BENIGN CONDITION OF BILIARY APPARATUS

1. SURGICAL ANATOMY
2. CHOLEDOCHAL CYSTS
3. BILIARY ATRESIA
4. GALLSTONE
5. MIRIZZI SYNDROME
6. CHOLEDOCHOCHOLITHIASIS
7. OBSTRUCTIVE JAUNDICE
8. CBD STRICTURE
SURGICAL ANATOMY
BILE

1. Daily up to 1000 ml of bile is secreted from the liver which contains water (98%), bile salts, bile
pigments, fatty acids, lecithin, cholesterol, and electrolytes with a pH more than 7.0.

2. Main function of gallbladder is to concentrate and store the bile. Capacity of gallbladder is 40–50 ml.

3. Bile salts form micelle which makes cholesterol soluble. Bile salts (i.e. salts of cholic and
chenodeoxycholic acids)

4. Primary Bile Acids= (cholic acid and chenodeoxycholic) acid which are formed by cholesterol from the
liver along with amino acids

5. Secondary Bile Acids= bacterial metabolites (deoxycholate and lithocholate) of primary bile acids
formed in the colon

6. What do they do? They help excrete cholesterol, aid in fat digestion and absorption of fat, cholesterol
and fat-soluble vitamins in the intestines
CHOLEDOCHAL CYSTS

1. It is defined as isolated/focal or combined/diffuse congenital dilatation of extra or intrahepatic biliary

tree.

2. It is congenital cyst with partial or complete weakness of the CBD biliary wall.
Types of Choledochal Cysts (Todani Modifica-
tion of Alonso-Lej Classification)

Type I: Dilatation of extrahepatic biliary tree (60%).

Type II: Diverticulum of extrahepatic biliary tree (5%).

Type III: Choledochocele—cystic dilatation of intraduo-

denal part of CBD (5%).

Type IV: Dilatation of extra- and intrahepatic or multiple

parts of extrahepatic biliary tree (30%).

Type IVa: Dilatation of extrahepatic and intrahepatic

biliary tree. It is 2nd most common.

Type IVb: Dilatation of multiple sections of the extra-

hepatic bile duct.

Type V: Dilatation of the only intrahepatic biliary tree

Diagnosis

US abdomen—unilocular cyst mainly in infants.

CT scan—mainly to see intrahepatic biliary system.

Treatment

Resection of extrahepatic biliary tree with removal of chole-dochal cyst along with cholecystectomy and
Roux-en-Y hepaticojejunostomy is the ideal treatment for choledochal cyst especially types I, II and IVb.
BILIARY ATRESIA

It may be either due to viral infection

or defective embryogen-
esis resulting in fibrosis of extra- and
intrahepatic biliary tree.

Classification
Correctable—10%.
Non Correctable—90%.

Type I: Atretic CBD—10%

Type II: Atretic CBD and common
hepatic duct
Type III: Atretic CBD, common
hepatic duct and right and left
hepatic ducts—88%
Diagnosis

1. Liver function test—conjugated hyperbilirubinaemia.

2. US abdomen shows triangular cord, tubular echogenicity extending above the bifurcation of the
portal vein which is more than 4 mm thick—diagnostic.
3. MRCP—100% accuracy.

Treatment
4. In correctable cases: Roux-en-Y jejunal anastomosis.
5. In non correctable cases, hepatic portal jejunostomy (Kasai operation).
6. Liver transplantation is becoming more popular in biliary atresia—ideal.
7. Presently Kasai (1974) portoenterostomy is done (in 8 weeks) as a preliminary procedure followed
by liver transplantation eventually.
GALLSTONES

Types

1. Cholesterol stones (Cholesterol solitaire—radiating crystal-line appearance) are 6% common, often

solitary.

2. Mixed stones are 90% common. It contains cholesterol, calcium salts of phosphate carbonate, palmitate,
proteins, and are multiple faceted.

3. Pigment stones are small, black or greenish black, multiple. Often they can be sludge like.

4. Common in “Fat, Fertile, Forty, Flatulent, Female”. Common in western countries and in north India.
Pathogenesis

I. Metabolic:
II. Infections and Infestations:
III. Bile stasis:
IV. Increased bilirubin production

Effects of the Gallstones

i. Silent asymptomatic stones occur in 10% of males and 20% of females.

ii. Biliary colic with periodicity,
iii. Acute cholecystitis.
iv. Chronic cholecystitis.
v. Empyema gallbladder.
vi. Perforation causing biliary peritonitis or pericholecystitic abscess.
vii. Mucocele of gallbladder.
viii. Limey gallbladder.
ix. Carcinoma gallbladder.

In cbd
Management of Gallstones

1. Ultrasound abdomen (gallstones are seen with posterior acoustic shadowing); plain X-ray abdomen;
LFT; total WBC count.
2. CT scan abdomen to rule out presence of CBC stones
3. Laparoscopic cholecystectomy ideal.
4. Open cholecystectomy is done through right subcostal Kocher’s incision. Open approach is used if
patient is not fit for laparoscopic surgery (anaesthesia);
MIRIZZI SYNDROME

1. In Mirizzi syndrome, gallstone impacts in the gallbladder wall and compresses it causing pressure
necrosis which further gets adherent to CHD/CBD wall. It eventually causes compression and later
occasionally leads into cholecystocholedochal fistula. It occurs either

2. from Hartmann’s pouch into CHD/CBD (common) or from fundus of gallbladder into the CBD.

3. Investigations – USG, CT scan, ERCP/MRCP to delineate duct anatomy, dilatation of intrahepatic

biliary system with block at CHD is found.

4. Mirizzi syndrome is suspected on CT scan, but usually identified on table. It needs cholecystectomy;
on table cholangiogram; and exploration of CBD. It often needs Roux-en Y hepaticojejunos-tomy.
CHOLEDOCHOLITHIASIS

It is stones in the CBD and biliary tree.

Classification
i. Primary—Rare—brown pigment stones.
ii. Secondary—Common—black pigment stones/cholesterol
stones. It is seen in 15% of gallstone disease; 75% are
cholesterol stones, 15% are pigment stones.

Charcot’s triad of ascending cholangitis

Intermittent pain (may be colicky)
Intermittent fever
Intermittent jaundice
Investigations

1. US abdomen may show gallstones, dilated CBD >8 mm

which suggests biliary obstruction. Sensitivity for CBD
stones is only 65%.

2. MRCP is noninvasive investigation which delineates biliary

tree anatomy and pathology clearly; but it is not therapeutic.

3. ERCP identifies pathology, site of block, stones, etc. (95%

sensitivity). It is therapeutic also for extraction of biliary
stones and stenting.

Treatment

4. ERCP—Therapeutic,
SURGICAL JAUNDICE (Obstructive Jaundice)

Definition

1. It is the jaundice that develops due to biliary obstruction, partial or complete or intermittent. It causes
conjugated hyperbilirubinaemia.

2. Normal serum bilirubin level is 0.2–0.8 mg%. Scleral icterus is visible when serum bilirubin level
exceeds 2.5 mg%.
Benjamin’s (1983) classification of biliary obstruction

Type 1: Complete obstruction Type 3: Chronic complete obstruction

Tumours—pancreatic, cholangiocarcinoma Bile duct stricture

CBD ligation—iatrogenic Congenital
Primary/secondary liver tumours Traumatic
Post-radiotherapy
Type 2: Intermittent obstruction Chronic pancreatitis
Cystic fibrosis
Choledocholithiasis
Periampullary tumour Type 4: Segmental obstruction
Choledochal cyst
Bile duct papilloma Traumatic
Hemobilia Sclerosing cholangitis
Duodenal diverticula Cholangiocarcinoma, intrahepatic biliary stones
(hepatolithiasis)
Investigations for Obstructive Jaundice
Treatment of Obstructive Jaundice

1. CBD stones—ERCP stone removal, choledocholithotomy, transduodenal sphincteroplasty,

choledochojejunostomy or choledochoduodenostomy.

2. Carcinoma periampullary or head of pancreas—Whipple’s operation or triple bypass or ERCP

stenting.

3. Biliary stricture—Stenting, choledochojejunostomy, Roux-en-Y hepaticojejunostomy.

4. Klatskin tumour—Radical resection or palliative stenting.

5. Biliary atresia—Kasai’s operation or liver transplantation.

6. Choledochal cyst—Excision, hepaticojejunostomy, mucosal resection.

CBD STRICTURES (BILIARY
STRICTURES)

Causes
1. Postoperative (80% common)
2. Inflammatory: Stricture following recurrent
attacks of cholangitis
3. Malignant: Due to cholangiocarcinoma.
4. Traumatic.

Investigations
x Ultrasound abdomen.
x Liver function tests.
x ERCP.
x On table cholangiography.
x MRCP.
Treatment
x ERCP stenting.
x Choledochoduodenostomy or jejunostomy.
x Roux-en-Y hepaticojejunostomy—ideal.
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