 Gall stones

 Ca head of Pancreas
 Periampullary Ca
 Cholangiocarcinoma
 Compression by metastatic lymph nodes
 Biliary strictures
 Pancreatitis
 Age
 Sex
 Abdominal pain-site
 Duraion
 Radiation
 Character

 Flatulent dyspepsia
 Nausea and vomiting
 Haematemesis/Malaena
 Jaundice
 Itching
 Bowel habit
 Appetite
 Fever
 Charcot’s triad
 Past history
 Personal History
 Jaundice
 Scratch marks
 Pedal oedema
 Clubbing
 Skin
 Umbelicus
 Contour of abdomen
 Visible lumps
 Exceptions
 Double impaction
 Pancreatic calculus
 Oriental
cholangiohepatitis (
ductal stones
formed secondary to
liver fluke
infestation)
 Mucocele of Gb
 GB ca
 Liver
 GB
 Stomach
 Troisier’s sign
IN THE LUMEN
 Gallstone
 Parasites
 Foreign body
 Hmeobilia
 Stricture
IN THE WALL
 Congenital atresia
 Choledochal cyst
 Carolis disease
 Tumors of bile duct
 Scleosing cholangitis
OUTSIDE THE WALL
 Carcinoma head of pancreas
 Periampullary carcinoma
 Pancreatitis
 Pesudocyst
 Metastatic carcinoma
 Chronic duodenal diverticulum
Type 1 – complete obstruction
 CA Head of pancreas
 Cholangiocarcinoma
 Ligation of CBD

Type 2 – intermittent obstruction

 Periampullary carcinoma
 Choledocholithiasis
 Choledochal cyst
 Duodenal diverticulum
 Type 3 – chronic incomplete obstruction
 Sclerosing cholangitis
 Chronic pancreatitis
 Stenosed bilioenetric anastomosis

 Type 4 – Segmental obstruction

 Sclerosing cholangitis
 Cholangiocarcinoma
 Hepatodocholithiais
 Dilatation/diverticula of CBD

 Causes
 Infectious agents
 Reflux of pancreatic enzymes via long
channel
 Genetic
 Autonomic dysfunction
 Type 1 – Fusiform
 Type 2 – Saccular
 Type 3 – Choledochocele
 Type 4 – Cystic dilatation of intra &
extrahepatic bile duct
 Type 5 – Multiple intrahepatic cyst
 Type I – Cystic dilatation of CBD- MC type
 Type II – Simple diverticulum of extrahepatic
biliary tree, prox to duodenum
 Type III – cystic dilatation of intraduodenal
portion of extrahepatic CBD
 Tyoe IV A – both intrahepatic and extrahepatic
cyst
 Type IV B – Multiple extrahepatic cyst without
intrahepatic involvement
 Type V – Intrahepatic cystic disease/Caroli’s
disease
 Sandbloom’s triad – Biliary colic, obstructive
jaundice, GI bleed

 Causes:
 Trauma
 Oriental cholangiohepatits
 Hepatic neoplasm
 Choledocholithiasis
 Diagnosis – Tc99m labelled RBC scan
 Rx- Therapeutic embolisation
 Progressive painless jaundice
 Pain
 Hematemesis and malena
 Chills and fever
 Diabetes mellitus
 Courvoisier sign
ULTRASOUND
 IHBRD
 Size of CBD < 8mm
 PD dilatation – Ca HOP
 Biliary stones
 Free fluid
 Mass lesions
 Liver mets
EUS
 Arterial involvement
 FNAC
 Operability
 Size of tumor
 Lymph node status
 Hepatic mets

MRI
 For upper end of biliary system
Tumour markers CA 19-9
UPPER GI SERIES
 Widening of C loop : ca HOP
 Reverse 3 sign : Periampullary carcinoma

Biochemical
 LFT
Coagulation profile

Urine examination
 Hydration
 Nutrition
 Correction of coagulation deficiency
 Correction of anemia
SIGNS OF INOPERABILITY
 Supraclavicular nodes
 Ascites
 Blumer shelf
 Liver mets
 Peritoneal mets
 Involvement of portal vein & SMV
 Para aortic node involvement
 Whipples
 PPPD

 INOPERABLE CASES

Biopsy
Neoadjuvant chemo – 5FU Gemcitabine
Endoscopic drainage
Cholecystojejunostomy
Gastrojejunostomy
 Charcots triad – pain fever jaundice
 Reynold’s pentad – pain fever jaundice mental
confusion

 Toxic
cholangitis – emergency
sphincterotomy/transhepatic drainage

 CBD stones – Endoscopic sphincterotomy/ Lap

cholecystectomy and CBD exploration
C/I for sphincterotomy:
 Stone > 2cm
 Stenosis of bile duct proximal to sphincter
RISK FACTORS
 Sclerosing cholangitis
 Chronic intrahepatic gallstones
 Caroli’s disease
 Choledochal cyst
 Ulcerative colitis
 Liver flukes
 Type 1 – involves CHD
 Type II – Proximal CHD that extends to
bifurcation
 Type III – Growth involving one hepatic duct
 Type IV - hilar
 Surgery – 5mm clearance, node and liver
resection
 R hepatic lobectomy, hepaticojejunostomy

 C/I– lymphnode involvement/hepatic hilar

vessel involvement

 Palliative stenting/ hepaticojejunostomy

THANK YOU