SURGERY II

Saint Louis University School of Medicine MMXXII

M.02 GALLBLADDER AND EXTRAHEPATIC BILIARY SYSTEM
Dr. Baldovino | October 13, 2020
OUTLINE
I. INTRODUCTION
II. GALLBLADDER ANATOMY
III. EXTRAHEPATIC BILIARY SYSTEM
IV. GALLBLADDER PHYSIOLOGY
V. DIAGNOSTIC MODALITIES
VI. GALLSTONE DISEASES
VII. CHOLANGITIS
VIII. BILIARY PANCREATITIS
IX. CHOLANGIOHEPATITIS
X. CHOLEDOCHAL CYST
XI. READING ASSIGNMENT

I. INTRODUCTION Figure 2. Gallbladder and its surrounding relations.

B.4. NECK
 From the upper infundibulum, it tapers to become the cystic
duct.
 Contains the Spiral valves of Heister (Spiral folds in Figure 1),
which are the infoldings in the wall of the cystic duct and are
responsible for maintaining its patency.
o Cause difficulty in cases of Transcystic Introperative
cholangiogram, or catheterization or probing of the
cystic duct

C. CYSTIC DUCT
 About 1-inch long and extends from the neck of the gallbladder to
the porta hepatis; here it joins the hepatic duct to form the
common bile duct.
 Only extrahepatic bile duct that is tortuous in appearance
 Usually passes downward for a short distance with the common
hepatic duct before joining it, but the cystic duct may present
Figure 1. Gallbladder, extrahepatic bile ducts, and pancreatic duct.
many variation or anomalies
 The gallbladder and the extrahepatic biliary tree include:  Variations of the cystic duct impose a surgical challenge in
o Entire common bile duct – starts from the common hepatic preventing bile duct injuries in gallbladder procedures.
duct to the Ampulla of Vater
o Gallbladder – pear-shaped organ

II. GALLBLADDER ANATOMY

A. GALLBLADDER
 Pear-shaped sac that is 7-10 cm long and has an average
capacity of 30-50 mL
o The presence of a distal obstruction at the level of the cystic
duct markedly distends the gallbladder; it can contain up to
300 mL of bile.
 Located at segments IVb and V of the liver

B. FOUR ANATOMIC AREAS OF THE GALLBLADDER

B.1. FUNDUS
 Rounded, blind end that projects 1 to 2 cm beyond the liver
 Sometimes forms a kink or notch, called the Phrygian cup
 Contains most of the smooth muscles of the organ
Figure 3. Cystic duct variations. A. Low junction between the cystic
B.2. BODY duct and common hepatic duct. B. Cystic duct adherent to the
 Main part and main storage area of the gallbladder that lies common hepatic duct. C. High junction between the cystic and the
on the liver fossa common hepatic duct. D. Cystic duct drains into right hepatic duct. E.
 Contains most of the elastic tissues, thus allowing distention Long cystic duct that joins common hepatic duct behind the
duodenum. F. Absence of cystic duct. G. Cystic duct crosses posterior
B.3. INFUNDIBULUM (HARTMANN’S POUCH) to common hepatic duct and joins it anteriorly. H. Cystic duct courses
 Located between the body and neck anterior to common hepatic duct and joins it posteriorly.
 Important landmark for cystic duct identification
D. BLOOD SUPPLY OF THE GALLBLADDER
 Bowed down towards the first portion of the duodenum by the
right edge of the lesser omentum, called the D.1. CYSTIC ARTERY
cholecystoduodenal ligament (See figure 2B)  Divided into an anterior and posterior division
 The course may vary, but it is usually found within the
o The cholecystoduodenal ligament is opened in order to identify
the cystic duct. hepatocystic triangle or Triangle of Calot
o Triangle of Calot – bounded by the cystic duct, common
hepatic duct, and the liver margin
 Variations in the cystic artery also pose a challenge in gallbladder
surgeries.

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Saint Louis University School of Medicine MMXXII
4. INTRADUODENAL BILE DUCT
 Joined on its left side by the main pancreatic duct
 Contains the Ampulla of Vater
o Ampulla of Vater – opens into the duodenum on the summit
of an elevation known as the duodenal papilla

B.2. BLOOD SUPPLY OF THE COMMON BILE DUCT

 Derived from the gastroduodenal artery and right hepatic
artery, with major trunks running along the medial and
lateral walls of the common bile duct, referred to as the 3
o’clock and 9 o’clock position
o This orientation makes the common bile duct more prone to
Figure 4. Blood supply of the gallbladder and the Triangle of Calot.
ischemia in bile duct injuries.
Figure 5. Variations of the cystic  In stone extractions, a longitudinal incision of the common
artery. A. Cystic artery from bile duct is performed.
right hepatic artery, about 80% o This prevents injury to the medial and lateral blood
to 90%. B. Cystic artery off the supply of the common bile duct.
right hepatic artery arising from
the superior mesenteric artery B.3. AMPULLA OF VATER
(accessory or replaced), about  Terminal portion of the common bile duct
10%. C. Two cystic arteries, one  Reservoir of the union of the intraduodenal bile duct and
from the right hepatic, the other the main pancreatic duct, forming an opening known as the
from the common hepatic artery, duodenal papilla
rare. D. Two cystic arteries, one  This provides access in performing endoscopic retrograde
from the right hepatic, the other cholangiopancreatography for extracting stones in the
from the left hepatic artery, rare. common bile duct.
E. The cystic artery branching VARIATIONS IN THE UNION OF THE BILE AND PANCREATIC
from the right hepatic artery and DUCTS
running anterior to the common SHORT COMMON - Most common
hepatic duct, rare. F. Two cystic CHANNEL - Common bile duct and main pancreatic duct
arteries arising from the right unite before there is an opening in the
hepatic artery, rare. Ampulla of Vater
NO COMMON Independent openings of both ducts in the
III. EXTRAHEPATIC BILIARY SYSTEM CHANNEL Ampulla of Vater
A. COMMON HEPATIC DUCT LONG COMMON Pathophysiology of choledochal cyst formation:
 Hepatocytes  canaliculi  biliary ductules  left and right CHANNEL retrograde reflux of pancreatic juices in
hepatic ducts the common bile duct
 ≤1 inch long
 Formed in the porta hepatis by the union of the right and
left hepatic ducts

B. COMMON BILE DUCT

 Common hepatic ducts and cystic duct  common bile duct (CBD)
 Also known as the ductus choledocus
 3-4 inches long
 Anatomically considered as the continuation of the common
hepatic duct
 Surgically considered as the union of the cystic duct and the
common hepatic duct
Figure 6. Variations in the union of bile and pancreatic ducts.
 Begins at the porta hepatis  descends on the free margin of the
lesser omentum  ends on the second portion of the duodenum in
IV. GALLBLADDER PHYSIOLOGY
its posteromedial surface
 Acts as a storage depot for bile
B.1. FOUR PORTIONS OF THE COMMON BILE DUCT
A. HORMONAL STIMULI OF THE GALLBLADDER
1. SUPRADUODENAL BILE DUCT
 Mediated by cholecystokinin
 Superior to the duodenum
 In between meals, when the Sphincter of Oddi is closed,
 1 inch long
bile produced by the hepatocytes enters the gallbladder
 Descends in the right margin of the lesser omentum
(gallbladder filling).
(cholecystoduodenal ligament) to the right hepatic artery and
 During storage, a large portion of the water in bile is
anterior to the portal vein
absorbed through the walls of the gallbladder, so that
 Part that is felt by a finger placed in the foramen of Winslow
gallbladder bile is 5-10 times more concentrated than that
originally secreted by the liver.
2. INFRADUODENAL BILE DUCT
 When food enters the duodenum  gallbladder contracts and the
 Inferior to the duodenum
Sphincter of Oddi relaxes  bile enters the small intestine
(gallbladder emptying)
3. RETRODUODENAL BILE DUCT
o Response is mediated by the secretion of cholecystokinin-
 Also known as the intrapancreatic bile duct
pancreatozymin (CCK-PZ) from the intestinal wall
 Most vascular portion
 Situated behind the duodenum

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 Rim sign – identified in about 20-30% of patients with
acute cholecystitis. The positive predictive value for acute
cholecystitis is about 95%.

Figure 7. Physiology of the gallbladder. Figure 9. HIDA scanning. A. Normal HIDA scan showing filling of the
extrahepatic biliary tree and gallbladder (white arrow). B. HIDA scan
V. DIAGNOSTIC MODALITIES with acute cholecystitis showing no filling of the gallbladder.
A. BLOOD TESTS
 Increased WBC count – may indicate or raise a suspicion of D. COMPUTED TOMOGRAPHY
cholecystitis or cholangitis  Utilized in the suspicion of malignancy
 Inferior to ultrasound in the diagnosis of stones
CHOLANGITIS CHOLESTASIS
- obstruction to bile flow
E. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
Elevated bilirubin, alkaline Elevated conjugated bilirubin,
 Little role in uncomplicated gallstone disease
phosphatase (ALP), serum alkaline phosphatase (ALP)
 Useful in identifying bile duct strictures and tumors:
aminotransferase (AST, ALT)
o Defines the anatomy of the biliary tree proximal to the
affected segment
B. TRANSABDOMINAL ULTRASONOGRAPHY
o Serves as a drainage for cases in which there is a
 Initial modality for the investigation of a suspected
proximal biliary tree obstruction causing jaundice,
disease of the biliary tree
obstructive jaundice, and cholangitis
 Noninvasive, painless, no radiation, and for critically ill patients
 Standard diagnostic tool for stone diagnosis
F. ENDOSCOPIC RETROGRADE
 Has a high sensitivity and specificity of >90%
CHOLANGIOPANCREATOGRAPHY (ERCP)
 The most common finding is a posterior acoustic shadowing
F.1. FOR DIAGNOSING
o Occurs due to stones that block the passage of
 Identify the Ampulla of Vater via upper GI endoscopy 
soundwaves in the regions behind them
cannulation and cholangiogram are done to map out the biliary
o Stones are acoustically dense and reflect the ultrasound
tree and identify obstructions, such as stone and tumor obstruction
waves back to the transducer. They move with changes
in position.
F.2. FOR THERAPEUTICS
o Polyps may be calcified and reflect shadows, but do not
 Identify the cause of obstruction  perform extraction of the
move with change in position.
stone
 A thickened gallbladder wall, pericholecystic fluid, and local
 ERCP balloon dilation of the Ampulla of Vater – provides a
tenderness with direct pressure by the ultrasound probe over the
larger opening and an access for stone extraction
fundus of the bladder (sonographic Murphy’s sign) may
 ERCP stent – for larger stones, a biliary diversion is made with
indicate acute cholecystitis.
freely draining bile and contrast to prevent cholangitis

G. MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY

(MRCP)
 Solely a diagnostic tool
 Offers a focused, noninvasive test for the diagnosis of
biliary tract and pancreatic disease
 Has a sensitivity and specificity of 95% and 89%, respectively for
detecting choledocholithiasis

Figure 8. Ultrasonography of the gallbladder. White arrows: stones

within gallbladder; black arrowheads: acoustic shadows from stones.

C. HEPATOBILIARY SCINTIGRAPHY OR HEPATOBILIARY

IMINODIACETIC ACID SCAN (HIDA SCAN)
 A diagnostic nuclear medicine procedure that uses radioactive
tracers (iminodiacetic acid) for direct biliary system and
indirect liver evaluations
 Radiotracer is taken up by hepatic Kupffer cells  detected within
Figure 10. MRCP. This view shows the course of the extrahepatic bile
10 minutes
 The gallbladder, bile ducts, and duodenum are visualized within
ducts (arrows) and the pancreatic duct (arrowheads).
one hour in fasting patients.
VI. GALLSTONE DISEASES
 Primarily used in the diagnosis of acute cholecystitis.
 “Most patients will remain asymptomatic from their gallstones
o Appears as a non-visualized gallbladder with prompt
throughout their life”
filling of the common bile duct and the duodenum,
 3% of asymptomatic individuals become symptomatic per year.
forming a Rim sign

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 3% to 5% of symptomatic patients will develop complicated  They are formed by supersaturation of unconjugated bilirubin
gallstones. within the bile. Deconjugation of bilirubin occurs normally in bile at
 2/3 of asymptomatic patients with gallstones remain asymptomatic a slow rate. Thus, excessive levels of conjugated bilirubin
after 20 years. This is the main reason why prophylactic excretion, as occurs in hemolytic disorders like hereditary
cholecystectomy is rarely done. spherocytosis and sickle cell disease will lead to an increased rate
of production of unconjugated bilirubin. Cirrhosis and hepatic
A. INDICATIONS OF PROPHYLACTIC CHOLECYSTECTOMY dysfunction may also lead to increased secretion of unconjugated
 Elderly patients with diabetes bilirubin directly from the liver. The insoluble unconjugated
 Individuals who will be isolated from medical care for extended bilirubin will then precipitate with calcium as insoluble calcium
periods of time bilirubinate, forming a pigment stone.
 Populations with increased risk of gallbladder cancer
 Porcelain gallbladder, a rare premalignant condition in which
the wall of the GB becomes calcified.
 Polyp of >1 cm because it has a 15-20% risk of malignant
transformation

B. GALLSTONE FORMATION
 The common primary event in stone formation is caused by
supersaturation of bile, which is almost always caused by Figure 12. Black pigment stones.
cholesterol hypersecretion.
2. BROWN PIGMENT STONES
 Typically found in the biliary tree of Asian populations and
are associated with stasis secondary to parasite infection
 In the Western population, brown stones occur as primary
bile duct stones in biliary strictures or other common bile
duct stones that cause stasis and bacterial infection.
 <1 cm, brownish yellow, soft and mushy
 Formed either in the gallbladder or bile duct secondary to
bacterial infection and bile stasis
 Bacteria, such as Escherichia coli, secrete β-glucuronidase that
enzymatically cleaves conjugated bilirubin to produce the insoluble
unconjugated bilirubin. This unconjugated bilirubin then
precipitates with calcium, and along with dead bacterial cell
bodies, forms soft brown stones in the biliary tree.

Figure 11. Pathophysiology of gallstones.

C. TYPES OF STONES IN GALLBLADDER DISEASES

CHOLESTEROL STONES PIGMENT STONES
Supersaturated with cholesterol Found in hemolytic anemia and
infection of the biliary tree
Gallbladder hypomotility promotes Increased unconjugated Figure 13. Brown pigment stones.
nucleation  precipitation of bilirubin in the biliary tree 
cholesterol from bile into vesicles  precipitate formation  D. GALLSTONE JOURNEY
cholesterol nucleation in bile is insoluble calcium bilirubinate
accelerated  mucus salts
hypersecretion traps crystals 
permitting aggregation into stones

C.1. CHOLESTEROL STONES

 “Pure cholesterol stones”
o <10% of gallstones, single large stones
 Cholesterol stones with bile pigment:
o Multiple, variable in size, hard and faceted, or
o Irregular, mulberry shaped and soft.
 Most are radiolucent, <10% are radiopaque.
 Gallstones are mostly cholesterol stones.

C.2. PIGMENT STONES

 Contain <20% cholesterol and are dark due to the presence
of calcium bilirubinate
 Usually associated with hemolytic anemias, biliary tract
infections, strictures, and malignancies

1. BLACK PIGMENT STONES

 Small, brittle, black, speculated
 Due to the supersaturation of calcium bilirubinate,
carbonate and phosphate
 Found in blood dyscrasias, such as hemolytic disorders
Figure 14. Plain gallstone that can become complicated.

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 Plain gallstones go to the cystic duct  obstruction of the 3. MANAGEMENT
gallbladder  acute cholecystitis  Indications:
 Gallstones go to the cystic duct  to the common bile duct o All patients with symptomatic gallstones require
(choledocholithiasis)  obstructive jaundice  increased liver cholecystectomy (open or laparoscopic approach)
function tests and total bilirubin (leukocytosis is not necessarily o Diabetic patients with symptomatic gallstones require prompt
seen) cholecystectomy because they are more prone to develop
 Complicated bile duct stones: gallstones travel down to the acute cholecystitis
Ampulla of Vater  complete obstruction  cholangitis o Pregnant women – safe cholecystectomy during the 2nd
trimester but can be anytime with acute cholecystitis
E. SYMPTOMATIC GALLSTONES  1st trimester – organogenesis
 Cases are usually identified as acute or chronic cholecystitis.  3rd trimester – premature labor
 Chronic cholecystitis occurs in 2/3 of untreated patients
with gallstone diseases. E.2. ACUTE CHOLECYSTITIS
 Recurrent attacks of pain, inaccurately labeled as biliary colic,  90-95% of the time: secondary to gallstones
are felt after a meal (50%) or during the night.  <1% is secondary to obstructing cystic duct – initiating event that
 Aschoff-Rokitansky sinuses leads to gallbladder distention, inflammation, and wall edema
o Normal mucosa that becomes atrophied with the epithelium  Gallbladder can distend up to 300 - 500 mL
protruding into a muscle coat  Macroscopic findings:
o Pathognomonic histopathologic finding in cases of o Wall is grossly thickened, reddish with subserosal hemorrhages
chronic cholecystitis o Mucosa is hyperemic with patchy necrosis
 It often begins as an attack of biliary colic with relapsing
and remitting pain in the right upper quadrant or
epigastrium that may radiate to the right back or
interscapular area. In contrast to biliary colic, the pain of acute
cholecystitis does not subside.
 Murphy’s sign
o Inspiratory arrest on deep palpation at the RUQ area
o Characteristic of acute cholecystitis

1. OTHER FORMS OF ACUTE CHOLECYSTITIS

MIRIZZI’S SYNDROME
 Form of acute cholecystitis wherein there is obstruction of the
Figure 15. Types of symptomatic gallstone. A. Chronic cholecystitis proximal bile ducts by severe pericholecystic inflammation
(pink, no pericholecystic fluid); B. Acute cholecystitis (thick, secondary to stone impaction in the cystic duct/
gangrenous, empyematous, presence of pericholecystic fluid). infundulum
 Gallbladder is inflamed  cannot identify the common bile duct 
E.1. CHRONIC CHOLECYSTITIS palpation of a hardened structure between cystic duct and
 >24 hours RUQ pain – suspect transformation of impacted common bile duct (Mirizzi’s Syndrome)
stone into acute cholecystitis  Pushes gallbladder mucosa towards the common bile duct  pain
 Hydrops of the gallbladder occurs when bile gets absorbed  Not necessarily a common bile stone stone
but the gallbladder epithelium continues to secrete mucus,  Presents as RUQ pain with jaundice, sometimes without fever
causing distention; >5 cm transverse diameter of the  Surgery is difficult to perform since the gallbladder is inflamed. The
gallbladder secondary to a cystic duct stone. treatment option is to insert a tube and let the inflammation
subside. Once inflammation subsides, surgery can already be
1. RISK FACTORS performed.
 4F’s – Fat, Female, Forty, Fertile
 Heredity has low risks when it comes to gallstone formation.
 Diet is the main culprit in the formation of gallstones.

2. OTHER FORMS OF CHRONIC CHOLECYSTITIS

CHOLESTEROLOSIS
 Accumulation of cholesterol in macrophages in the
gallbladder mucosa
 Macroscopic appearance: “strawberry gallbladder”

ADENOMYOMATOSIS
 “Cholecystitis glandularis proliferans”
 Presence of hypertrophic smooth muscle bundles and Figure 17. Mirrizi’s Syndrome. Impacted gallstone in the cystic duct
ingrowth of mucosal glands into muscle layer causes dilatation of the proximal bile duct and distention of the entire
 Mostly polyp in nature gallbladder.
 Ultrasound finding: pearl necklace sign usually indicates
gallbladder adenomyomatosis EMPHYSEMATOUS GALLBLADDER/CHOLECYSTITIS
 Acute cholecystitis that occurs when there is a gas forming
organism in the gallbladder lumen
 Presence of pus
 It important for a physician to know whether it is an acute or
chronic cholecystitis because surgical intervention is different.
o Acute cholecystitis with an emphysematous gallbladder –
operation is delayed because of difficulty in dissecting the
inflamed, probably gangrenous, gallbladder
Figure 16. Pearl necklace sign. o Chronic cholecystitis with recurrent bouts of right upper
quadrant pain – operation is much easier

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COMPLICATION IN THE PANCREAS 3. TREATMENT
 Obstruction of the periampullary area is most commonly due INITIAL TREATMENT
to a pancreatic head tumor  distention of the gallbladder  Intravenous hydration
(hydropic gallbladder that is different from the hydropic distention  Pain reliever
secondary to stones)  Broad-spectrum antibiotics – should cover gram-negative enteric
 Courvoisier gallbladder: organisms, as well as anaerobes
o Distention of the gallbladder wherein the RUQ area can be
palpated without eliciting any pain (no inflammation) AFTER MEDICAL MANAGEMENT
o Characteristic for a periampullary tumor  CHOLECYSTECTOMY – definitive treatment
o Palpable non-tender gallbladder in the presence of jaundice EARLY CHOLECYSTECTOMY DELAYED OR LATE
that is unlikely caused by gallstones. CHOLECYSTECTOMY
o Usually indicates a neoplastic stricture obstructing the distal
2-3 days after the onset of 6-10 weeks after medical
common bile duct
symptoms management
Early cholecystectomy is preferred over delayed
2. DIAGNOSTICS
cholecystectomy. Several studies have shown that unless the patient
HIDA SCAN (BILIARY SCINTIGRAPHY)
is unfit for surgery, early cholecystectomy should be recommended as
 Rim sign in acute cholecystitis (90-95% very diagnostic)
soon as possible, as it offers the patient a definitive solution in one
 Positive result: no uptake at the area of the gallbladder for about
hospital admission, quicker recovery times, similar complication rates,
60 minutes from the time the technetium was given
and an earlier return to work.
 (+) gas = acute cholecystitis
 Nuclear-based; exposure to radiation TYPES OF GALLBLADDER SURGERY
OPEN -
TECHNIQUE
LAPAROSCOPIC - Procedure of choice for acute cholecystitis
TECHNIQUE - Absolute contraindications: uncontrolled
coagulopathy and end-stage liver disease
- Relative contraindication: inability of a
patient to tolerate pneumoperitoneum or
general anesthesia

Figure 18. Rim sign on HIDA scan.

ULTRASOUND
 Effective at documenting the presence or absence of stones
 Can show gallbladder wall thickening and pericholecystic
fluid, both of which are highly suggestive of acute cholecystitis
 Posterior shadowing: absence of echoes
 Ultrasound is 85% up to 95% more specific and sensitive in
diagnosing gallbladder stones as compared to CT scan. CT scan
and MRI are only done when malignancy is suspected.

Figure 21. Laparoscopic techniques.

 PERCUTANEOUS CHOLECYSTECTOMY PROCEDURE
o Procedure of choice for unfit and unstable patients with
complicated acute cholecystitis
o Puncture the inflamed gallbladder  drain content
o When the inflammation subsides  perform definitive
procedure (surgery)

Figure 19. Ultrasound findings in acute cholecystitis.

Figure 22. Percutaneous cholecystostomy procedure.

Figure 20. Difference of acute and chronic cholecystitis in ultrasound.

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F. CHOLEDOCHOLITHIASIS (COMMON BILE DUCT STONE)
 6-12% of patients with gallstones have common bile duct stones.

F.1. TYPES OF COMMON BILE DUCT STONES

1. PRIMARY COMMON BILE DUCT STONES
 Form in the common bile duct lumen
 Brown pigment stones
 Secondary to biliary stasis and infection
o Biliary stasis can be caused by biliary strictures, papillary
stenosis, tumors, or other (secondary) stones
 Follow the contour of the bile duct; mushy and soft in consistency
 Asian populations

2. SECONDARY COMMON BILE DUCT STONES Figure 24. ERCP.

 Migrated stones from the gallbladder  ERCP can enlarge the opening of the Ampulla of Vater, which
 Mostly cholesterol types of stones provides access to the common bile duct during stone extraction.
 Usually hard, speculated  When common bile duct stones cannot be extracted, ERCP stent
 Western nations can be placed in order to prevent cholangitis.
F.2. CLINICAL FEATURES
 RUQ pain and jaundice, nausea and vomiting
 Elevated WBC count in the stage of cholangitis, alkaline
phosphatase, bilirubin, transaminases
 Ball-valving effect:
o Symptoms may be also intermittent, such as pain and transient
jaundice caused by stones that are temporarily impacted in the
Ampulla of Vater but subsequently moves away

F.3. DIAGNOSIS
1. ULTRASOUND
 Primary diagnostic tool of choice in assessing stones in the
Figure 25. ERCP continuation.
common bile duct
 A dilated common bile duct with a diameter of >8 mm along with
2. OPEN VS. LAPAROSCOPIC COMMON BILE DUCT
gallstones, jaundice, and biliary pain  highly suggestive of
EXPLORATION
common bile duct stones
OPEN EXPLORATION
 Useful for documenting stones in the gallbladder (if still
 Done when there is a dilatation of >1.5 cm in the common bile
present), and determining the size of the common bile duct
duct
 Primary repair, common bile duct closure, or T-tube placement is
2. ENDOSCOPIC CHOLANGIOGRAPHY
done during common bile duct exploration and stone extraction in
 Gold standard for diagnosing common bile duct stones
the biliary tree. T-tube placement is done in order to divert the
 Has the distinct advantage of providing a therapeutic
biliary flow.
option at the time of diagnosis
 If a choledochotomy is performed, primary repair can be
considered in large ducts, while smaller ducts should be repaired
over a T-tube.

Figure 23. Ultrasound and ERCP of common bile duct stones.

F.4. TREATMENT OPTIONS

 Gallstones with common duct bile stones – preoperative or Figure 26. Primary repair and T-tube placement.
intraoperative ductal clearance followed with laparoscopic
cholecystectomy PARAMETER LAPAROSCOPIC CBDE OPEN CBDE
 Open chdolecystectomy, intraoperative cholangiography, common DIFFICULTY OF More difficult Less difficult
bile duct exploration with or without tube placement PROCEDURE
 Biliary enteric bypass procedure AVERAGE 4-6 hours 1-2 hours
OPERATING TIME
1. ENDOSCOPIC RETROGRADE RECOVERY 24 hours 3-5 days
CHOLANGIOPANCREATOGRAPHY (ERCP) DUCTAL CLEARANCE POSTOPERATIVE - Pain
 Requested prior to a laparoscopic or open cholecystectomy in COMPLICATION
patients with obstructing jaundice secondary to gallbladder stones
with common bile duct stones. This prevents the formation of a
non-dilated common bile duct (usually less than 1 cm) that is
prone to ischemic changes.

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LAPAROSCOPIC EXPLORATION
TRANSCYSTIC BASKET Basket is advanced past the stone and
RETRIEVAL USING opened  stone is entrapped in the
FLUOROSCOPY basket  removed together from the
cystic duct
TRANSCYSTIC Basket is passed through the working
CHOLEDOCHOSCOPY AND channel of the scope  stone is
STONE REMOVAL entrapped under direct vision  view
from the choledochoscope
CHOLEDOCHOTOMY AND Small incision is made in the common
STONE REMOVAL bile duct  duct is cleared of stones 
T-tube left in the duct with one end
taken out through the abdominal wall
for decompression

Figure 28. Biliary enteric anastomosis.

VII. CHOLANGITIS
A. COMPLICATIONS OF COMMON BILE DUCT STONES
A.1. ACUTE CHOLANGITIS
 Ascending bacterial infection associated with partial or complete
obstruction of bile duct

A.2. GALLSTONE PANCREATITIS

B. CAUSES
Figure 27. Endoscopic retrograde cholangiopancreatography.  Common bile duct stones, strictures, and periampullary tumors

3. BILIARY ENTERIC ANASTOMOSIS C. CLINICAL FEATURES

 A segment of the small intestine, mostly jejunum, is C.1. CHARCOT’S TRIAD
connected to the biliary tree.  Indicative of ascending cholangitis
 Performed in cases where there is bile duct injury, biliary  Signs and symptoms: RUQ or epigastric pain, fever, and jaundice
strictures, or in patients with multiple procedures.
 Stones pass through the Ampulla of Vater  inflammation and C.2. REYNOLD’S PENTAD
fibrosis  narrowing of passage  biliary stasis  tendency of  Indicative of toxic cholangitis
stone formation (biliary enteric bypass still has a role in correcting  Signs and symptoms: RUQ or epigastric pain, fever, jaundice,
or biliary tree structures) hypotension or septic shock, and mental status changes

TYPES OF BILIARY ENTERIC ANASTOMOSIS D. TREATMENT

CHOLEDOCHODUODENOSTOMY - A bypass is performed using  The initial treatment of patients with cholangitis includes broad-
the common bile duct and spectrum IV antibiotics to cover enteric organisms and
first portion of the anaerobes, fluid resuscitation, and rapid biliary
duodenum decompression
- Passage of bile to the  Endoscopic retrograde cholangiopancreatography (gold
duodenum without the standard)
Ampulla of Vater
- Distal common bile duct is VIII. BILIARY PANCREATITIS
opened longitudinally while  Mostly associated with common bile duct stones
the duodenum is incised  Obstruction of the pancreatic duct by an impacted stone
transversely  interrupted through the Ampulla of Vater leads to pancreatitis.
sutures are placed between  The initial management of gallstone pancreatitis is supportive,
the two structures including admission for bowel rest, IV hydration, and pain
CHOLEDOCHOJEJUNOSTOMY - Higher anastomosis control.
- Common bile duct and  Treatment of choice: ERCP with sphincterotomy and stone
jejunum are divided  removal
Roux-en-Y limb of the o Pancreatitis should be resolved first before performing
jejunum is anastomosed to cholecystectomy.
the choledochus
HEPATICOJEJUNOSTOMY - Entire extrahepatic biliary IX.CHOLANGIOHEPATITIS
tree is resected  “Recurrent pyogenic cholangitis”
reconstruction is done with Endemic in the Orient
a Roux-en-Y limb of the It affects both sexes equally and occurs most frequently in the
jejunum third and fourth decades of life.
- Percutaneous transhepatic  Secondary to bacterial and parasitic infections:
stents are placed across the o E. coli, Klebsiella spp. or Bacteroides located in the biliary tree
procedure. o Clonorchis sinensis, Ascaris lumbricoides, Opisthorchis viverrini
 Biliary stricture causing stone formation

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 Treatment: Hepatectomy or biliary enteric anastomosis B. MANAGEMENT
when there is narrowing or stricture in the extrahepatic biliary tree TYPES I AND II Excision of the cystic dilations in the
o Patients usually succumb to liver failure because a big portion (SACCULAR extrahepatic biliary tree, including
of the liver is removed during hepatectomy. DIVERTICULUM OF THE cholecystectomy, with either simple cyst
o The counterpart of cholangiohepatitis in the Philippines is COMMON BILE DUCT) excision or duct resection with Roux-en-Y
Biliary Tuberculosis, whereby the intrahepatic biliary duct hepaticojejunostomy is ideal
becomes narrow due to tuberculoma or granuloma formation. TYPE III Create a treatment challenge as full resection
(INTRADUODENAL) would require pancreaticoduodenectomy.
X. CHOLEDOCHAL CYSTS Sphincterotomy and surveillance is generally
 Choledochal cysts are congenital cystic dilatations of the recommended over formal excision
extrahepatic and/or intrahepatic biliary tree TYPE IV Excision of all cystic tissue and reconstruction
 Variations on the union of biliary duct and the pancreatic duct is again recommended. For type Iva,
opening into the Ampulla of Vater additional segmental resection of the liver
 “Long Common Channel Theory” (aka Babbitt’s Theory) may be required if intrahepatic stones,
o Pathophysiology in the formation of choledochal cysts strictures, or abscesses are present
 >90% of patients have an anomalous pancreatobiliary duct TYPE V Multiple and can affect the entire liver. In
junction with the pancreatic duct joining the common bile duct >1 (CAROLI DISEASE) advanced stages, this may result in cirrhosis
cm proximal to the Ampulla of Vater. and liver failure necessitating liver
o Results in a long common channel  allows free reflux of transplantation
pancreatic secretions into the biliary tree  inflammatory
changes, increased biliary pressure, and cyst formation XII. READING ASSIGNMENT
 <50% – triad: abdominal pain, jaundice, epigastric mass A. BILE DUCT INJURIES
 >15% – risk of cholangiocarcinoma  Incidence shows laparoscopic cholecystectomy appeared to show a
higher rate of injury to the bile ducts compared to the open
A. TYPES OF CHOLEDOCHAL CYST approach.
A.1. TYPE I CHOLEDOCHAL CYST o Factors associated with bile duct injury during laparoscopy:
 Fusiform or cystic dilatation of the extrahepatic biliary tree acute or chronic inflammation, obesity, anatomic
 Most common type, >50% of choledochal cysts variations, and surgical technique
 Highest risk of malignancy (>60%)  Inadequate exposure, or failure to correctly identify
structures before ligating or dividing them is the most
A.2. TYPE II CHOLEDOCHAL CYST common causes of significant biliary injury.
 Saccular diverticulum of the extrahepatic biliary tree  Excessive cephalad retraction of the gallbladder may align
 Rare, <5% of choledochal cysts the cystic duct with the common bile duct, and the latter
may then be mistakenly clipped and divided.
A.3. TYPE III CHOLEDOCHAL CYST  Careless use of electrocautery can lead to thermal injury.
 When a bile duct dilatation within the duodenal wall, also  Dissection deep into the liver parenchyma may cause injury
known as choledochoceles to intrahepatic ducts, and poor clip placement close to the hilar
 5% of choledochal cysts area or to structures not well visualized can result in a clip across a
 Lowest malignancy risk of any choledochal cyst (~2%) bile duct.
 Only type of choledochal cyst that can be treated with  Encountered during open surgery or laparotomy because of
endoscopic maneuver misidentification of the different parts of the gallbladder
and the extrahepatic biliary tree.
A.4. TYPE IVA AND IVB CHOLEDOCHAL CYST  Due to difference in the anatomy
 5-10% of choledochal cysts, multiple cysts
 Type IVA – affects both intrahepatic bile duct and A.1. DIAGNOSIS
extrahepatic bile duct  Intraoperative bile leakage, recognition of the correct
 Type IVB – only affects cystic dilatation of the extrahepatic anatomy, or an abnormal cholangiogram led to the diagnosis
bile duct of a bile duct injury.
 Bile duct injuries typically result in either leaks or
A.5. TYPE V CHOLEDOCHAL CYST obstructions related to strictures.
 Also known as the intrahepatic biliary cyst or Caroli cyst  If a drain was placed at the time of surgery, bilious fluid may
 Very rare, 1% of choledochal cysts be seen.
 Caroli disease/cyst  A CT scan or ultrasound can show either a fluid collection in
o Highest mortality; the only one treated with liver the gallbladder fossa (biloma), or free fluid (bile) in the
transplant peritoneum.
 ERCP or HIDA scan can be utilized to better localize the site
of the bile leak.
 MRI cholangiography, if available, provides an excellent,
noninvasive delineation of the biliary anatomy both
proximal and distal to the injury.
 Endoscopic or percutaneous cholangiography may also be
helpful to confirm the diagnosis, depending on the location
and type of injury.

A.2. MANAGEMENT
 Depends on the type, extent, and level of the injury, as well
as the timing of its diagnosis
 Drains should be placed in the surgical bed and antibiotics
initiated.
 If a complete obstructive transection has occurred, it may
also be necessary to place a percutaneous transhepatic
Figure 29. Types of choledochal cysts.

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drainage catheter to decompress the biliary tree prior to  Certain types of choledochal cysts
transfer.  Primary sclerosing cholangitis, anomalous
 Bile leaks from small bile ducts (<3 mm) or those draining pancreaticobiliary duct junction, and exposure to
a single hepatic segment can safely be ligated. If the carcinogens (azotoluene, nitrosamines)
injured duct is ≥4 mm, however, it is likely to drain
multiple segments or an entire lobe and thus needs to be B.2. CLINICAL MANIFESTATIONS
repaired or reimplanted.  Generally indistinguishable from those associated with
 Minor injuries to the common bile duct or common hepatic duct cholecystitis and cholelithiasis
are traditionally managed with placement of a T-tube that  Signs and symptoms: abdominal discomfort, right upper quadrant
has been modified by cutting the ends to allow for its pain, nausea, and vomiting
placement in and removal from the bile duct.  Less common symptoms: jaundice, weight loss, anorexia, ascites,
 Major bile duct injuries, intraoperatively found, are and abdominal masses
managed with reconstruction with a biliary-enteric
anastomosis or a duct-to-duct repair over a T-tube. B.3. DIAGNOSIS
 Laboratory findings, if abnormal, are most often consistent
A.3. STRASBERG CLASSIFICATION with biliary obstruction.
 Gives us the idea on what part is injured  Ultrasonography (70-100% sensitivity) often reveals a
 <2 cm below common bile duct – reconstruction can be thickened, irregular gallbladder wall (>3 mm) with
performed hypervascularity or a mass replacing the gallbladder.
 CT scan may be helpful in identifying a gallbladder mass and
evaluating for nodal spread or local invasion into adjacent
organs or vasculature.
 MRCP allows for complete assessment of biliary, vascular,
nodal, hepatic, and adjacent organ involvement.
 Endoscopic ultrasound (EUS) can be a useful tool in staging
and evaluating for local invasion, as well as obtaining
tissue diagnosis through fine needle aspiration.

B.4. STAGING
T1 Tumors are limited to the lamina propria or muscular layer
of the gallbladder.
T2 Tumors invade the perimuscular connective tissue without
extension beyond the serosa or into the liver.
T3 Tumors grow beyond the serosa, or invade the liver or
other adjacent organs.
Figure 30. Strasberg classification. T4 Tumors are those that have grown into major blood vessels
or two or more structures outside the liver.

B.5. TREATMENT
 Surgical resection remains the only curative option for
gallbladder cancer.
TREATMENT PER STAGE
T1 Simple laparoscopic cholecystectomy with a near 100%
overall 5-year survival rate
T2 Extended cholecystectomy
T3 Higher likelihood of intraperitoneal or distant spread.
However, if no peritoneal or nodal involvement is found,
complete tumor excision with an extended right
hepatectomy and possible caudate lobectomy with
lymphadenectomy
B. GALLBLADDER CARCINOMA T4 Considered unresectable.
 Rare malignancy that occurs predominantly in the elderly.
 It is an aggressive tumor, with a poor prognosis that is usually C. CHOLANGIOCARCINOMA
not diagnosed until it has become advanced and is causing  Rare tumor arising from the biliary epithelium and may
symptoms. occur anywhere along the biliary tree
 Likely related to a combination of chronic inflammation,  Half are located at the hepatic duct bifurcation (Klatskin
infection, genetics, and environmental exposures, such as tumors), with 40% occurring more distally and 10% being
heavy metals and tobacco intrahepatic.
 80-90% of gallbladder cancers are adenocarcinomas.
C.1. RISK FACTORS
B.1. RISK FACTORS  Choledochal cysts, ulcerative colitis, hepatolithiasis, biliary-enteric
 Cholelithiasis is the most important risk factor for gallbladder anastomoses, hepatitis B and C, cirrhosis, biliary tract infections
carcinoma with Clonorchis spp. (liver flukes), and chronic typhoid carriers
 Larger stones (>3 cm) are associated with a 10-fold  Exposure to dietary nitrosamines, thorotrast, or dioxin
increased risk of cancer.  Primary sclerosing cholangitis – 5-10%
 Higher in symptomatic than asymptomatic gallstones
 More commonly seen in the setting of cholesterol stones C.2. PATHOLOGY
 Polypoid lesions (>10 mm) of the gallbladder carry a 25% risk.  95% of bile duct cancers are ductal adenocarcinomas with
 Solitary or sessile polyps, or those showing rapid growth on the vast majority occurring in the extrahepatic biliary tree.
serial imaging, particularly if in the presence of gallstones or age  They are divided into nodular (the most common type), scirrhous,
 >50 “porcelain” gallbladder – 10% risk diffusely infiltrating, or papillary.

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 Intrahepatic cholangiocarcinoma makes up approximately CHECKPOINT
10% of cases.
 Perihilar cholangiocarcinoma, also referred to as Klatskin Identify what is being asked:
tumors, is further classified based on anatomic location by 1. Dissection of this ligament exposes the cystic duct.
the Bismuth-Corlette classification. 2. This is the standard diagnostic modality for gallbladder
stones
C.3. BISMUTH-CORLETTE CLASSIFICATION 3. This type on endoscopic procedure has both diagnostic
TYPE I Tumors are confined to the common hepatic duct. and therapeutic functions
4. Gallstone formed when in prolonged GB hypomotility.
TYPE II Klatskin tumors involve the bifurcation without the
5. A condition that is considered as a premalignant
involvement of the secondary intrahepatic ducts.
condition of the gallbladder wherein the walls
TYPE IIIa Tumors extend into the right and left secondary
demonstrate calcifications.
AND IIIb intrahepatic ducts, respectively.
TYPE IV Tumors involve both the right and left secondary
ANSWERS: (1) Cholecystoduodenal ligament (2) Ultrasound (3) ERCP (4)
intrahepatic ducts.
cholesterol, (5) porcelain

Figure 31. Bismuth-Corlette classification of bile duct tumors.

C.4. CLINICAL MANIFESTATIONS

 Painless jaundice – most common initial presentation
 Pruritus, mild RUQ pain, anorexia, fatigue, and weight loss
 Some patients have normal physical examination

C.5. DIAGNOSIS
 Elevated liver function tests in asymptomatic patients
 Tumor markers:
o Elevated CA 125 and CEA (nonspecific)
o CA 19-9 (specific)
 Ultrasound, CT scan, MRCP, cholangiography, ERCP, PTC

C.6. TREATMENT
 Surgical resection offers the only chance for cure, but
unfortunately many patients have advanced disease at the time of
diagnosis.
 Palliative procedures aimed to provide biliary drainage and
prevent liver failure and cholangitis are often the only
therapeutic possibilities available.
 For curative resection, the location and local extension of
the tumor dictates the extent of the surgery required.
Distal bile duct tumors are often resectable but may require
pancreaticoduodenectomy (Whipple procedure).
 For patients with distal bile duct cancer found to be
unresectable on surgical exploration, perform Roux-en-Y
hepaticojejunostomy, cholecystectomy, and
gastrojejunostomy.
 The best outcomes in perihilar cholangiocarcinoma are seen in
patients who undergo neoadjuvant chemoradiation followed
by liver transplantation.
 Photodynamic therapy has been proposed as a palliative
measure for patients with unresectable disease has been
found to prolong survival and improve quality of life in
patients with biliary stents.

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