biliary system l.
Skip this Video
Loading SlideShow in 5 Seconds..
Biliary system PowerPoint Presentation
Download Presentation
Biliary system

Loading in 2 Seconds...

play fullscreen
1 / 147

Biliary system - PowerPoint PPT Presentation

  • Uploaded on

Biliary system. Anatomy. Plain x ray. GB stone in 10 %. Gas in biliary tree. Gall stone ileus. Gas in GB wall. Porcilin GB. Radiological investigations Oral Cholecystography. We comment on Site Size Shape Filling Defect Function Concentration of dye contractility. Investigations.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

Biliary system

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
plain x ray
Plain x ray

GB stone in 10 %

Gas in biliary tree

Gall stone ileus

Gas in GB wall

Porcilin GB

radiological investigations oral cholecystography
Radiological investigationsOral Cholecystography
  • We comment on
    • Site
    • Size
    • Shape
    • Filling Defect
    • Function
      • Concentration of dye
      • contractility

Imaging techniques

Ultrasound this is most useful

  • Most important to show intrahepatic bile ducts dilatation
  • Measure the diameter of CBD (normal up to 7 mm)
  • Comment on the status of the GB and its stones
  • Visualize CBD diameter, stones or areas of narrowing
  • Tumors in the region of the pancreas is seen

CT (conventional or helical) competes with the U/S especially as regards the pancreatic tumors.

  • Preoperative cholangiogram
    • IV cholangiogram
    • PTC
    • ERCP
  • Intra operative
  • T tube ( post operative )
investigations for a case of obstructive jaundice
Investigations for a case of obstructive jaundice


  • ERCP is an outpatient procedure that combines endoscopic and radiologic modalities to visualize both the biliary and pancreatic duct systems.
    • Endoscopically, the ampulla of Vater is identified and cannulated.
    • A contrast agent is injected into these ducts, and
    • x-ray images are taken to evaluate their caliber, length, and course.
  • ERCP is used to
    • get a final diagnosis and
    • do biopsy of ampullary tumors, or brush cytology.
investigations for a case of obstructive jaundice19
Investigations for a case of obstructive jaundice


  • It can be also therapeutic for
    • stone extraction by Dormia basket or
    • insertion of a stent, both are preceded by sphincterotomy.
  • It has its risks
    • ascending infections,
    • perforations,
    • pancreatitis, an
    • bleeding due to sphincterotomy done routinely before CBD cannulation
congenital caroli s syndrome
Congenitalcaroli’s syndrome

congenital intrahepatic dilated bile ducts

investigations for a case of obstructive jaundice31
Investigations for a case of obstructive jaundice


  • a sensitive noninvasive method of detecting biliary and pancreatic duct stones, strictures, or dilatations within the biliary system.
  • It is also sensitive for helping detect cancer.
investigations for a case of obstructive jaundice32
Investigations for a case of obstructive jaundice

MRCP (contraindications)

Absolute include

  • the presence of a cardiac pacemaker,
  • cerebral aneurysm clips,
  • ocular or cochlear implants
  • ocular foreign bodies.

Relative contraindications include

  • the presence of cardiac prosthetic valves,
  • neurostimulators,
  • metal prostheses,
  • penile implants
investigations for a case of obstructive jaundice33
Investigations for a case of obstructive jaundice


  • performed by a radiologist using fluoroscopic guidance.
  • The liver is punctured to enter the peripheral intrahepatic bile duct system.
  • An iodine-based contrast medium is injected into the biliary system and flows through the ducts.
  • Obstruction can be identified on the fluoroscopic monitor.
investigations for a case of obstructive jaundice34
Investigations for a case of obstructive jaundice


  • It is especially useful for lesions proximal to the common hepatic duct.
  • Still, ERCP is generally preferred.
  • PTC is reserved for use if ERCP fails or when altered anatomy precludes accessing the ampulla.
investigations for a case of obstructive jaundice35
Investigations for a case of obstructive jaundice


Complications of this procedure include

  • the possibility of allergic reaction to the contrast medium.
  • peritonitis.
  • intraperitoneal hemorrhage, sepsis
  • cholangitis.
  • subphrenic abscess.
  • lung collapse.
  • Severe complications occur in 3% of cases
investigations for a case of obstructive jaundice41
Investigations for a case of obstructive jaundice
  • Endoscopic ultrasound (EUS) combines endoscopy and US to provide remarkably detailed images of the pancreas and biliary tree.
  • It uses higher-frequency ultrasonic waves compared to traditional US (3.5 MHz vs 20 MHz)
  • allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-FNA).
acute cholecystitis
Acute Cholecystitis
  • Acute obstructive (Calcular)
  • Acute Acalcaus
  • Acute emphysematous
acute obstructive calcular pathology
Acute obstructive (Calcular)(Pathology)
  • Calcular obstruction
  • GB become hyperemic, oedematous & distended
  • Chemical inflammation
    • Release of Phosphlipases
    • Act on lecithin which is a mucosal protector transforming it into
      • Lysolecithin (mucosal toxin
      • Arachidonic acid (PG precursor) (inflammation)
  • Sepsis
    • Ecoli, klebsilla & strept which occur later on
acute obstructive calcular pathology44
Acute obstructive (Calcular)(Pathology)
  • Following acute inflammation the condition end by one of the following
    • Resolution
    • Mucocele
    • Empyema
    • Gangrene And perforation
    • Bilo-enteric fistula
acute a calcular cholecystitis
Acute Acalcular Cholecystitis
  • It form 8 %
  • Risk factors are
    • Sepsis
    • Starvation
    • Prolonged TPN
    • Ileus
    • Morphine use > 6 days
acute a calcular cholecystitis46
Acute Acalcular Cholecystitis
  • Pathology is not knowen
    • Prolonged distention of GB , Bile stasis & inspissations lead to mucosal injury and vessel thrombosis
    • Hypersensitivity to concomitant antibiotics
    • Gangrene occur in 25 % of cases
acute emphysematous gb
Acute emphysematous GB
  • Caused by mixed poly-microbial infection including gas forming bacteria
  • 70% male , diabetics
  • Thrombosis of cystic artery is the cause
  • It lead tom
    • Gangrene in 75 %
    • Perforation in 15 %
clinical picture
Clinical picture
  • Patient 5 F
  • General
    • High fever with shivering
    • Nausea, vomiting & biliary dyspepsia
  • Local
    • Biliary colic
    • Tenderness
      • Murphy’s sign
      • Boa’s sign
    • Complication
clinical picture50
Clinical picture
  • The attack of biliary colic is the start with visceral type of pain (diffuse, colicky, radiating, and associated with vomiting)
  • Later on after 6 to 8 hours, the pain localizes to the right hypochondrium, and become associated with tenderness, rebound T, and rigidity and mild fever (somatic pain)
  • The presence of distended gall bladder is the hallmark of the disease, either discovered clinically or by U/S
  • In 25% of cases the bilirubin rises, due to compression of the CBD (Mirrizi syndrome) or less commonly due to an associated stone CBD
  • Serum amylase should be a routine as well as plain X ray abdomen (pancreatitis, and perforation or gas in biliary system
acute calculous cholecystitis
Acute calculous cholecystitis
  • Obstruction of GB outlet leads to chemical inflammation, which persists for 72 h then a fate of the following, will occur
    • Resolution (most common), with relief of obstruction ~>scarring and non-function of GB
    • Resolution of the inflammatory process with persistence of the obstruction (mucocele of the GB)
    • Persistence of infection (empyema of the gall bladder) with obstruction persistence
    • Gangrene and acute perforation leading to localized pericholecystic abscess or generalized frank biliary peritonitis
    • Chronic perforation with development of biliary eneteric fistula
  • Laboratory
    • Leucocytosis
    • Liver function
    • S. amylase
  • Radiological
    • Plain xray
    • US
    • Doppler US
    • HIDDA scan
    • CT scan & MRI
investigations the best is ultrasound
Investigations: the best is ultrasound
  • An ultrasound is the most common screening test.
  • It is 90-95% sensitive for cholecystitis
  • It is 78-80% specific.
  • For simple cholelithiasis, it is 98% sensitive and specific.
investigations the best is ultrasound54
Investigations: the best is ultrasound
  • Findings include gallstones or sludge and one or more of the following conditions:
    • Gallbladder wall thickening (>2-4 mm)
    • Gallbladder distention (diameter >4 cm, length >10 cm)
    • Pericholecystic fluid from perforation or exudate
    • Air in the gallbladder wall (indicating gangrenous cholecystitis)
    • Sonographic Murphy sign (86-92% sensitive, 35% specific), pain when the probe is pushed directly on the gallbladder (not related to breathing)
treatment conservative
Treatment (conservative)
  • NPO, nasogastric & IV fluids
  • Analgesic, antipyretic & spasmolytic
  • Antibilotic
    • Broad spectrum ( cephalosporins )
    • Metronidazole & aminoglycoside
  • Follow up and surgery
    • In the same admission
    • Interval cholecystectomy
treatment surgical
Treatment (surgical)
  • Urgent if
    • Doubt in diagnosis
    • Failure to improve
    • Complication
  • We perform
      • Chole-cyst-ectomy
      • retrograde Chole-cyst-ectomy
      • Chole-cyst-ostomy
      • Subtotal Chole-cyst-ectomy
      • Mini Chole-cyst-ectomy
      • Laparscopic Chole-cyst-ectomy
treatment surgical57
Treatment (surgical)
  • Established Non-progressive disease
    • Interval Chole-cyst-ectomy
    • Early chole-cyst-ectomy

Increase bile pigments


Decrease phosphlipid

&bile salts







cholesterol stone
Cholesterol stone
  • 75% of stones formed in sterile GB (10% infection)
  • Protein matrix
  • cholesterol (70%)
  • bile pigment
  • Ca carbonate
  • Ca palmitate (Ca salts deposited at periphery, their amount determine the radiolucency)
cholesterol stone61
Cholesterol stone
  • Two types
    • Pure cholesterol
      • Oval or rounded
      • mamillated or mullbery-surfaced
      • pale yellow in color
      • solitary big size (100% cholesterol rounded)
    • 60% cholesterol (mixed)
      • Multiple mediums sized (60% cholesterol, faceted)
      • brownish polished surface
gall stones64
Gall stones


formation involves 7 processes
Formation involves 7 processes
  • Super saturation with cholesterol
  • Incomplete transfer of cholesterol from vesicles to micelles
  • Formation of vesicles with high cholesterol
  • Aggregation and fusion of unstable vesicles
  • Cholesterol crystallization (mucin is a nucleating agent)
  • Biliary sludge formation (mucin+ cholesterol+ Ca+pigment ~precursor of stones)
  • Stone growth
black pigment stone
Black Pigment Stone
  • 25% of stones.
  • It is common in cirrhotics, after terminal ileum resection and in hemolytic diseases. Formed in a sterile GB (20% infection rate)
  • Composed of bilirubin polymer without Ca palmitate and +cholesterol (25%)+matrix of organic material
  • Usually multiple, small, irregular, dark green or black in color
  • Hard in consistency and cut surface is layered
  • Formation
    • Elevated concentration of mono-conjugated bilirubin
    • lower bile salt concentration is the usual constitution in forming patients
    • yet the exact pathogenesis is not known
brown pigment stone
Brown Pigment Stone
  • Rare ductal stones caused by infection by gram -ve bacteria releasing B glucuronidase releasing free bilirubin
  • Composed mainly of
    • Ca bilirubinate,
    • Ca palmitate + small amounts of cholesterol
    • matrix of organic material
  • Amorphous soft stones
gall stone disease
Gall stone disease
  • Symptom less
    • no interference
    • interference in
      • Diabetics
      • Acromegalic
      • Calcified
      • Patient under go surgical intervention
  • Symptomatic
    • Chronic cholecystitis
    • Acute biliary colic, acute cholecystitis
    • Jaundice
clinical presentations
Clinical presentations
  • Acute cholecystitis
  • Empyema of the gallbladder
  • Mucocele of the gallbladder
  • Biliary colic
  • 'Flatulent dyspepsia'
  • Mirrizi's syndrome
  • Obstructive jaundice
  • Pancreatitis
  • Acute cholangitis
chronic calcular cholecystitis
Chronic calcular cholecystitis

Clinical picture

  • Recurrent attacks of epigastric or right hypochondrial pain (persistent pain)
  • May be attacks of severe biliary colic
  • Nausea &vomiting
  • Flatulent dyspepsia with intolerance to fatty meals
  • Tenderness in right hypochondrium (Murphy’s
Treatment :
  • Cholecystectomy either conventional or laparoscopic is the ideal treatment for symptomatic patients.
  • Patients with asymptomatic gall stones can be left without surgery specially if cirrhotics.
  • However patients with a calcified or porcelain gallbladder should consider elective cholecystectomy due to the increased risk of carcinoma (25%).
laparoscopic cholecystectomy lc
Laparoscopic cholecystectomy (LC)
  • Shown to be equally as effective as open cholecystectomy in controlled trials
  • Pre-operative ERCP is indicated if:
    • Recent jaundice
    • Abnormal liver function tests
    • Significantly dilated common bile duct
    • Ultrasonic suspicion of bile duct stones
  • Indication
    • Trauma
    • Inflammation
      • Acute & chronic
      • Mucocele
      • empyema
    • Tumor
    • Torsion
    • As a part of other operations
  • Incisions
    • Subcostal (Kocher’s)
    • Upper right paramedian
    • Right upper transverse
    • Upper midline
  • Preliminary exploration
    • Signs of cholecystitis
    • Associated pathology
      • Saint’s triade
      • Welkie’s triade
      • Pancrease
      • Stone in CBD

Saint’s triade

Welkie’s triade

  • Packing of the field & retractors

GB is grasped

Separation of GB



Identification of Calot’s

operative complications
Operative complications
  • Injury to important structure
    • Common bile duct injury:
      • observed more frequently in the laparoscopic approach.
      • Iatrogenic common bile duct injury often results from a combination of inexperience of the surgeon, the presence of anomalous biliary anatomy, and acute inflammation.
    • Duodenum injury
    • Pancreatic and liver injury
  • Ligation of Rt hepatic artery
  • Primary hge
    • Injury of cystic artery
    • Injury of Rt hepatic
    • Injury portal vein
    • GB bed
post operative complications
Post operative complications
  • General
    • Chest & abdomen
    • DVT
    • Infection:
      • Spillage of stones into the peritoneal cavity during cholecystectomy increases the risk of infection and abscess formation.
      • Wound infections also are possible but are less common in the laparoscopic approach..
post operative complications91
Post operative complications
  • Local
    • Bleeding:
      • Reactionary slipped ligature
      • 2 ry hge if infection which may lead to collection above IVC ( Waltman- Walter syndrome)
    • Ligation of
      • CBD or CHD
      • Hepatic artery
    • Biliary peritonitis
    • Biliary fistula
    • Subphrenic collection
    • Postcholecystectomy syndrome
post cholecystectomy syndrome
Post cholecystectomy syndrome
  • Organic causes
    • Long stump of cystic duct
    • Missed stone
    • Stricture
    • Stenos is of sphincter of Oddi
  • Non organic causes
    • Psycho-somatic
    • Biliary dyskinesia
long stump of cystic duct
Long stump of cystic duct
  • If stone is formed
    • Stump must be excised with
    • Stone extraction
  • If no stones
    • symptomatic treatment
missed stone after cholecystectomy
Missed stone after cholecystectomy
  • Confirm diagnosis by US & ERCP
  • Minimal invasive
    • ERCP sphincterectomy & stone extraction by Dormia Basket
    • PTC then choledochoscpic extrction
  • Surgical
    • Supradoudenal choledochotomy
    • Transdoudenal sphincteroplasty
  • Minimal invasive by stent insertion
  • Surgical
    • Roux en Y choledocho jujunostomy
    • Roux en Y hepatico jujunostomy
post cholecystectomy syndrome100
Post cholecystectomy syndrome
  • Organic causes
    • Long stump of cystic duct
    • Missed stone
    • Stricture
    • Stenos is of sphincter of Oddi
  • Non organic causes
    • Psycho-somatic
    • Biliary dyskinesia
post cholecystectomy syndrome101
Post cholecystectomy syndrome
  • Stenos is of sphincter of Oddi
    • Endoscopic papillotomy and sphincterotomy
    • Sphincteroplasty
    • Choledocho doudenotomy
  • Biliary dyskinesia
    • Endoscopic papillotomy and sphincterotomy
  • GB stone (commonest)
  • Primary stones of CBD usually (Brown)
    • Parasites
    • Stasis
    • FB
    • cholangitis
clinical picture104
Clinical picture
  • Symptom less 20 %
  • Symptoms
    • Charcot’s triade
      • Jaundice
      • Pain
      • Fever
    • Raynaud’s pentale
      • Charcot’s triade
      • Hypotension
      • Altered mental status
  • Laboratory
    • CBC
    • Liver function
    • urine
  • Radiological
    • US
    • ERCP
    • MRCP
    • PTC
management of stone cbd
Management of stone CBD
  • Support liver by correction of the general condition by I.V. fluids for hydration
  • Support kidney by Mannitol (hypotension and hyperbilirubinemia together causes renal shut down)
  • Prevent infection by antibiotics,
  • Prevent bleeding by correction of the avitaminosis K by parentral vitamin administration
concurrent common bile duct and gallbladder stones
Concurrent common bile duct and gallbladder stones
  • Preoperative ERCP, with clearance of the common bile duct, followed by LC
  • Open cholecystectomy and common bile duct exploration
  • Combined laparoscopic-endoscopic management:
    • Endoscopic sphincterotomy and stone extraction are performed on the operation table
    • after the surgeon has passed a guidewire through the cystic duct into the duodenum
    • to help the endoscopist because the procedure is performed with the patient in the supine position.
  • LC, with postoperative ERCP
management of a case of stone cbd
Management of a case of stone CBD

Minimal invasive

  • Endoscopic extraction of calculi followed by cholecystectomy whether surgical or most commonly laparoscopic
  • PTC which provide drainage and subsequent choledochoscopy & stone extraction
management of a case of stone cbd109
Management of a case of stone CBD
  • Conventional choledochtomy
    • Chole cystectomy and supra doudenal choledochtomy choledocholithotomy (exploration of the common bile duct)
    • Trans doudenal sphincterotomy
    • Choledocho douden ostomy
indications of common bile duct exploration supra doudenal choledochtomy
Indications of common bile duct exploration (supra doudenal choledochtomy)
  • Preoperative
    • confirmation of the presence of CBD stones (U/S, ERCP, or operative cholangiography)
    • Jaundice or history of jaundice
    • History of pancreatitis (although it is usually due to a passing stone)
  • Operative
    • Stone palpable in CBD
    • Dilated CBD with thick lusterless fibrous wall, with mud inside
    • Dilated cystic duct specially if there is multiple small stones in the gall bladde
  • Postoperative
    • Surgical Jaundice
management of a case of stone cbd112
Management of a case of stone CBD

T tube insertion which should be

  • Widest possible diameter
  • Latex or red rubber (never plastic)
  • Exist from one side of the choledochotomy wound
  • Horizontal limb is cut to lie below the carina and above the common channel
  • Vertical limb comes out straight from the abdomen
  • T tube cholangiography is done on the 4 th days and tube is extracted at the 10-12 days after 24-hour occlusion without problems (fever, leakage, or pain)
management of stone cbd114
Management of stone CBD

Sphincterotomy or sphincteroplasty done In the presence of

  • stenosed termination of CBD or
  • an impacted stone in its lower end that cannot be extracted from the choledochotomy wound

the ampulla is attacked through a duodenal incision and the ampulla should undergo either sphincterotomy or sphincteroplasty at 10 or 11-oclock positions to avoid pancreatic duct injury

management of a stone cbd
Management of a stone CBD

Chole docho duodenostomy is done (in the following situations)

  • In dilated CBD (more than one cm)
  • In case there is multiple stones (> 4 stones in CBD) because of the high possibility of missing a stone inside
  • Presence of intrahepatic biliary stones
  • Stricture of the lower end of CBD
missed stone after cbd exploration
Missed stone after CBD exploration
  • Confirm diagnosis bt US & ERCP
  • Wait for 6 weeks
  • Hydrostatic pressure
  • Minimal invasive
    • ERCP sphincterectomy & stone extraction by Dormia Basket
    • PTC then choledochoscpic extrction
  • Surgical
    • Supradoudenal choledochotomy
    • Transdoudenal sphincteroplasty
  • Pre-hepatic (Hemolytic)
  • Hepatic
  • Post hepatic (Obstructive)
pre hepatic hemolytic
Pre-hepatic (Hemolytic)
  • Congenital abnormal
    • Shape
      • spherocytosis,
      • eleptocytosis
    • Hb
      • thalssemia,
      • sickle cell
    • Enzymes
      • G6 PD,
      • pyruvate kinase
pre hepatic hemolytic120
Pre-hepatic (Hemolytic)
  • Acquired
    • Immune hemolytic
      • Collagenic SLE, Rheumatoid
      • Tumor lekemia, lymphoma
      • Infections malaria, syphilis
      • Drugs penicillin tetracycline, quinidine, aSPIRIN
    • Non immune
      • Septicemia
      • Burn
      • Metal poisoning
      • Mismatch blood transfusion
      • Haematoma
      • Snake venum
  • Acute
    • Viral
    • Amoebic or bacterial
    • Alcoholic
    • Liver cell necrosiis
    • Drugs
      • Direct hepatotoxic
        • A antibiotics (Tetracycline),
          • Analgesic (salycilate, paracetamol)
          • Antihelminthic carbon tetra chloride
          • Anaesthestics fluthane
          • Arsenic
    • Drugs
      • Direct hepatotoxic
        • B benzidine dervative TNT
        • C cytotoxic 5FU
      • Intra hepatic cholestasis
        • Non sensitivity methyl testosterone
        • Sensitivity neomercazole, thiuracil, chloropromazine
        • Hypersensitivity PASA
  • Chronic
    • Chronic active
    • Cirrhosis
    • Primary hepatic cirrhosis
    • Space occuping lesions
obstructive jaundice etiology
Obstructive jaundice (Etiology)
  • Common
    • Common bile duct stones
    • Carcinoma of the head of pancreas
    • Malignant porta hepatis lymph nodes
  • Infrequent
    • Ampullary carcinoma
    • Pancreatitis
    • Liver secondaries
obstructive jaundice etiology124
Obstructive jaundice (Etiology)
  • Rare
    • Benign strictures - iatrogenic, trauma
    • Recurrent cholangitis
    • Mirrizi's syndrome
    • Sclerosing cholangitis
    • Cholangiocarcinoma
    • Biliary atresia
    • Choledochal cysts
calcular obstruction
Calcular obstruction
  • Intermittent (can be progressive if stone is impacted)
  • Usually no reaching high levels
  • Pain is colicky in nature, and typical for biliary colic
  • G.B not palpable except very rarely if its neck is obstructed too (double stone)
malignant obstruction
Malignant obstruction
  • Progressive except very rarely in ampullary tumors where sloughing can give temporary decrease
  • Usually reaching high levels
  • Pain is constant and referred to the back in pancreatic tumor, while it is absent in CBD tumors
  • G.B is palpable except in Klatskin tumors
complications of obstructive jaundice
Complications of obstructive jaundice
  • Ascending cholangitis
    • Charcot's triad is classical clinical picture which is formed of intermittent pain, jaundice and fever
    • Cholangitis can lead to hepatic abscesses
    • Need parenteral antibiotics and biliary decompression
    • Operative mortality in elderly of up to 20%
complications of obstructive jaundice131
Complications of obstructive jaundice
  • Clotting disorders
    • Vitamin K required for gamma-carboxylation of Factors II, VII, IX, XI
    • Vitamin K is fat-soluble. No absorbed. So it needs to be given parenterally
    • Urgent correction will need Fresh Frozen Plasma
    • Also endotoxin activation of complement system
complications of obstructive jaundice132
Complications of obstructive jaundice
  • Hepato-renal syndrome
    • Poorly understood
    • Renal failure post intervention
    • Most probably due to gram negative endotoxinaemia from gut
    • Preoperative lactulose may improve outcome by improving altered systemic and renal haemodynamics
  • Drug Metabolism
    • Half-life of some drugs prolonged. (E.g. morphine)
    • Impaired wound healing.
investigations for a case of obstructive jaundice133
Investigations for a case of obstructive jaundice


  • Raised
    • Direct bilirubin (in most of the cases the indirect bilirubin also rises due to hepatic cellular malfunction).
    • Alkaline phosphatase
    • Gamma glutamyl transferase
    • 5 nucleotidase
investigations for a case of obstructive jaundice134
Investigations for a case of obstructive jaundice


  • Mild elevation or normal
    • SGOT & SGPT (these are shooting in viral hepatitis)
  • Slightly depressed or normal
    • Prothrombin time (due to avitaminosis K)
    • Urine urobilinogen
investigations for a case of obstructive jaundice135
Investigations for a case of obstructive jaundice

Imaging techniques

  • Ultrasound this is most useful
  • CT (conventional or helical) competes with the U/S especially as regards the pancreatic tumors.
  • ERCP
  • MRCP
  • PTC
  • EUS
treatment for cholangiocarcinoma of cbd
Treatment for cholangiocarcinoma of CBD


  • Plastic stent insertion through ERCP
  • Stent insertion through percutanous transhepatic route
  • Self-expanding stainless steel wire biliary endoprosthesis is new modality with high patency rate, and less infection rate
treatment for cholangiocarcinoma of cbd140
Treatment for cholangiocarcinoma of CBD


  • Bypass surgery
    • Round ligament approach for Klatiskin tumors (on condition that the carina is permitting right to left communication)
    • Hepatico jujenostomy for middle and low tumors
    • Cholecystojujenostomy for low tumors.
    • usually we add gastrojujenostomy and enteroanastomosis (triple anastomosis) for pancreatic head tumors
treatment for cholangiocarcinoma of cbd141
Treatment for cholangiocarcinoma of CBD

For operable cancers

  • For Klastiskin tumor,
    • segment IV excision provides good access to the confluence
    • allows good proximal clearance and facilitates hepaticojujenostomy
  • For middle tumors excision of the tumor from just below the carina to the duodenum is done with hepaticojujenostomy
  • For distal tumors. Whipple operation is done
biliary stricture etiology
Biliary strictureEtiology
  • Congenital (biliary atresia)
  • Traumatic (most important, and usually follow cholecystectomy)
    • Complete ligation of CBD
    • Narrowing of the duct by partial inclusion in a ligature
    • Ischemia of the duct, or diathermy injury
  • Inflammatory Sclerosing cholangitis (multiple strictures separated by normal or dilated segments).
  • Cholangiocarcinoma
sclerosing cholangitis
Sclerosing cholangitis
  • PSC (primary sclerosing choangitis ) is a chronic cholestatic biliary disease characterized by non suppurative inflammation and fibrosis of the biliary ductal system.
  • The cause is unknown but is associated with autoimmune inflammatory diseases such as chronic ulcerative colitis.
sclerosing cholangitis146
Sclerosing cholangitis
  • Most patients present with fatigue and pruritus and, occasionally, jaundice.
  • The natural history is variable but involves progressive destruction of the bile ducts, leading to cirrhosis and liver failure.
biliary stricture
Biliary stricture
  • Investigations used are similar to those used in any case of obstructive jaundice (U/S then CT, ERCP, MRCP or PTC
  • Treatment is centered on creating a biliary enteric anastomosis with mucosa-to-mucosa sutures without compromising the blood supply of any of the ends.