Liver

Gallbladder Biliary tree

Acute cholecystitis
Empyema of gallbladder
Mucoceal of gallbladder
Cholangitis
RPC
Pancreatitis
Biliary Patholgy
History and Examination
Previous biliary surgery
Previous history of biliary pathology
Epigastic / RUQ pain
Duration of pain
Associate symptoms / signs
E.g. Tea color urine, jaundice, stool color
Vital signs
Pulse, resp rate, blood pressure, temperature
Toxic or not ??
X rays
Abdominal supine x ray
Gallstone
Aerobilia
CXR --- right side pleural effusion
Blood test
WCC, LFT, amylase
ECG
Aerobilia
Acute cholecystitis
Acute cholecystitis
Blockage of cystic duct
Tissue oedema . Ischaemia infection
Ultrasound abdomen
Thickened gallbladder wall
Sonographic murphys sign
Pericholecystic fluid
Gallstone
Conservative Vs Early Lap +/- open
cholecystectomy Vs Cholecystostomy
Medical / GA risk of the patient
Acute Cholecystitis
Ultrasound abdomen
Thickened gallbladder wall
Pericholecystic Fluid
Sonographic murphy sign
Also look at:
Free fluid
CBD size / CBD stone
Gallstones
Acute Cholecystitis
Early Vs Delay Cholecystectomy
Medical risk too high for GA operation
Precutaneous Cholecystostomy
Decompress the gallbladder
Drain infected bile / pus
Still require antibiotic
Precutaneous Transhepatic Cholecystostomy
Cholecystostomy
Decompress the gallbladder
Observe for improvement
Continue deterioration
? Perforated gallbladder urgent operation
Tube blocked
Drain content and amount
Bile production approx 500mls per day
Mucous only blocked cystic duct
Lots of bile (500mls or above) CBD stone
Check cholecystogram
Tube position
Position of stone in gallbladder (cystic duct still obstructed ?)
Cholangiogram (any CBD stone drop stone)
Definitive Rx plan
Lap cholecystectomy
Conservative Rx / Removal of tube
Cholecystogram
Cholangitis
Cholangitis
Cholangitis
Fever
RUQ pain
Jaundice
+/- Confusion
Biliary Decompression
Need to check clotting profile
Vit K IV 10mg daily
Antibiotics
Definitive Mx
Aim to remove causative
factors
Assess patient clinical status
Vital parameters
Resuscitation
Biliary decompression
Ultra-urgent Vs urgent/early
Charcots triad
Biliary decompression
ERCP
Endoscopic retrograde cholangiopancreatogram
PTBD
Percutaneous transhepatic biliary drainage
ECBD
Exploration of common bile duct
ERCP
Internal stent
ERCP not suitable
ERCP with previous B1 gastrectomy
ERCP with previous B2 gastrectomy
Definitely higher risk of perforation
Cholangitis
What if ERCP failed ??
Anatomical problem
Technical difficulties
Patient condition poor
Respiratory problem
Severe sepsis / MOF
External PTBD
Percutaneous Transhepatic Biliary Drainage
External PTBD Right side system
Percutaneous Transhepatic Biliary Drainage
Under LA, interventional radiological procedure
Risks
Contrast allergies, Local anaesthetic agents allergies
Liver laceration, bleeding, traumatic tapping
NOT suitable in patient with marked ascites
Tube complications
Kinking, blockage, dislodgement
Patient usually spike high fever after procedure
Need injection of contrast into biliary tree ---
bacteraemia
External PTBD
Right or left system ?
Usually communicable except in case of tumour
Usually external PTBD at initial stage
Short procedure time, less manipulation
Aim is to decompress the biliary system
Internal external PTBD
Aim to direct bile into duodenum
Need better cholangiogram first (therefore wait till 1 wk after
inflammation settle and edema subside)
Lost of fluid, electrolytes
Able to disconnect the bed side bag
Allow future ERCP (two hand technique) if initial ERCP
failed due to difficult cannulation
Percutaneous Transhepatic Biliary Drainage
eksternal PTBD
Sistem kanan atau kiri?
Biasanya menular kecuali dalam kasus
tumor
PTBD Biasanya eksternal pada tahap
awal
Waktu prosedur yang singkat, kurang
manipulasi
Tujuannya adalah untuk dekompresi
sistem bilier
PTBD eksternal - internal
Bertujuan untuk empedu langsung ke usus
dua belas jari
Perlu cholangiogram lebih baik pertama
(karena menunggu sampai 1 minggu
setelah peradangan menetap dan edema
mereda)
Kehilangan cairan, elektrolit
Mampu melepas tas samping tempat tidur
Biarkan ERCP masa depan (dua teknik
hand) jika ERCP awal gagal karena
kanulasi sulit
Internal external PTBD
Internal-external PTBD
ERCP two hand technique
Internal external PTBD
ERCP
Monitor patient progress
Vital signs
Clinical signs
Drainage amount and content
Suspect blockage revision ?
Definitive Management Plan
Surgery
Trans PTBD dilatation and removal of CBD
stone
Percutaneous Transhepatic Biliary Drainage
Remember to use correct antibiotic
Send for
Cholangitis can be quickly lethal especially in elderly
Need accurate clinical assessment and appropriate treatment
Timing of biliary decompression is crucial
Recurrent Pyogenic Cholangitis
L
R
ERCP of a case of RPC
Stones
RPC
Appropriate antibiotic
According to previous bile culture
Depends on the disease distribution
Peripheral and / or Central
Decompression of biliary system
Definitive Treatment
Exploration of common bile duct +/- drainage
procedure
Choledochoduodenostomy
Choledochojejunostomy
Liver segmentectomy
RPC
Before definitive procedure
Need to correctly assess
Biliary drainage and function of the liver
Accurate assessment of the distribution of the
disease
CT abdomen
EHIDA scan
RPC Right Lobe CT
RPC Left lobe
RPC
Definitive treatments Vs conservative Plan
Need to BALANCE the risk of OT and the
problems of disease process
Disease process
Recurrent attack
Liver abscess formation
Cholangiocarcinoma