FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)

Lecturer: Kim Shi Tan, M.D.

References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

ANATOMY OF GALLBLADDER*
• bile salts are reused and reabsorbed → liver → bile production
• Principal lipids - cholesterol, phospholipid
• Color of bile - pigment bilirubin diglucuronide
• Color green or greenish-yellowish

BILIARY TREE

• Pear-shaped sac-like structure located in the gallbladder fossa

• Gallbladder fossa divides liver into anatomic right and left lobes
• Lined by a single, tall columnar epithelium that contains cholesterol
and fat globules
• Average capacity of 30-50mL, but can contain up to as much as
300mL if distended
• Parts of the gallbladder
• Fundus: rounded, blind end that normally extends 1-2 cm • The biliary tree originated from the liver going into the second
beyond the liver’s margin. It contains most of the smooth portion of the duodenum & behind it is the pancreas
muscles of the organ • Right & left hepatic duct (from liver) →common hepatic duct→cystic
• Body (corpus): main storage area and contains most of the duct (from gallbladder)→common bile duct
elastic tissue, extends from the fundus and tapers into the neck
• Infundibulum: if enlarged, is called the Hartmann's pouch BLOOD SUPPLY AND LYMPHATICS*
• Neck: funnel-shaped area that connects to the cystic cystic duct • Cystic artery - main blood supply; branch of the right hepatic
artery (90% of the time)
PHYSIOLOGY* • Venous drainage - directly to the liver, through the small veins
• Store and concentrate hepatic bile by absorbing water • Lymphatic drainage - drains first into a single node before it goes
• Deliver bile to the duodenum or intestine to the lymphatic channels, at the border of the neck
• Gallbladder secretes mucus glycoproteins
• Originates in the tubuloalveolar glands found in the mucosa ENTEROHEPATIC CIRCULATION*
lining the infundibulum and neck of the gallbladder
• Protects the mucosa because of the digestive component so
that there will be no injury to the gallbladder
• Can also accumulate in an obstructed gallbladder, which gives
hydrops of the gallbladder
• Gallbladder can still distend because of the mucus accumulation

SPHINCTER OF ODDI*
• regulates flow of bile (and pancreatic juice) into the duodenum,
• prevents the regurgitation of duodenal contents into the biliary tree,
Small Intestines → drained by the Superior Mesenteric Veins → goes
diverts bile into the gallbladder.
to the liver through the Portal Vein
• Release of bile is done contraction of gallbladder and relaxation of
sphincter of Oddi and is dependent on neurogenic, humoral or
chemical stimuli. • Vitamin A, D, E, and K - fat-soluble vitamins are absorbed with
bile in the intestines
Action Innervaition Other factors • Bile enters the small intestine through the Ampulla of Vater
to heelp absorb and digest the different products (Carbohydrates,
Stomach distention, Fats, Proteins, and Vitamin A, D, E, K)
Contraction
Vagus nerve CCK released from the • In patients with bile duct obstruction:
(Parasympathetic)
duodenum • No bile in the intestine →Patient would not be able to absorb
Vitamin K →End up with prolonged Prothrombin Time
Relaxation
Splanchnic nerve Atropine, VIP →Predisposing the patient to bleeding if he will undergo
(Sympathetic)
surgery
• Patient should be given vitamin K parenterally
BILE*
• Liver produces 500-1000 mL of bile per day Important segment of the intestines is the distal
• Mainly composed of H2O, electrolytes, bile salts, proteins, lipids, segment (ileum)
and bile pigments • Where bile acids and bile salts and go back to the liver for
• Primary bile salts - cholate, chenodeoxycholate; conjugated with recirculation
taurine and glycine in the liver • All the component of bile acids and salts needs to be
• Bile salts: 80% absorbed in the terminal ileum; 20% deconjugated • reabsorbed because if one component is not reabsorbed, prone
by gut bacteria to developing gallbladder stones
• Enterohepatic circulation
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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

EXTRAHEPATIC BILE DUCTS • Segment 1 is behind & 2,3,4,5,6,7,8 is in front

Segment Lobe of liver

1 Caudate lobe

2,3,4 Left lobe

5,6,7,8 Right lobe

• If you look at the picture you can see that the liver has its convexity
anteriorly & concavity posteriorly

Common bile duct

• From the duodenum up to the superior portion of the duodenum
is the total length of the common bile duct
• In relation to the duodenum:
• Supra-duodenal: above the duodenum
• Infra- duodenal: below the duodenum
• Retro-duodenal: behind the duodenum
• Intramural: within the wall of the duodenum
• Distal common bile duct- Infra duodenal + intramural
• Proximal common bile duct: Retroduodenal + Supra-
duodenal • Line between the gallbladder bed separates the Right & left lobe of
Hepatoduodenal ligament the liver
• Hepatic artey proper, portal vein, common bile duct • Caudate lobe- both in the right & left lobe of the liver
SECOND ORDER DIVISION
• Based on bile ducts & hepatic artery
LIVER Anatomical Couinad liver Term for surgical resection
term segments referred to

Right anterior 5,8 Right anterior

section sectionectomy

Right posterior 6,7 Right posterior

section sectionectomy

Left medial 4 Left medial

section sectionectomy or
• Falciform ligament- divides the left lateral & medial lobe resection of segment 4
• Ligamentum teres
• Rex Cantile’s line or Portal fissure : divides the liver into right & Left lateral 2,3 Left lateral
left section sectionectomyor
• R. Hepatic duct drain from the right liver bisegmentectomy of 2,3
• L. Hepatic duct drain from the left liver
COUINAD LIVER SEGMENT
• It is important to understand the second order of division for us to
know which segement of the liver is being resected (ex. Right
posterior sectionectomy: segments 7 & 6 is being resected)

Hepatic segments- CT SCAN

• Divides the liver into 8 segments

• Each segments are independent from one another because they
have their own biliary & venous drainage
• Each segments are so independent that you can resect one • You can easily demarcate the lesion in the liver if you are familiar
independently from the other. with the segments of the liver
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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

HEPATIC DIVISION • Cholangiography: in the the hilum of the biliary tree you can see
that there no separation of the right & left hepatic ducts & all the
ducts emnates from the center

• The picture shows us that the liver has 2 planes

• Rex cantlie’s line/ portal fissure/ Median plane: from the • May show abnormality in the finger & toes of the patient which may
gallbladder bed to the IVC. Divides the right & left liver lobe be a sign of a liver anomaly
• Falciform ligament/ Lateral Intersectorial plane: divides the left
lateral & medial left lobe EMBRYOLOGY

DIVISION OF PLANES

• A: Intrauterinely, only one plane

• B: before birth, the plane separates into 2 Medial plane & Lateral
Intersectorial • Foregut: esophagus, stomach, duodenum, ligament of trietz, liver,
• C: LIP separates the Intrahepatic ducts into right & left pancreas & spleen
• D:after birth: complete separation of the right & left hepatic ducts • Liver & the biliary tree is on the right side & pancreas on the
other→clockwise rotation→biliary tree behind the duodenum &
FUSION OF PLANES fusion of the ventral & dorsal pancreas

BILE DUCT VARIATION

• The picture shows an intraoperative picture of GB

• Normally the MP & LIP are separated by the segment 4, however in
the picture the 2 planes are align because there is no separation

• It is always the the right posterior hepatic duct that is always

aberrant
• Most common: Right hepatic duct→right posterior & anterior
hepatic duct→Left hepatic duct (57%)
• If the anomaly of the right posterior is more proximal it is clinically
significant because it drains the bulk of the liver
• If the anomaly is more distal (ex. Drains into the cystic duct) it will
be clinically insignificant since it drains only the minority of the liver

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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

GALLBLADDER & CYSTIC DUCT ANOMALIES* Complications

(choppy sa part na to si doc :( ) • Most are due to stagnation of bile flow
• Pancreatitis
• Suppurative cholangitis
• Gall stone & CBD stone formation
• Rupture of cysts
• Cholangiocarcinoma- seen in 10% to 30% cases. malignant
cystic degeneration is common due to chronic mucosal irritation
from refluxed pancreatic enzymes
Operative management
• Type I: excision of the cysts with its mucosa & reconstruction by
Roux-en-Y hepatico-jejunostomy
• Type II: excision of the diverticulum & suturing of the CBD wall
• Type III: endoscopic sphincterectomy
• Type IV: Extrahepatic biliary resection, cholecystectomy, & biliary
reconstruction
• Multiple bladders & cystic duct insertion • Type V: Liver transplantation, hepatectomy
• If the cystic duct drains the major portion of the liver then it is
clinically significant BLOOD SUPPLY TO CBD & CHD
• A - Low junction between the cystic duct and common hepatic
duct (CHD)
• B - Cystic duct adherent to the CHD
• C - High junction between the cystic and CHD
• D - Cystic duct drains into the right hepatic duct
• E - Long cystic duct that joins CHD in the duodenum
• F - Absence of cystic duct
• G - Cystic duct crosses posterior to CHD and joins it anteriorly
• H - Cystic duct courses anterior to CHD and joins it posteriorly
CHOLEDOCHAL CYSTS
• Dilatation of the extrahepatic & intrahepatic bile ducts
• Classified into 5 types
• Can occur in the presence of pancreatico-biliary maljunction
(PBM)- the common bile duct is very far behind the opening of the
pancreatic duct (nahuhuli) • Branches of the common hepatic artery
• 2 arteries beside the bile duct running side by side ( 3 & 9 o’clock)
• Malignancy: most omnious complication
with no collaterals (just like the fingers).
• Treatment: surgical excision of cysts with construction (extrahepatic
duct) • Significance: when you cut a segment of the bile duct it may
cause ischemic problem to the bile duct (precarious blood supply)
CYSTIC ARTERY VARIATIONS*

Type I • fusiform dilatation of common bile duct

Type II • diverticulum at the common bile duct

Type III • dilatation of the distal common bile duct & • The cystic artery can be aberrant
pancreatic duct • A - Cystic artery from right hepatic artery (80-90%)
• B - Cystic artery from R hepatic artery from superior
Type IVa • fusiform dilatation of common bile duct & mesenteric artery (10%)
intrahepatic dilatation (types I & V) • C - Two cystic arteries, one from R hepatic artery, other from
common hepatic artery, rare
Type IVb • fusiform dilatation of common bile duct & dilatation • D - Two cystic arteries, one from the R hepatic artery, and one
of distal common & pancreatic ducts (Types I & III) from L hepatic artery
• E - Cystic artery branching from the R hepatic artery and
Type V • Intrahepatic dilatation/Caroli disease running anterior to CHD, rare
• F - Two cystic arteries arising from the R hepatic artery, rar
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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

TRIANGLE OF CALOT /HEPATOCYSTIC TRIANGLE • Hepatic lobules

• Portal triad
• Bile ducts- drain the bile from the hepatocyte
• Vein- drain blood from the intestine into the liver
• Artery- carries oxygen to the liver
• Extrahepatic bile duct obstruction→ bile regurgitates back→
destruction of the liver cell
• Infection of bile ducts→ liver→ sinusoids → IVC→ right heart→
sepsis
• Normally the liver can contain mild infections because in
• Triangle of calot- the surgeon may cut the cystic artery between the sinusoids you have the Von Kupffer cells however
• Superior: inferior border of cystic artery if the infection is to virulent or severe then the liver cannot
• Right side: common hepatic duct contain it, hence sepsis will ensue
• Left side: cystic duct • Hepatocytes
• Hepatocystic triangle- more safe to use for surgery • Space of disse
• superior: inferior portion of segment 4 of the liver • Between the lining of the sinusoid & liver cells
• Right side: common hepatic duct • Space where exchange of nutrients & metabolites occurs
• Left side: cystic duct • Any pathology that destroys the space of disse will cause
ischemia of the hepatocytes leading to cell death
PORTA HEPATIS • Amyloid→ obliterates the space of disse→ isolates the
liver cell→ liver failure

• Bilirubin pathway
• Blood→ enter the liver via sinusoids →conjugation of
bilirubin→ bile→ bile ducts
• Bile duct obstruction
• extrahepatic bile duct obstruction→ cholestasis→ bile
regurgitates back to the liver cells→ destroys the liver
(apoptosis)
• Significance: if there is bile obstruction it must be
• Space between the liver & duodenum immediately repaired before liver failure ensues
• Covered by a peritoneal reflection which is the hepatoduodenal
• >25 days of bile obstruction- point of no return
ligament
• Made up of: CLINICAL PRESENTATION
• Superior: common hepatic duct
• Acute Abdomen
• Middle: hepatic artery
• Inflammatory- cholecystitis
• Inferior: portal vein
• Obstructive- calculous, neoplasm, cholangitis
FORAMEN OF WINSLOW
• Hemorrhagic- hemobilia
• Traumatic - iatrogenic
• Reasons for consultation
• Pain
• Jaundice- due to obstruction
• Painless jaundice- malignancy
• Pain
• Visceral pain
• Midline, diffuse, sympathetic overflow
• Associated with nausea & vomiting, & excessive
• Space behind the porta hepatis persperation
• Significance: you can put index finger behind & thumb in front of • felt by the patient subserved by the sympathetic nervous
the porta hepatis if there is bleeding of the hepatic artery system & cannot be elicited by the physician
(Pringle manuever) • Divided into 3 zones:
LIVER PARENCHYMA

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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

• Zone 1 • To make it more accurate we separate the somatic regions

• Epigastrium, right & left hypochondrium into 9
• Usually at the center that diffuses to the right & left • The red on the picture are the 3 regions that will give you
associated with sympathetic symptoms (ex. nausea, a very significant & accurate diagnosis
vomiting, persperation) • Acute cholecystitis- right hypochondriac pain, right
• affectation of the foregut (esophagus, stomach, subcostal tenderness, Murphy’s sign
duodenum, liver, hepatobiliary, spleen , • Acute appendicitis- right iliac area
pancreas ,up to the ligament of trietz) • Sigmoid diverticulitis- left iliac area
• Zone 2 • Briquet syndrome
• supraumbilical to be specific (infraumbilical • Psychosomatic disorder that is usually applicable to
already refers to the midline retroperitoneal females
structures) • Multiple surgeries
• Midgut (from the ligament of treitz up to the mid • Willing to undergo another surgery
transverse colon) • Jaundice
• jejunum, ileum, cecum, appendix, ascending colon, • Sclera
hepatic flexure, mid transverse colon • Skin- may be due to carotenemia, lycopenemia, Addison
• Ex. patient with acute appendicitis he/she may feel a disease, picric acid (chemical during WWWII)
supraumblical pain (other textbook is epigastric) • Urine
• Zone 3 • Stool
• Hindgut • Elevated B1-
• From the mid transverse colon down to the rectum & • Elevated B2-(ex. Biliary tree obstruction)
pelvic organs (ex. ovary, uterus, bladder)
Obsatructive Jaundice Icteric sclera + Yellow/Dark-colored
• Somatic pain (B1 and B2 elevation) urine + Acholic stools

Hemolytic Jaundice patient shows icteric isclera & normal

(B1 elevation) colored urine (ex. Hemolytic anemia)

Iicteric sclera, tea colored urine &

Hepatitic jaundice
acholic stool

LABORATORY TESTS
• Liver function test: routinely requested tests are those who assess
the enzymatic, excretory and metabolic function of the liver. Tests
for detoxification and RES is only requested when the patient is
with cirrhosis.
• Caused by somatic pain fibers
• Discrete (localized) SGPT
Enzymatic
• Peritoneal signs inflammation of liver parenchyma
• Anywhere in the abdomen as long as there is peritoneal
Requested to assess for obstruction.

irritation
Indirect/Direct bilirubin
• infection & irritation due to leaking of gastric juice or
Alkaline phosphatase
duodenal juice→ Anterior parietal abdominal pain
secreted by the lining epithelium of the distal
• Associated with muscle guarding
cholangioles keeps on secreting ALP into the bile
• Morey reflex- reflex from the parietal peritoneum
duct and should be excreted into the intestines. If
→S C→b r a i n→e ff e r e n t fi b e r s→a b d o m i n a l m u s c l e
Excretory there is obstruction, there will be elevation. This is
contract→muscle guarding & hyperesthesias
why some patients have elevated ALP but doesn’t
have jaundice, it signifies that the lesion affects
the distal cholangioles, not the common bile duct.

[SAMPLEX] CBD obstruction= Increased B1, B2

and ALP

Distal cholangioles= ALP only

Albumin, Globulin
Reversal of A/G ratio is probably seen in markedly
damaged liver (liver cirrhosis)

[SAMPLEX] Protime (most sensitive for metabolic

Metabolic
function)

Even when the liver is minimally deranged,

prolonged PT will be seen with ample supply of
vitamin K.

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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

Ammonia Small space to focus the magnetic fields in producing images. MRCP
Reserved for patients with severe liver disease. doesn’t use dye, it enhances the fluid inside the hepatobiliary tree.
Detoxification Since the liver cannot remove the ammonia in the The crescent-shaped obstruction can be seen distally.
blood, patients can develop hepatic
encephalopathy. Endoscopic Retrograde Cholecysto-Pancreatography (ERCP)

Technetium Sulfur Colloid scan

Reticuloendot Uptake by the RES, since the liver is the largest
helial System RES organ, the Von Kupfer cells will uptake the
(RES) TSC. In patients with cirrhosis, splenic uptake of
TSC will be more dominant than the liver.
ULTRASOUND 2D/3D/4D

• More invasive, a scope is inserted into the mouth to duodenum, then

a dye is injected to the ampulla of Vater (at the second portion of
duodenum) to allow visualization. If there is a choledochal cyst,
confluence may not be seen, because the CBD enters far before the
union.
• Combination of endoscope and fluoroscopy/X-ray
• [SAMPLEX] Best initial imaging procedure in patients suspected to • Advantages:
have obstructive jaundice
• Direct visualization of the ampullary region
• Ultrasound doesn’t penetrate the gallstones, so it produces shadows • Direct access to the distal common bile duct
behind (acoustic shadowing).
• Both diagnostic and therapeutic
• Principle of ultrasound: sound waves or echo
• White - reflects solid or liquid Intraoperative Cholangiography (IOC)
• Black - reflects air
• Initial investigation for suspected diseases of the GB and biliary tree
• >90% sensitivity and specificity for GB stones, it can also
detect GB polyps, sediments, lodge, stones
• Extrahepatic bile ducts are also visualized except for the
retroduodenal portion, as it enters the duodenum
• Common bile duct (CBD) stones can sometimes be visualized
• Obstruction of the CBD can just manifest as dilated CBD,
obstruction by a stone, pancreatic mass, or periampullary tumor
Uses C-ARM
CT SCAN GALLSTONE DISEASES

• More accurate and faster but exposes the patient to radiation.

• Left: Imaging shows a ductal dilatation located intrahepatically,
which means the patient has extrahepatic bile duct obstruction.
• Right: Stones are inside the liver ductal system, with some
dilatation.

Magnetic Resonance Cholecysto-Pancreatography (MRCP)

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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

Indications for a Laparoscopic/Open Cholecystectomy Cystic duct calculus

I. Symptomatic Gallbladder diseases
• Painful (caused by stones), palpable
1. Acute calculous cholecystitis: infection gallblader

2. Hydrops, Empyema: obstruction of cystic duct

• The stone is at the cystic duct or at
3. Mirizzi’s syndrome: huge stones at the neck of the GB, the neck of the gallbladder, the
causing the obstruction of bile flow to the CBD, obscuring the complete occlusion of the
triangle of Calot. gallbladder. The mucosa will absorb
4. Acalculous cholecystitis all the pigments and will secrete
II. Asymptomatic gallstones (75%): preemptive or prophylactic mucus, this is called “hydrops” or
surgery [SAMPLEX] white bile. If not treated
Prophylactic surgery is indicated to the following: immediately, bacteria may invade
1. High risk of gallbladder carcinoma (American Indians) and may cause pus accumulation,
2. Morbidly obese persons which is empyema. There is no
3. Recipients of heart and lung transplant jaundice because the CBD is not
4. “En passant”: when you are doing a surgery for another obstructed.

pathology near the gallbladder, it might be included if

• If the stone is big enough to impinge
there is an indication. the common hepatic duct or the
**Renal transplant patients and diabetic patients are not candidates triangle of Calot is obliterated, this
for the procedure. will cause wall necrosis and fistula
formation.

Laparoscopic/Open Cholecystectomy for symptomatic gallstone III

disease in pregnancy
• First trimester is avoided due to danger of spontaneous abortion,
and teratogenicity
• Second trimester is the most preferred period for surgery.
• Third trimester has danger of Preterm labor.

OBSTRUCTIVE BILIARY DISEASES

Courvoisier Laws

• Mirrizi type 1 occurs before onset

Distal bile duct malignancy of fistula formation. The stone is
• The patient has a “Courvoisier’s impinging on the common hepatic
gallbladder” is when a dilated duct, neck, and wall but still intact.
gallbladder with malignancy of distal There is jaundice.

common bile duct

• Mirizzi type 2 is when the wall
• (due to pancreatic/duodenal or bile disappeared due to pressure
I duct mlaignancy), occludes the necrosis, and fistula has occurred.
distal bile duct
There is jaundice.

• The obstruction will cause • Mirrizi type 3 and 4 depends on the

generalized dilatation of the penetration of the stone.
hepatobiliary system.

• Painless since the increase in Proximal bile duct malignancy

pressure is gradual. [SAMPLEX]
• Painless, painless

Distal bile duct calculus • Malignancy of the bifurcation of the

• Painful (caused by stones), non- proximal hepatic duct.

palpable gallbladder
IV
• The intrahepatic ducts are dilated.
• Patient with multiple gallstone, and The extrahepatic ducts are
may pass through the cystic duct excluded.

and obstruct the CBD. The patient • Klatskin tumor is located at the
will develop severe abdominal pain bifurcation.
II
due to the sudden increase of
pressure caused by the obstruction.
Painful with jaundice Courvoisier II, III (Mirizzi)
• The gallbladder may not dilate
simultaneously with the ducts due to Painful, without Courvoisier III
the fibrosis and inflammation. jaundice Empyema, Hydrops
(chronic irritation caused by the
Painless jaundice Courvoisier I, IV
stones)
• Ampullary malignancy

• Pancreatic head malignancy

• Duodenal malignancy

• Hilar malignancy

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FEU-NRMF: SURGERY 3A- HEPATOBILIARY SURGICAL CONDITIONS (2020)
Lecturer: Kim Shi Tan, M.D.
References: Lecture PPT, recording, Medisina trans* (use at your own risk!)

• An ascending bacterial infection in association with partial or

complete obstruction of the bile ducts
Pain Jaundice Involved structures
• Mechanical obstruction of bile flow facilitates bacterial contamination
I - + Generalized dilation • Because it is connected to the intestine, where in there is vast
bacterial flora
II + + Dilated GB • Significant biliary bacterial contamination + biliary obstruction
III (Mirizzi) + + Dilated GB • Stones – most common cause of obstruction
• Bile in the bile ducts is kept sterile by the continuous bile flow and by
III (empyema, hydrops) + - DIlated GB the presence of antibacterial substances, such as bile
• Obstruction due to gallstone > malignancy, will increase pressure in
IV - + non-distended GB the biliary tree. This is characterized by the presence of bacteria and
increased pressure, there is development of the symptoms.
BILE DUCT MALIGNANCY • Pressurized infection of the biliary tree is dangerous. Bacteria may
disseminate quickly into the system.
• Acute non-toxic cholangitis (Charcot’s triad): fever, jaundice and
pain.
• Acute toxic cholangitis (Reynold’s pentad): Charcot’s triad with,
hypotension and sensorium changes.
• Escherichia coli is the most commonly seen organism if blood
culture is done. [SAMPLEX]

TREATMENT FOR CHOLANGITIS

• Perihilar- most common, 67%

• Distal- 27%
• Intrahepatic- 6%
JAUNDICE

• Supportive, Antibiotics: give antibiotics that targets the common

causative organisms (KEEP2 BC: Klebsiella, Enterobacter,
Escherichia coli, Proteus, Pseudomonas, Bacteroides, Clostridium)
• Decompression of the bile duct done by:
• PTCD
• ERCP
• Surgery is done when the patient is resuscitated, final surgery is
done to remove the obstruction. [SAMPLEX]

HEMOBILIA
• Bleeding in the biliary tree
• Liver trauma, blunt right upper abdominal trauma [SAMPLEX]
• Arterobilous fistula
• Biliary malignancy
CHOLANGITIS
• Clinical presentation: pain, jaundice, anemia, hematochezia
• Diagnosis is done by selective angiography
• Treatment: arterial embolization surgery [SAMPLEX]

TRAUMATIC
• Abdominal trauma; blunt or penetrating
• Iatrogenic (most common/dreaded); open or laparoscopic surgery
• Visualization of triangle of Calot must be done prior to ligation of
cystic duct.

(sana samplex)

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