladder & Hepatobiliary Tree
Hepatobiliary Scintigraphy or Hepatobiliary Iminodiacetic Acid - Diagnostic brushings for biliary stricture can be obtained at the
(HIDA) Scanning time of the procedure.
- Noninvasive evaluation of the liver, gallbladder, bile ducts and - In the hand of experts, the success rate of CBD cannulation and
duodenum that provides both an anatomic and functional cholangiography is more than 90%
information.
- The primary use of biliary scintigraphy is in the diagnosis of acute Complications
cholecystitis. - Pancreatitis (3.5%)
o appears as a nonvisualized gallbladder, with prompt filling - Bleeding
of the common bile duct and duodenum. - Perforation
- Infection (cholangitis)

Endoscopic Choledochoscopy
- small fiber-optic cameras that can be threaded through
endoscopes used during ERCP has facilitated the development of
intraductal endoscopy.
- Provide direct visualization of the biliary and pancreatic ducts.
o Increase the effectiveness of ERCP in the diagnosis of
certain biliary disease.
- Introductory endoscopy has shown to have therapeutic
applications that include:
o biliary stone lithotripsy
Figure 1. A is the normal HIDA scan which shows filling of the extrahepatic o direct stone extraction in high risk surgical patients.
biliary tree and gallbladder. Picture B in a patient with acute cholecystitis shows
- Safe and effective.
no filling of the gallbladder.

- Sensitivity and specificity are 95% for each Endoscopic Ultrasound

- False-positive results can occur in patients in a - Improved significantly in the recent years
o nonfasting state - Offers additional diagnostic utility for the work-up of biliary
o on parenteral nutrition disease.
o in the setting of gallbladder stasis, recent narcotic use, or - Requires a specialized 30° endoscope with either a radial or linear
alcoholism. ultrasound transducer at its tip.
- Filling of the gallbladder and the CBD with the late or absent filling - Results are operator dependent and requires skilled endoscopist
of the duodenum indicates an obstruction at the ampulla. but offer non-invasive imaging of the bile ducts and adjacent
- Biliary leaks as a complication of surgery, the gallbladder and the structures.
biliary tree can be confirmed and frequently localized by the - Useful in identifying choledocholithiasis and evaluation of the
biliary scintigraphy. retroduodenal portion of the bile duct and tumors near or
behind the duodenum, and their resectability.
Magnetic Resonance Imaging (MRI) - Fine-needle aspiration (FNA) of tumors or lymph nodes,
- Can generate high-resolution anatomic images of the biliary tree therapeutic injections, or drainage procedures under direct
and the pancreatic duct, liver, gallbladder and pancreas similar to ultrasonic guidance can be performed.
those obtained facute rom the CT scan.
- MRI with magnetic resonance cholangiopancreatography Percutaneous Transhepatic Cholangiography
(MRCP) - Used in the setting in which biliary can’t be accessed
o Offers a focused, non-invasive test for the diagnosis of the endoscopically, antigrade cholangiography can be performed.
biliary tract and pancreatic disease. - It is by accessing the intrahepatic bile ducts percutaneously with
o Preferred imaging modality for precise evaluation of biliary a small needle under fluoroscopic guidance.
and pancreatic duct pathology. - Through the catheter, an antigrade cholangiogram can be
▪ Reserving the endoscopic retrograde obtained and therapeutic interventions such as: can be
cholangiopancreatography for therapeutic purpose performed
only. 1. Tissue sampling
o Sensitivity (95%) and specificity (89%) in detecting 2. Biliary drain insertions
choledocholithiasis. 3. Stent placements

Endoscopic Retrograde Cholangiopancreatography (ERCP) PTC has little role in management of patients with uncomplicated
- Both diagnostic and therapeutic modality in treatment of gallstone disease but can be useful in patients with bile duct
gallbladder and pancreatic disease. strictures or tumor as it can define the anatomy of biliary tree
- The procedure requires at least IV sedation and, in some cases, proximal to the affected segment.
general anesthesia.
- Valuable for its therapeutic capabilities.
Complications
- Advantages include the ff:
o direct visualization of the ampullary region - Bleeding
o direct access to the distal common bile duct for - Cholangitis
cholangiography or choledochoscopy. - Bile leak
o Both diagnostic and therapeutic use - Other catheter-related problems
- Clearing the common bile duct of stones – biliary sphincterotomy
and stone extraction (done after ductal stones are identified on
endoscopic cholangiogram) → done to clear bile duct of the stones

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 Surgery | Hepatobiliary Tract Part 1: Gallbladder & Hepatobiliary Tree
BENIGN LESIONS AND MALIGNANT TUMORS OF THE LIVER o Prior or current use of estrogen oral contraceptives is a clear
Liver is an organ commonly involved either primarily or secondary risk for the development of liver adenomas
with vascular, metabolic, infectious and malignant processes.
Anatomy:
Benign Liver Lesions - Grossly
o Soft and encapsulated
- Occur in up to 20% of the general population
o Tan to light brown
- More common than malignant tumors
- Histologically
- Most common benign lesions are:
o Lack bile duct glands and Kupffer cells
o Cyst
o No true lobules
o Hemangioma
o Congested or vacuolated hepatocytes due to glycogen
o Hepatocellular Adenoma
deposition
o Focal Nodular Hyperplasia
o Bile Duct Hamartoma
Diagnostics:
- CT Scan
Hepatic Cyst o Sharply defined borders and can be confused with
- It can arise: metastatic tumors.
o Primary (congenital) o With venous phase contrast – hypodense or isodense
▪ Well-defined thin wall and no solid component and are o Arterial phase contrast – subtle hypervascular enhancement
filled with homogenous, clear fluid. often is seen.
▪ Simple cyst containing thin serous fluid. - MRI scans
▪ Found in about 5-14% of the population. o Hyperintense on T1-weighted images
o Secondary o Enhanced early after gadolinium injection
▪ From trauma (seroma or biloma), infection (pyogenic
or parasitic), or neoplastic disease.
Contrast agent has improved our ability to differentiate hepatic
adenoma from focal nodular hyperplasia with high degree of
Hemangioma
accuracy.
- Most common solid benign mass that occur in the liver.
- Large endothelial-lined vascular spaces and represent congenital
Complications:
vascular lesions that contain fibrous tissues and small blood
- Carries significant risk of spontaneous rupture with
vessels that eventually grow.
intraperitoneal bleeding which clinically presents as abdominal
- Mostly women and occurs in 2-20% of the population.
pain
- Large lesion – can cause symptoms as a result of compression of
- Spontaneous intraperitoneal hemorrhage (10% to 25% of cases)
adjacent organs or intermittent thrombosis
- Risk of malignant transformation to a well-differentiated HCC
- Spontaneous rupture or bleeding is rare.
- If the patient is symptomatic – surgical resection is considered
Management:
which can be accomplished by:
- Large hepatic adenomas (>4-5 cm)
o Enucleation
o Surgical resection
o Formal hepatic resection

Focal Nodular Hyperplasia

It would depend on the location and involvement of intrahepatic
- Solid benign lesion of the liver
vascular structures and hepatic ducts.
- Hyperplastic response to an anomalous artery
- More common in women of child-bearing age
Diagnostics: - Do not rupture spontaneously
- Majority can be diagnosed by liver imaging studies. - No significant risk of malignant transformation
o CT scan
▪ Large hemangiomas show asymmetrical nodular Diagnostics:
peripheral enhancement that is isodense with large - CT scan
vessels and exhibit progressive centripetal o diagnostic tool of choice
enhancement fill-in over time. o Well circumscribed lesion with a typical central scar
o MRI: - MRI Scan
▪ Hypointense on T1-weighted images o Hypointense on T1-weighted images
▪ Hyperintense on T2-weighted images o Isointense to hyperintense on T2-weighted images.
▪ With gadolinium enhancement – peripheral nodular o Lesions are hyperintense but become isointense on delayed
enhancement. imaged on gadolinium administration.

Cation should be exercised in ordering a liver biopsy if the suspected Management:

diagnosis is hemangioma. It is due to the risk of bleeding from the - Reassurance and prospective observation irrespective of size
biopsy site especially if the lesion is at the edge of the liver. - Surgical resection is recommended when the patient is
o Symptomatic
o Hepatic adenoma or HCC cannot be definitively excluded
Adenoma
- Benign solid neoplasm of the liver
Malignant Liver Tumors
- Commonly seen in premenopausal women more than 30 years of
age - Can originate from within the liver or from extrahepatic primary
- Mostly solitary site
- Risk from contraceptive use o Hepatocellular Carcinoma
o Cholangiocarcinoma
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 Surgery | Hepatobiliary Tract Part 1: Gallbladder & Hepatobiliary Tree
- It preferentially grows along the length of the bile duct often
Hepatocellular Carcinoma involving the periduct lymphatics with frequent lymph node
- 5th most common malignancy worldwide metastasis.
- High fatality rate - Surgical resection
o 3rd most common cause of cancer death worldwide. o Offers the only chance of care for cholangiocarcinoma
- Major risk factors: ▪ The location and extent of tumor dictate the operative
o Viral hepatitis (B or C) approach
o Alcoholic cirrhosis - Liver transplant
o Hemochromatosis o Recommend for multicentric lesions
o NASH
- Cirrhosis (70-90%) – associated w/hepatocarcinoma Peripheral (Intrahepatic) Cholangiocarcinoma:
- Less common than the hilar cholangiocarcinoma
Diagnostics:
- Predominately supplied by the hepatic artery. Factors Predictive of Poor Survival:
- CT scan - In patients who underwent resection
o Appears hypervascular during the arterial phase 1. Vascular invasion
o Relatively hypodense during the delayed phase due to 2. Histologically positive margins
early washout of the contrast medium by the arterial blood. 3. Multiple tumors
- MRI scan - These revealed poor 3-year survival for all the patients.
o Enhances the arterial phase after a gadolinium injection
because of the hypervascularity and because of
hypodensity in the delayed phase due to contrast washout.
o Variable on T1-weighted images
o Hyperintense on T2-weighted images
- Has the tendency to invade the portal vein in the presence of an
enhancing portal vein thrombus which is highly suggestive of
HCC.

Management:
- Treatment is complex
- It is best managed by a multi-disciplinary liver transplant team

Figure 2. For patients without cirrhosis who develop carcinoma, resection is

the treatment of choice. If the resection is not possible because of poor liver
function and the hepatocellular carcinoma meet a transplant criteria, liver
transplantation is the treatment of choice.

Cholangiocarcinoma
- Bile duct cancer (adenocarcinoma)
o It forms in the biliary epithelial cells.
- 2nd most common liver malignancy
- Subclassification:
o Peripheral (Intrahepatic) bile duct cancer
▪ Tumor mass within a hepatic lobe or at the periphery of
the liver.
o Central (Extrahepatic) bile duct cancer
▪ Hilar cholangiocarcinoma (Klatskin’s tumor)
▪ Obstructive jaundice

Hilar Cholangiocarcinoma:
- Difficult to diagnose and typically presents as a stricture of the
proximal hepatic duct
o Painless jaundice

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