CHAPTER 29 - Gallbladder and Extrahepatic Biliary System Seymo r !

" Sch#art$ A%AT&'( ) ct System The extrahepatic biliary system be*ins #ith the hepatic d cts and ends at the stoma o+ the common bile d ct in the d oden m" The ri*ht hepatic d ct is +ormed by the intrahepatic con+l ence o+ dorsoca dal and ,entrocranial branches" The +ormer enters #ith a sharp c r,e- #hich acco nts +or the +act that calc li are less common in this se*ment" The le+t hepatic d ct is lon*er than the ri*ht and has a *reater propensity +or dilatation as a conse. ence o+ distal obstr ction" The t#o d cts /oin to +orm a common hepatic d ct that is 0 to 1 cm in len*th" !t is then /oined at an ac te an*le by the cystic d ct to +orm the common bile d ct 23i*" 29-45" The common bile d ct is approximately 6 to 44"7 cm in len*th and 8 to 49 mm in diameter" The pper portion is sit ated in the +ree ed*e o+ the lesser oment m- to the ri*ht o+ the hepatic artery and anterior to the portal ,ein" The middle third o+ the common d ct c r,es to the ri*ht behind the +irst portion o+ the d oden m- #here it di,er*es +rom the portal ,ein and hepatic arteries" The lo#er third o+ the common bile d ct c r,es more to the ri*ht behind the head o+ the pancreas- #hich it *roo,es- and enters the d oden m at the hepatopancreatic amp lla 2o+ :ater5- #here it is +re. ently /oined by the pancreatic d ct" The portions o+ the d ct are re+erred to accordin* to their relationship to intestinal ,iscera;s prapancreatic- intrapancreatic- and intrad odenal" The nion o+ the bile d ct and the main pancreatic d ct +ollo#s one o+ three patterns" The str ct res may< 245 nite o tside the d oden m and tra,erse the d odenal #all and papilla as a sin*le d ct= 225 /oin #ithin the d odenal #all and ha,e a shortcommon- terminal portion= or 205 exit independently into the d oden m" Separate ori+ices ha,e been demonstrated in 29 percent o+ a topsy specimens- and in/ection into cada,ers re,eals re+l x +rom the common bile d ct into the pancreatic d ct in 71 percent" Radio*raphically- re+l x +rom the common bile d ct into the pancreatic d ct is present in abo t 48 percent o+ cases" The sphincter o+ &ddi s rro nds the common bile d ct at the amp lla o+ :ater" This pro,ides control o+ the +lo# o+ bile and- in some cases- pancreatic / ice" An amp llary sphincter that is present in one-third o+ ad lts may prod ce a common channel +or the terminal common and pancreatic d cts" Gallbladder The *allbladder is located in the bed o+ the li,er in line #ith that or*an>s anatomic di,ision into ri*ht and le+t lobes" !t is a pear-shaped or*an #ith an a,era*e capacity o+ 79 m? and is di,ided into +o r anatomic portions< the + nd s- the corp s or body- the in+ ndib l m- and the nec@" The + nd s is the ro nded- blind end that normally extends beyond the li,er>s mar*in" !t may be n s ally @in@ed and present the appearance o+ a Aphry*ian cap"B !t contains most o+ the smooth m scle o+ the or*anin contrast to the corp s or body- #hich is the ma/or stora*e area and contains most o+ the elastic tiss e" The body tapers into the nec@- #hich is + nnel-shaped and connects #ith the cystic d ct" The nec@ s ally +ollo#s a *entle c r,e- the con,exity o+ #hich may be distended into a dilatation @no#n as the in+ ndib l m- or Hartmann>s po ch"

The #all o+ the *allbladder is made p o+ smooth m scle and +ibro s tiss e- and the l men is lined #ith a hi*h col mnar epitheli m that contains cholesterol and +at *lob les" The m c s secreted into the *allbladder ori*inates in the t b lar al,eolar *lands in the *lob lar cells o+ the m cosa linin* the in+ ndib l m and nec@" The *allbladder is s pplied by the cystic artery- #hich normally ori*inates +rom the ri*ht hepatic artery behind the cystic d ct" !t is approximately 2 mm in diameter and co rses abo,e the cystic d ct +or a ,ariable distance- ntil it passes do#n the peritoneal s r+ace o+ the *allbladder and branches" :eno s ret rn is carried thro *h small ,eins- #hich enter directly into the li,er +rom the *allbladder- and a lar*e cystic ,ein- #hich carries blood bac@ to the ri*ht portal ,ein" ?ymph +lo#s directly +rom the *allbladder to the li,er and drains into se,eral nodes alon* the s r+ace o+ the portal ,ein" The ner,es o+ the *allbladder arise +rom the celiac plex s and lie alon* the hepatic artery" 'otor ner,es are made p o+ ,a* s +ibers mixed #ith post*an*lionic +ibers +rom the celiac *an*lion" The pre*an*lionic sympathetic le,el is at T6 and T9" Sensory s pply is pro,ided by +ibers in the sympathetic ner,es co rsin* to the celiac plex s thro *h the posterior root *an*lion at T6 and T9 on the ri*ht side" The *allbladder is connected #ith the common d ct system ,ia the cystic d ct- #hich /oins the common hepatic d ct at an ac te an*le" The se*ment o+ the cystic d ct ad/acent to the *allbladder bears a ,ariable n mber o+ m cosal +olds that ha,e been re+erred to as the A,al,es o+ HeisterB b t do not ha,e any ,al, lar + nction" !mmediately behind the cystic d ct resides the ri*ht branch o+ the hepatic artery" The len*th o+ the cystic d ct is hi*hly ,ariable- tho *h the a,era*e is aro nd 1 cm" :ariations o+ the cystic d ct and its point o+ nion #ith the common hepatic d ct are s r*ically important 23i*" 29-25" The cystic d ct may r n parallel to the common hepatic d ct and act ally be adherent to it" !t may be extremely lon* and nite #ith the hepatic d ct at the d oden m" !t may be absent or ,ery short and ha,e a hi*h 2cephalad5 nion #ith the hepatic d ct- in some cases /oinin* the ri*ht hepatic d ct instead" The cystic d ct may spiral anteriorly or posteriorly in relation to the common hepatic d ct and /oin it on the le+t side" Con*enital biliary atresia is disc ssed in Chap" 0C" Anomalies The classic description o+ the extrahepatic biliary passa*es and their arteries applies in only abo t one-third o+ patients" There are s r*ically important anomalies in the *allbladder>s position and +orm- and e,en its n mber 23i*" 29-05" !solated con*enital absence o+ the *allbladder is extremely rare= a topsy incidences o+ 9"90 percent ha,e been reported" Be+ore the dia*nosis is made- the presence o+ an intrahepatic ,esicle or le+t-sided or*an m st be r led o t" ) plication o+ the *allbladder #ith t#o separate ca,ities and t#o separate cystic d cts has an incidence o+ approximately 4 in 1999" The accessory *allbladder may be sit ated on the le+t side- and its cystic d ct may empty into the le+t hepatic d ct rather than the common d ct" Patholo*ic processes s ch as cholelithiasis and cholecystitis may in,ol,e one or*an #hile the other is spared" The *allbladder may be +o nd in a ,ariety o+ anomalo s positions" The so- called A+loatin* *allbladderB occ rs #hen there is an increase in the peritoneal in,estment" The or*an may be completely in,ested by peritone m #ith no mesentery" !n other instances- the *allbladder may be s spended +rom the li,er by a complete mesentery-

or the nec@ may ha,e a mesentery in #hich the cystic artery lies- #hile the + nd s and body are +ree" This condition occ rs in abo t 7 percent o+ patients and predisposes to torsion and res ltin* *an*rene or per+oration o+ the ,isc s" A le+t-sided *allbladder #ith the cystic d ct enterin* directly into the le+t hepatic d ct or common d ct is extremely rare- as is the sit ation @no#n as retrodisplacement- in #hich the + nd s extends bac@#ard in the +ree mar*in o+ the *astrohepatic oment m" The *allbladder may also be totally intrahepatic- a sit ation that occ rs in many animals" !n h man bein*s- the partial or complete intrahepatic *allbladder is associated #ith an increased incidence o+ cholelithiasis" Anomalies o+ the cystic d ct #ere described earlier 2see 3i*" 29-25" Accessory hepatic d cts are present in approximately 47 percent o+ cases" ?ar*e d cts are s ally sin*le and drain a portion o+ the ri*ht lobe o+ the li,er /oinin* the ri*ht hepatic d ctcommon hepatic d ct- or in+ ndib l m o+ the *allbladder" Small d cts 2o+ ? sch@a5 may drain directly +rom the li,er into the body o+ the *allbladder" Dhen these d cts *o nreco*ni$ed and are not li*ated or clipped at cholecystectomy- an acc m lation o+ bile 2biloma5 may occ r in the s bhepatic area" Anomalies o+ the hepatic artery and the cystic artery are present in abo t 79 percent o+ cases 23i*" 29-15" A lar*e accessory le+t hepatic artery- ori*inatin* +rom the le+t *astric artery- occ rs in abo t 7 percent o+ cases" !n abo t 29 percent o+ cases- the ri*ht hepatic artery ori*inates +rom the s perior mesenteric artery- and in abo t 7 percent o+ cases there are t#o hepatic arteries< one ori*inatin* +rom the common hepatic and other +rom the s perior mesenteric artery" The ri*ht hepatic artery is , lnerable d rin* s r*ical proced res- partic larly #hen it parallels the cystic d ct and is adherent to it or #hen it resides in the mesentery o+ the *allbladder" A Acaterpillar h mpB ri*ht hepatic artery may be mista@en +or the cystic artery" The ri*ht hepatic artery may co rse anteriorly to the common d ct" !n 49 percent o+ cases- the cystic artery ori*inates +rom the le+t hepatic artery or +rom the / nction o+ the le+t or ri*ht hepatic arteries #ith the common hepatic artery" !n abo t 47 percent o+ cases- the cystic artery passes in +ront o+ the common hepatic d ct- rather than to the ri*ht o+ or posterior to this d ct" )o ble cystic arteries occ r in abo t 27 percent o+ cases- and they may both arise +rom the ri*ht hepatic artery- or one may ha,e another ori*in" Cystic )isease o+ the Extrahepatic Biliary Tract 2Choledochal Cyst5 Con*enital cystic abnormalities may occ r thro *ho t the entire biliary system- i"e"+rom intrahepatic biliary radicles to the terminal common d ct" !ntrahepatic cystic dilatation is disc ssed in Chap" 26" Choledochal cysts are disc ssed in Chap" 0C" There are three ma/or ,arieties 23i*" 29-75< cystic dilatation in,ol,in* the entire common bile d ct and common hepatic d ct #ith the cystic d ct enterin* the choledochal cyst= a small cyst s ally locali$ed to the distal common bile d ct= and di++ se + si+orm dilatation o+ the common bile d ct" Con*enital biliary atresia is disc ssed in Chap" 0C" PH(S!&?&G( Bile 3ormation The normal ad lt #ith an intact hepatic circ lation and cons min* an a,era*e diet prod ces #ithin the li,er 279 to 4999 m? bile per day" This is- in lar*e part- an acti,e process that ta@es place #ithin the hepatocytes and is dependent on a s pply o+

oxy*en" The secretion o+ bile is responsi,e to ne ro*enic- h moral- and chemical control" :a*al stim lation increases secretion- #hereas splanchnic ner,e stim lation res lts in decreased bile +lo#- probably related to ,asoconstriction" The release o+ secretin +rom the d oden m a+ter the stim l s o+ hydrochloric acid- brea@do#n prod cts o+ proteins- and +atty acids increases bile +lo# and the prod ction o+ an al@aline sol tion by the canalic li" Bile salts are also choleretic and a *ment bile secretion by the li,er" The acti,e transport o+ bile acids +rom the hepatocytes into the canalic li creates an osmotic *radient that ca ses #ater to di++ se into those canalic li" !n addition- there is a Abile acid-independentB acti,e transport o+ electrolytes and other sol tes into the canalic li #ith conse. ent passi,e di++ sion o+ #ater and sol tes" Composition o+ Bile The main constit ents o+ bile are #ater- electrolytes- bile salts- proteins- lipids- and bile pi*ments" Sodi m- potassi m- calci m- and chloride ha,e the same concentration in bile as in extracell lar +l id or plasma" As secretion increases- there is an increase in the concentration o+ bicarbonate and in pH- and a sli*ht increase in chloride" The pH o+ hepatic bile is s ally ne tral or sli*htly al@aline and ,aries #ith diet= an increase in protein shi+ts the pH to the acidic side" Cholesterol and phospholipids are synthesi$ed in the li,er" The rate o+ cholesterol synthesis- s b/ect to a ne*ati,e +eedbac@ mechanism- is inhibited by hi*h cholesterol inta@e" Bile acids- prod ced endo*eno sly or ta@en orally- red ce cholesterol synthesis and increase cholesterol absorption +rom the intestine" The synthesis o+ phospholipids is also re* lated by bile acids" The concentrations o+ cholesterol and phospholipids are both lo#er in hepatic bile than in plasma" The principal bile acids- cholic and deoxycholic acids- are synthesi$ed +rom cholesterol #ithin the li,er= they are con/ *ated there #ith ta rine and *lycine and act #ithin the bile as anions that are balanced by sodi m" The concentration o+ these salts #ithin li,er bile is 49 to 29 mE.E?" Proteins are present in bile in lesser concentrations than in plasma- #ith the exception o+ m coproteins and lipoproteins that are not present in plasma" ?i,er bile also contains nesteri+ied cholesterollecithin- and ne tral +ats" The color o+ the bile secreted by the li,er is related to the presence o+ the pi*ment bilir bin di*l c ronide- #hich is the metabolic prod ct o+ the brea@do#n o+ hemo*lobin and is present in bile in concentrations 499 times *reater than in plasma" A+ter this pi*ment has been acted pon by bacteria #ithin the intestine and con,erted into robilino*en- a small +raction o+ the robilino*en is absorbed and secreted into the bile" Gallbladder 3 nction The *allbladder pro,ides stora*e and concentration o+ bile" The selecti,e absorption o+ sodi m- chloride- and #ater res lts in a concentration o+ bile salts- bile pi*mentsand cholesterol ten times hi*her than in li,er bile" The *allbladder m cosa has the *reatest absorpti,e po#er per nit area o+ any str ct re in the body" This rapid absorption pre,ents a rise in press re #ithin the biliary system nder normal

circ mstances" The absorption o+ +l id by the *allbladder is dri,en by an ener*ydependent acti,e transport o+ sodi m and a conse. ent passi,e transport o+ #ater" Secretion o+ m c s- approximately at the rate o+ 29 m?Eh- protects the m cosa +rom the lytic action o+ bile and +acilitates the passa*e o+ bile thro *h the cystic d ct" This m c s ma@es p the colorless- A#hite bileB present in hydrops o+ the *allbladder res ltin* +rom obstr ction o+ the cystic d ct" The *allbladder also secretes calci m in the presence o+ in+lammation or obstr ction o+ the cystic d ct" 'otor Acti,ity The passa*e o+ bile into the d oden m in,ol,es the coordinated contraction o+ the *allbladder and relaxation o+ the sphincter o+ &ddi" Some bile +lo#s +rom the *allbladder contin o sly and there are rhythmic contractions occ rrin* t#o to six times per min te and mediatin* press res less than 09 mmH2&" The *allbladder>s emptyin*- ho#e,er- is mainly a response to the in*estion o+ +ood and the release o+ cholecysto@inin 2CCF5 by the d oden m" CCF also relaxes the terminal bile d ct- the sphincter o+ &ddi- and the d oden m" A+ter the intra,eno s in/ection o+ CCF- the *allbladder is t#o-thirds e,ac ated #ithin 09 min" CCF exerts its contractile e++ects mainly thro *h action directly on the *allbladder smooth m scle cells- b t also ,ia interaction #ith choliner*ic ner,es" There is a +eedbac@ inhibition o+ CCF secretion by bile acids and proteases" Somatostatin has a direct inhibitory action a*ainst CCFind ced *allbladder contraction" The ,a* s ner,e stim lates contraction o+ the *allbladder- and splanchnic sympathetic stim lation is inhibitory to its motor acti,ity" Altho *h ,a*otomy +or d odenal lcer increases the si$e and ,ol me o+ the *allbladder- the rate o+ emptyin* is nchan*ed" Parasympathomimetic dr *s contract the *allbladder- #hereas atropine leads to relaxation" 'a*nesi m s l+ate is a potent e,ac ator o+ the *allbladder" Emptyin* o+ the *allbladder ta@es place 09 min a+ter in*estion o+ a +atty meal" There is an increased ris@ o+ *allbladder disease in patients on prolon*ed total parenteral n trition 2TP%5 beca se o+ the lac@ o+ intestinal stim l s and conse. ent stasis o+ bile #ithin the or*an" Gallbladder +illin* occ rs #hen the press re in the bile d ct is *reater than that #ithin the *allbladder" This is correlated #ith red ced CCF le,els b t is also a++ected by ,asoacti,e intestinal polypeptide 2:!P5- pancreatic polypeptide 2PP5- and peptide (( 2P((5" The common bile d ct can be sho#n to ha,e #a,es o+ peristalsis" ) rin* star,ationthe sphincter o+ &ddi maintains an intrad ctal press re that approximates the maximal exp lsi,e press re o+ the *allbladder- i"e"- 09 cmH2&- thereby pre,entin* emptyin*" ) rin* the interdi*esti,e periods- the hormone motilin re* lates sphincteric press re to allo# contin o s +lo# o+ small amo nts o+ bile into the d oden m" A+ter the in*estion o+ +ood- the sphincteric press re is red ced to 49 cmH2&" Dhen press re #ithin the extrahepatic bile d cts is *reater than 08 cmH2&- secretion o+ bile is s ppressed" Biliary dys@inesia lac@s ob/ecti,e +indin*s" The term has been sed to describe dist rbances o+ biliary tract motility that occ r in the absence o+ anatomic chan*es" !t has been applied as a primary condition and as a complication o+ biliary tract s r*ery"

Pain has been noted to occ r a+ter the in*estion o+ +atty +oods and the in/ection o+ CCF at the time that contraction o+ the *allbladder is ind ced" Biliary tract pain has also been ascribed to spasm o+ the sphincter o+ &ddi" The concept o+ hyperplastic cholecystosis- characteri$ed by hyperconcentration and excessi,e emptyin* o+ the *allbladder mani+est on a cholecysto*ram- is . estionable- b t cholecystectomy has been reported to be c rati,e in symptomatic patients" Enterohepatic Circ lation A+ter the bile enters the d oden m- o,er 69 percent o+ the con/ *ated bile acids are absorbed in the terminal ile m- and the remainder is decon/ *ated by bacterial acti,ity and absorbed in the colon" E,ent ally- almost 97 percent o+ the bile acid pool is absorbed and ret rns ,ia the portal ,eno s system to the li,er" &nly 7 percent is excreted in the stool- thereby permittin* a relati,ely small pool o+ bile acids to ha,e maximal e++ecti,eness" A ne*ati,e +eedbac@ mechanism re* lates the hepatic synthesis o+ bile acids" Dhen the distal ile m has been resected- there is s ally adaptation- b t occasionally the lac@ o+ a +eedbac@ mechanism persists and ca ses si*ni+icant diarrhea" )!AG%&S!S &3 B!?!AR( TRACT )!SEASE 2See also Ga ndice in Chap" 22"5 Radiolo*ic St dies Abdominal Hltrasono*raphy Hltraso nd ima*in* is the most #idely applied dia*nostic techni. e +or biliary tract disease in electi,e and emer*ent sit ations" !t pro,ides anatomic and patholo*ic in+ormation #ith *reat +lexibility and portability- and at lo# cost" The techni. e may be limited by obesity and lar*e amo nts o+ intestinal *as" Hltrasono*raphy employs a hi*h-+re. ency ,ibration in #hich alternate compression and rare+action #a,es tra,el thro *h the tiss e and are re+lected o++ o+ tiss es or items that di++er in aco stic impedance" The re+lected portion o+ the so nd beam ret rns to a transd cer to create an ima*e" There is ,ariability in the . ality o+ ima*es- and the techni. e is operator dependent" The *allbladder is readily ima*ed beca se echo-+ree bile contrasts #ith the or*an>s #all and the li,er parenchyma" The intrahepatic and extrahepatic ma/or bile d cts are also de+ined" Calc li can be demonstrated in more than 97 percent o+ cases in #hich they are present" The discrimination o+ d ctal dilatation has an acc racy o+ 99 percent" Hltrasono*raphy is the most cost e++ecti,e and reliable method +or demonstratin* *allstones" They appear as re+lecti,e +oci #ithin the *allbladder or d cts and cast aco stic shado#s 23i*" 29-85" A stone impacted in the *allbladder nec@ or cystic d ct may be di++ic lt to detect beca se the #alls themsel,es ret rn stron* echoes" Hltrasono*raphy has been sed to * ide lithotripsy" Hltraso nd ima*in* also pro,ides dia*nostic in+ormation +or ac te and chronic cholecystitis" The characteristic si*ns incl de edema and thic@enin* o+ the *allbladder #all- occasionally *as in the #all- and absence o+ ,is ali$ation o+ the or*an" Thic@enin* and edema o+ the #all is partic larly se+ l in establishin* the dia*nosis o+ acalc lo s cholecystitis #hen they are co pled #ith tenderness o,er the or*an e,o@ed by press re o+ the ltraso nd probe" Hltrasono*raphy also can establish the dia*noses o+ hydrops- porcelain *allbladder- adenomas- and carcinomas"

Hltraso nd is the +irst radiolo*ic step in the e,al ation o+ /a ndice beca se it pro,ides a sensiti,e method +or detectin* intrahepatic and extrahepatic d ctal dilatation" The le,el o+ obstr ction can be de+ined by tracin* the dilatation do#n to a point or termination" !t can distin* ish bet#een intrad ctal calc li and t mors as the ca sati,e a*ent" Postoperati,ely it readily de+ines bilomas and s bhepatic abscesses" Abdominal Radio*raphy Plain x-ray +ilms o+ the abdomen are o+ limited ,al e in assessin* patients #ith *allstones or #ith /a ndice" S pine and pri*ht +ilms o+ the abdomen may be se+ l in excl din* other ca ses o+ abdominal pain- s ch as a per+orated ,isc s or a bo#el obstr ction" The presence o+ si*ni+icant amo nts o+ calci m #ithin *allstones- #hich occ rs in 47 to 29 percent o+ patients- ca ses stones to appear as opaci+ied ob/ects located in the ri*ht pper . adrant on plain x-ray +ilms 23i*" 29-C5" There are a n mber o+ n s al circ mstances in #hich complications +rom *allstones may be s **ested by speci+ic radio*raphic +indin*s" The presence o+ *as #ithin the biliary tree o tlinin* its anatomy occ rs in patients #ith a cholecystenteric +ist la 2abnormal comm nication bet#een the *allbladder and d oden m- #hich typically occ rs as a conse. ence o+ chronic cholecystitis5" &paci+ication o+ the *allbladder- or o+ parts o+ it- occ rs in patients #ith a AporcelainB *allbladder" Gas b bbles may be present in the #all o+ the *allbladder in patients #ith emphysemato s cholecystitis 2in+ection secondary to anaerobic- *as-prod cin* or*anisms5" &ral Cholecysto*raphy &ral cholecysto*raphy- a relati,ely simple and e++ecti,e test +or dia*nosin* *allstones#as introd ced by Graham and Cole in 4921" Dhile this test may permit ,is ali$ation o+ *allstones #ithin the *allbladder- the critical + nction that is assessed is the absorpti,e ability o+ the *allbladder" A radiopa. e iodine containin* halo*enated dye is orally in*ested by the patient" The dye is +irst absorbed by the *astrointestinal tract and extracted in the li,er" The li,er excretes the dye into the biliary d ct lar systemand the dye then passes thro *h the cystic d ct into the *allbladder" Hltimately- i+ the *allbladder has normal m cosal + nction- the dye becomes concentrated thro *h the physiolo*ic absorption o+ #ater and sol tes" A Apositi,eB st dyIone s **esti,e o+ *allstones or *allbladder patholo*yIocc rs #hen stones are noted as +illin* de+ects in a ,is ali$ed- opaci+ied *allbladder 23i*" 29-65 or #hen the dye is not ade. ately concentrated and the *allbladder cannot be ,is ali$ed" Dhen non,is ali$ation occ rsa second- do ble dose o+ contrast medi m is +re. ently administered" Altho *h the acc racy o+ this modality has been reported to be as hi*h as 97 percent- a n mber o+ important limitations ha,e red ced its se" 3alse positi,es may occ r #hen patients ha,e been noncompliant or ha,e been nable to in*est the tablets beca se o+ na sea and emesis or *eneral medical conditions= #hen the tablets ha,e not been absorbed thro *h the *astrointestinal tract or ha,e not been excreted into the biliary tract as a res lt o+ hepatic dys+ nction= or #hen there is some technical problem #ith the e. ipment" &ral cholecysto*raphy has been lar*ely replaced by the de,elopment and re+inement o+ abdominal ltrasono*raphy" Comp ted Tomo*raphy and 'a*netic Resonance !ma*in* Comp ted tomo*raphy 2CT5 is sed to assess biliary dilatation and calc li 23i*" 29-95b t beca se both can be st died more readily by ltraso nd ima*in*- CT is not ro tinely per+ormed" CT is in+erior to ltrasono*raphy +or the detection o+ stones" The

ma/or application o+ CT is to de+ine the co rse and stat s o+ the extrahepatic biliary tree and ad/acent str ct res" !ntra,eno s contrast enhancement o+ the biliary tract is mandatory in this st dy" Hse o+ CT is an inte*ral part o+ the di++erential dia*nosis o+ obstr cti,e /a ndice" 'a*netic resonance ima*in* c rrently has little application in biliary disease" Dith the introd ction o+ ne# contrast a*ents- its applicability may be expanded" Biliary Scinti*raphy A+ter techneti m 99m-labeled deri,ati,es o+ iminodiacetic acid 2H!)A5 are in/ected intra,eno sly- they are cleared by the F p++er>s cells in the li,er and excreted in the bile" %ormally- a+ter in/ection- pea@ acti,ity is detected in the li,er in 49 min- and the biliary d cts can be identi+ied shortly therea+ter" The *allbladder is ,is ali$ed #ithin 89 min in +astin* s b/ects 23i*" 29-495" The test is partic larly applicable #hen the dia*nosis o+ ac te cholecystitis is bein* considered" E,idence o+ cystic d ct obstr ction- as indicated by non,is ali$ation o+ the *allbladder- is hi*hly dia*nostic" The isotopic ,is ali$ation o+ the *allbladder essentially precl des the dia*nosis" The acc racy o+ the test in dia*nosin* ac te cholecystitis is abo t 9C percent" Perc taneo s Transhepatic Cholan*io*raphy 2PTC5 Dith +l oroscopic * idance- a small needle is introd ced nder local anesthesia thro *h the abdominal #all and into the s bstance o+ the li,er" A+ter position in a bile d ct has been con+irmed- a * ide #ire is introd ced and a catheter can be placed" PTC +acilitates dia*nosis by pro,idin* a cholan*io*ram and permits therape tic inter,ention- as necessary- based on the clinical sit ation" The techni. e has little role in the mana*ement o+ patients #ith ncomplicated *allstone disease- b t it has been partic larly se+ l +or patients #ith more complex biliary problems- incl din* strict res and t mors 23i*" 29-445" PTC is the pre+erred approach +or patients in #hom ltrasono*raphy demonstrates intrahepatic d ctal dilatation and no extra hepatic d ctal dilatation- e"*"- Flats@in>s t mor at the con+l ence o+ the ri*ht and le+t hepatic d cts" As #ith any in,asi,e proced re- there are potential ris@s< bleedin*- cholan*itisbile lea@- and other catheter-related problems" Hematobilia occ rs o+ten b t is s ally sel+-limitin* and o+ little conse. ence" Endoscopic Retro*rade Cholan*iopancreato*raphy 2ERCP5 Hsin* a side-,ie#in* endoscope- the biliary tract and pancreatic d ct can be int bated and ,is ali$ed" This proced re is *enerally per+ormed #ith the patient nder li*ht intra,eno s sedation" Ad,anta*es o+ ERCP incl de direct ,is ali$ation o+ the amp llary re*ion and direct access to the distal bile d ct- #hich +acilitates dia*nosis and therape tic inter,ention" This test is *enerally not re. ired #hen dealin* #ith patients #ho ha,e beni*n *allbladder disease- tho *h it has been o+ enormo s bene+it +or patients #ith common bile d ct disease 2beni*n and mali*nant5" This is partic larly tr e +or the e,al ation and treatment o+ patients #ith obstr cti,e /a ndice #hen there is dilatation o+ the common d ct or *allbladder 23i*" 29-425" Choledochoscopy Ri*id and +lexible choledochoscopes inserted into the s prad odenal common d ct to ,is ali$e the l men o+ the extrahepatic d cts ha,e been sed to determine the presence or absence o+ calc li= an acc racy o+ o,er 99 percent has been reported" The techni. e is sed as an ad/ nct to operati,e cholan*io*raphy #hen the common d ct

is explored" Choledochoscopy can also aid in the remo,al o+ stones and bile d ct t mors- and in inspectin* and obtainin* biopsy samples +rom stenoses" TRAH'A Penetratin* and %onpenetratin* !n/ ries o+ the Gallbladder !n/ ries o+ the *allbladder are ncommon- occ rrin* in 2 to 6 percent o+ patients #ith ma/or abdominal tra ma" Penetratin* in/ ries are s ally ca sed by * nshot #o nds or stab #o nds= they also occ r rarely d rin* a needle biopsy proced re o+ the li,er" %onpenetratin* in/ ries are extremely rare" 3e#er than 499 cases ha,e been reportedand in only 29 percent #as the tra ma isolated to the *allbladder" The types o+ tra matic in/ ries to the *allbladder incl de cont sion- a, lsionlaceration- r pt re- and tra matic cholecystitis" Cont sion is di++ic lt to ,eri+y b t may be associated #ith ,a* e or temporary symptoms that re. ire no speci+ic therapy" The cont sed area may nder*o necrosis and per+orate" A, lsion o+ the *allbladder +rom its li,er bed occ rs as a res lt o+ nonpenetratin* in/ ry" Dhen the *allbladder>s attachments are torn the or*an s ally han*s by its nec@ b t may be attached only by the cystic d ct and artery" :ol, l s o+ the *allbladder may res lt" Tra matic cholecystectomy- in #hich the cystic d ct- cystic artery- and *allbladder attachments are transected- has been reported" ?aceration is the most common type o+ in/ ry +ollo#in* penetratin* #o nds b t also may res lt +rom bl nt tra ma" )elayed r pt re o+ the *allbladder can occ r days to #ee@s +ollo#in* in/ ry" Tra matic cholecystitis is an n s al condition that occ rs as a res lt o+ bl nt tra ma" Bleedin* into the *allbladder- +rom in/ ry o+ the *allbladder or o+ the li,er- precipitates cholecystitis and sometimes *an*rene o+ the *allbladder" The retained blood may clot and bloc@ the cystic d ct- in #hich case the patient presents #ith the mani+estations o+ hematobilia- incl din* intermittent /a ndice- colic@y pain- hematemesis- and melena" E++ects o+ !ntraperitoneal Bile The e++ects o+ extra,asation o+ bile into the peritoneal ca,ity depend on #hether or not the bile is in+ected" Dhen in+ected bile escapes into the peritoneal ca,ity- a + lminatin* and o+ten +atal peritonitis res lts" Dhen bile is sterile- ho#e,er- it is #ell tolerated and res lts in a chemical peritonitis that may be relati,ely mild" !n the ma/ority o+ *allbladder in/ ries- the or*an is normal and the bile is sterile" The +act that sterile bile is relati,ely innoc o s is borne o t by the ,ery lo# mortality rate associated #ith nonpenetratin* #o nds o+ the *allbladder" Contin o s lea@a*e o+ nonin+ected bile- ho#e,er- is not innoc o s" The extra,asated bile may prod ce ascites or become encysted- and extensi,e chemical peritonitis ca ses an o tpo rin* o+ +l id into the peritoneal ca,ity +rom the *eneral circ lation that may res lt in shoc@" There is also some e,idence that lar*e amo nts o+ bile salts may be toxic" Clinical 'ani+estations Bile lea@a*e thro *h the penetratin* #o nd s **ests the possibility o+ dama*e to the biliary system- b t d odenal laceration may ha,e a similar mani+estation" Dith bl nt tra ma- mani+estations may be delayed +or 08 h or more- in part beca se typically there are other serio s in/ ries that mas@ in/ ry o+ the biliary tract- and sterile bile itsel+ ca ses only minimal symptoms" The presence o+ se,ere shoc@ and pain in the ri*ht pper . adrant or lo#er part o+ the ri*ht side o+ the chest sho ld raise clinical s spicion o+ *allbladder in/ ry" The mani+estations o+ bacterial peritonitis may ens eor i+ the bile lea@a*e is minimal- the patient may appear to reco,er b t s bse. ently

de,elop ascites or an intraperitoneal cyst" The +indin* o+ bile-stained +l id d rin* dia*nostic paracentesis is s **esti,e- b t a ne*ati,e tap does not excl de *allbladder in/ ry" !n most instances the dia*nosis is made at celiotomy- emphasi$in* the need +or care+ l examination o+ the biliary system a+ter abdominal tra ma" Treatment The in/ red *allbladder has been s ccess+ lly treated by simple s t re o+ the laceration- cholecystostomy- and cholecystectomy" !n *eneral- it is pre+erable to remo,e the tra mati$ed *allbladder" Cholecystectomy is s ally . ite easy to per+orm- since the *allbladder is rarely diseased- and it m st be per+ormed i+ the *allbladder has been a, lsed or the cystic artery torn" !n the se,erely ill patientcholecystostomy may be sed +or treatment o+ the extensi,e laceration or tra matic cholecystitis in order to red ce the time o+ operati,e proced re and a,oid in/ ry to the common d ct" Pro*nosis is directly related to the incidence o+ associated in/ ries" !n/ ry o+ the Extrahepatic Bile ) cts Rare cases o+ solitary penetratin* #o nds in,ol,in* the bile d ct ha,e been reportedb t there is s ally associated tra ma to other ,iscera" Approximately 429 cases o+ tra matic r pt re o+ the extrahepatic bile d ct ha,e been reported- and in 29 cases complete transection occ rred" The clinical mani+estations are similar to those described +or *allbladder in/ ry" Treatment consists initially o+ metic lo s exploration- partic larly i+ in/ ry to the *allbladder has been excl ded and bile has been demonstrated retroperitoneally or #ithin the peritoneal ca,ity" A Focher mane ,er sho ld be per+ormed to r le o t per+oration o+ the common d ct behind the d oden m" The presence o+ hematoma in this re*ion sho ld raise the s r*eon>s s spicions" Tan*ential in/ ries may be treated by primary repair" Complete transection o+ the common hepatic d ct or the common bile d ct 2e"*"- by a penetratin* @ni+e #o nd5 may be treated by debridement and an endto-end anastomosis o,er a T t be- #hich sho ld be le+t in place +or se,eral #ee@s" !n most cases o+ complete transection and in/ ries ca sed by bl nt tra ma- ho#e,er- the proximal end o+ the d ct sho ld be anastomosed to a Ro x-en-( limb o+ /e/ n m" The patient sho ld be placed on an appropriate re*imen o+ antibiotics" &perati,e !n/ ry o+ the Bile ) cts The *reat ma/ority o+ in/ ries o+ the extrahepatic biliary d ct system are iatro*enicocc rrin* in the co rse o+ laparoscopic or open cholecystectomy" !n o,er C9 percent o+ cases- the cholecystectomy had apparently been carried o t #itho t incident" )ia*nosis !n approximately 47 percent o+ the cases- d ctal in/ ries are reco*ni$ed and treated at the time o+ operation" The remainin* 67 percent become mani+est by either increasin* obstr cti,e /a ndice or pro+ se and persistent draina*e o+ bile thro *h a +ist la" Ga ndice s ally becomes mani+est in 2 to 0 days- b t in some instances it does not de,elop +or #ee@s" !t may be contin o s or intermittent= i+ intermittent- it is +re. ently accompanied by attac@s o+ chills and +e,er- s **estin* ascendin* cholan*itis" Hepatome*aly almost al#ays accompanies /a ndice i+ it has been persistent +or se,eral #ee@s- and splenome*aly also may occ r i+ secondary biliary cirrhosis has e,ol,ed" Some patients do not display the si*ns or symptoms o+ partial or complete bloc@a*e ntil months or years a+ter s r*ical treatment" Bloc@a*e in s ch

cases is the res lt o+ increasin* +ibrosis and narro#in* o+ the channel or o+ repeated episodes o+ cholan*itis- #hich in t rn leads to +ibrosis" ERCP or PTC most clearly de+ines the site o+ obstr ction or lea@" Treatment Patients #ith /a ndice or persistent +ist la re. ire a ,i*oro s preoperati,e re*imen that incl des a hi*h-protein- lo#-+at diet and intra,eno s administration o+ +at-sol ble ,itamins- partic larly ,itamin F" Concomitant portal hypertension #ith bleedin* ,arices may precl de repair o+ the common d ct= the portal hypertension is s ally best treated by a splenorenal sh nt beca se o+ extensi,e scarrin* in the ri*ht pper . adrant" &perati,e Approach !n/ ry o+ the bile d ct reco*ni$ed d rin* s r*ical operation sho ld be corrected #ith an immediate reconstr cti,e proced re" Restoration o+ the contin ity o+ the d ct #ith an end-to-end anastomosis o,er a T t be may be +easible a+ter a sharp transection- b t strict re de,elops in abo t hal+ the cases" )irect anastomosis is s ally impractical +or ac te in/ ries and chronic strict res #here the proximal end o+ the d ct sho ld be anastomosed to a Ro x-en-( o+ /e/ n m" A m cosa-to-m cosa approximation pro,ides the best lon*-term res lts" !+ this is not +easible- a lateral-lateral anastomosis bet#een the le+t hepatic d ct and a Ro x-en-( limb o+ /e/ n m 2Hepp- So pa lt5 is pre+erable to the Smith transhepatic m cosal p ll-thro *h techni. e" The ?on*mire operation- #ith transection o+ the le+t lobe o+ the li,er and anastomosis o+ the /e/ n m to a lar*e intrahepatic bile d ct- has been associated #ith disco ra*in* res lts" The operati,e mortality o+ patients #ith chronic strict re is reported to be 0 to 7 percent" A satis+actory res lt is obtained in abo t C9 percent o+ patients a+ter one or more operati,e proced res" !+ the patient is symptom-+ree 1 years a+ter reconstr ctionthe c re is almost al#ays permanent" GA??ST&%ES Composition The ma/or elements in,ol,ed in the +ormation o+ *allstones are cholesterol- bile pi*ment- and calci m" &ther constit ents incl de iron- phosphor s- carbonatesproteins- carbohydrates- m c s- and cell lar debris" !n Destern c lt res- most stones are made p o+ the three ma/or elements and ha,e a partic larly hi*h content o+ cholesterol- a,era*in* C4 percent" P re cholesterol stones are ncommon- s ally lar*e #ith smooth s r+aces- and solitary" Bilir bin pi*ment stones are also ncommon- #ith a characteristic smooth- *listenin*- *reen or blac@ s r+ace" The pi*ment stones may be Ap reB or consist o+ calci m bilir binate" The Ap reB pi*ment stones are s ally associated #ith hemolytic /a ndice or sit ations in #hich the bile is abnormally concentrated" !ncreased red blood cell destr ction a+ter cardiac ,al,e replacement has res lted in prod ction o+ *allstones" Calci m bilir binate stones are pre,alent in Asia- #here they constit te 09 to 19 percent o+ all *allstones" 3ormation Gallstones +orm as a res lt o+ solids settlin* o t o+ sol tion" The sol bility o+ cholesterol depends on the concentrations o+ con/ *ated bile salts- phospholipids- and cholesterol in bile" ?ecithin is the predominant phospholipid in bile- and- altho *h insol ble in a. eo s sol tions- it is dissol,ed by bile salts in micelles" Cholesterol is

also insol ble in a. eo s sol tion b t becomes sol ble #hen incorporated into the lecithin-bile salt micelle" By plottin* the percenta*es o+ cholesterol- lecithin- and bile salts on trian* lar coordinates 23i*" 29-405- the limits o+ micellar li. id in #hich bile is less than sat rated #ith cholesterol may be de+ined" Abo,e these limits- the bile is either a s persat rated li. id or a t#o-phase system o+ li. id bile and solid crystalline cholesterol" Perhaps no more than 09 percent o+ biliary cholesterol is transported in micelles- and o+ that the ma/ority is carried in a ,esic lar +orm" These ,esicles are made p o+ lipid bilayers similar to those +o nd in cell membranes" The ,esicles are able to sol bili$e more cholesterol than are micelles- and the stability o+ these str ct res is belie,ed to be the @ey determinant o+ cholesterol sat ration and precipitation" C rrent theory s **ests that there is an e. ilibri m bet#een the physicochemical phases o+ these ,esicles s ch that the +ormation o+ li. id crystals may or may not res lt in act al *allstones" Dhen crystals achie,e macroscopic si$e d rin* a period o+ entrapment in the *allbladder- *allstones +orm" The basic secretory de+ect in nonobese patients is decreased bile salt and phospholipid secretion" Con,ersely- in obese s b/ects cholesterol secretion is *reatly increased #itho t any red ction in bile salt or phospholipid secretion" % cleation is the process by #hich cholesterol monohydrate crystals +orm and a**re*ate" The time re. ired +or n cleation is shorter in patients #ith *allstones than in those #itho t stones" Speci+ic heat-labile *lycoproteins #ithin cholesterol-sat rated bile ind ce ,esic lar a**re*ation and conse. ent stone *ro#th" 3actors that ha,e been implicated in the +ormation and precipitation o+ cholesterol incl de constit tional elements- bacteria- + n*i- re+l x o+ intestinal and pancreatic +l id- hormones- and bile stasis" Constit tional elements are best exempli+ied in the Pima !ndians- o+ #hom C9 percent o+ +emales by a*e thirty and C9 percent o+ males by a*e sixty ha,e *allstones" The 'asai o+ Fenya- in contrast- do not ha,e *allstones" E,idence in +a,or o+ in+ection as a ca se incl des the isolation o+ s ch or*anisms as Escherichia coliSalmonella typhi- and Streptococc s species +rom *allbladder #alls and +rom the center o+ stones in a hi*h percenta*e o+ cases- and the demonstration o+ slo#-*ro#in* actinomycetes reco,ered +rom o,er hal+ the stones examined in one series" Gi,en that *allstones de,elop in the absence o+ in+ection or in+lammation- in+ection appears not to be a ni,ersal +actor" !n Asians- concretions are @no#n to +orm abo t li,er +l @es and other parasites #ithin the bile d cts" The re+l x +actor recei,es s pport +rom the +indin*s o+ pancreatic en$ymes in the *allbladders o+ patients #ith cholelithiasis" Trypsin dist rbs colloidal balance- and pancreatic phospholipase A can con,ert lecithin into toxic lysolecithin" Hormones ha,e been implicated in a npro,ed correlation bet#een calc li and parity- diabeteshyperthyroidism- and the predominance in +emales" Stasis- #hich incl des temporary cessation o+ bile +lo# into the intestine and sta*nation in the *allbladder- has also been assi*ned a ma/or role in stone +ormation" Temporary bile stasis may be d e to + nctional disorders or to a mechanical bloc@a*e in the re*ion o+ the choledochod odenal / nction or the *allbladder" The interr ption o+ bile +lo# to the intestine is associated #ith an interr ption in enterohepatic circ lation- #hich in t rn is accompanied by a decrease in the o tp t o+ bile salts and phospholipids- red cin* the sol bility o+ cholesterol" Dhen more than 29 percent o+

bile is di,erted- the bile salt pool cannot be maintained" Bile salt secretion is also diminished by red ction o+ the distal third o+ the intestine- explainin* the de,elopment o+ stones in patients #ith ileal resection or disease" Cholecystectomy ca ses a *reater +raction o+ the bile salt pool to cycle aro nd the enterohepatic circ lation- thereby increasin* bile salt and phospholipid secretion" Sol bility has been in,esti*ated as a possible re*imen to pre,ent the de,elopment o+ stones in patients at ris@ as #ell as to dissol,e stones already +ormed" Chenodeoxycholic acid and rsodeoxycholic acid- #hich replenish the bile acid pool and red ce cholesterol synthesis and secretion- administered to potential stone +ormers may ret rn s persat rated bile to its normal composition- pre,entin* stone +ormation" !n one series the dr * #as administered +or 2 years= complete dissol tion o+ radiol cent stones occ rred in 40"7 percent o+ patients" Partial dissol tion occ rred in 14 percent" The e++ects #ere more +re. ent in #omen- in thin patients- and in patients #ith ser m cholesterol le,els *reater than 22C m*Ed?" Clinically si*ni+icant hepatotoxicity #as rare" The direct instillation into the *allbladder o+ a*ents that are capable o+ dissol,in* cholesterol *allstones has become a reality lar*ely as a res lt o+ ad,ances in inter,entional radiolo*ic technolo*y" Altho *h experience is limited- in+ sion o+ a potent cholesterol sol,ent- methyl-tert-b tyl ether 2'TBE5- into the *allbladder ,ia a perc taneo sly placed catheter has been sho#n to be e++ecti,e in selected patients in achie,in* *allstone dissol tion" This proced re is in,asi,e and is there+ore associated #ith some speci+ic ris@s- incl din* hemorrha*e and catheter-related and dr *re* lated problems" The ma/or disad,anta*e o+ this technolo*y is the hi*h rec rrence rate- #hich approaches 79 percent at 7 years" ?ithotripsy has s ccess+ lly +ra*mented biliary calc li b t *enerally is not re*arded as appropriate therapy beca se a diseased or*an remains to +orm ne# stones and the +l shin* e++ected by normal bile +lo# is not e. i,alent to that o+ rinary +lo#" Pi*ment stones can be + rther classi+ied as either Abro#nB or Ablac@B stones" Bro#n stones ha,e a characteristic appearance and consistency and are typically +o nd in Asia" These stones pres mably occ r as a res lt o+ in+ection and are . ite similar to primary bile d ct stones" Blac@ stones- by contrast- typically are not associated #ith in+ected bile" These stones are +o nd in patients #ith hemolytic disorders or cirrhosis" Altered sol bili$ation o+ ncon/ *ated bilir bin #ith precipitation o+ calci m bilir binate and insol ble salts is pres med to be the common +inal path#ay +or the +ormation o+ all pi*ment stones- re*ardless o+ the clinical settin*" Asymptomatic Gallstones The liberal se o+ cholecysto*raphy and ltrasono*raphy has res lted in the dia*nosis o+ calc li in patients #itho t symptoms re+erable to the biliary tract" !n se,eral lar*e series o+ asymptomatic patients #ith *allstones #ho #ere +ollo#ed #itho t s r*ical treatment- symptoms de,eloped in 79 percent- and serio s complications occ rred in 29 percent" By contrast- 'cSherry and associates reported that only 49 percent o+ patients de,eloped symptoms d rin* a mean 7-year +ollo#- p" Similarly- Gracie and Ransoho++ reported a 47-year c m lati,e probability o+ de,elopin* symptoms o+ 46 percent +or 420 patients #ith asymptomatic *allstones- and no deaths +rom *allbladder disease"

The relationship o+ cholelithiasis and carcinoma o+ the *allbladder is also o+ some si*ni+icance" A re,ie# o+ se,eral series sho#ed that the incidence o+ calc li in cancer o+ the *allbladder ran*ed +rom 87 to 499 percent- #ith a mean o+ 99 percent" Con,ersely- the incidence o+ cancer o+ the *allbladder in patients #ith symptomatic *allstones ran*ed +rom 4 to 47 percent- #ith a mean o+ 1"7 percent" Com+ort and associates reported no carcinoma amon* 442 patients #ith asymptomatic cholelithiasis" !n *eneral- patients #ith asymptomatic *allstones sho ld not be treated" )yspepsiaer ctations- and +lat lence are not re*arded as speci+ic symptoms" Dith the ad,ent o+ laparoscopic cholecystectomy- the n mber o+ cholecystectomies per+ormed has increased" Cholecystectomy +or asymptomatic stones may be appropriate +or elderly patients #ith diabetes and +or indi,id als #ho #ill be isolated +rom medical care +or an extended period" Cystic ) ct &bstr ction Temporary obstr ction to the o t+lo# o+ bile +rom the *allbladder is responsible +or the most common mani+estation o+ calc lo s disease- #hich is biliary colic" This consists o+ the intermittent spasmodic pain in the ri*ht pper . adrant- o+ten radiatin* to the sho lder or scap la- and precipitated by a +atty or +ried meal" The attac@s are sel+-limitin* b t ha,e a tendency to rec r in an npredictable manner" Si*ni+icant temperat re ele,ation or le @ocytosis are ncommon" The bilir bin and al@aline phosphatase le,els are normal or sli*htly ele,ated beca se o+ an in+lammatory process- and hyperamylasemia may be present" The treatment is cholecystectomypre+erably by the laparoscopic approach- and is best per+ormed d rin* that hospitali$ation b t not as an emer*ent proced re" Calc li- s ally o+ the cholesterol type- may become impacted in the cystic d ct or the nec@ o+ the *allbladder- res ltin* in #hat is called hydrops o+ the *allbladder" The bile is absorbed- and the *allbladder becomes +illed and distended #ith m cino s material" The *allbladder is *enerally palpable and tender- and the impacted stone #ith the res ltin* edema may encroach on the common d ct and ca se mild /a ndice" Altho *h hydrops may persist #ith +e# conse. ences- early cholecystectomy is *enerally indicated to a,oid the complications o+ biliary tract in+ection- empyema- or per+oration o+ the *allbladder" !n . estionable cases- isotopic scannin* o+ the *allbladder +ollo#in* intra,eno s CCF can de+ine cystic obstr ction or patency" Choledocholithiasis Common d ct stones may be sin*le or m ltiple and are +o nd in 1 to 42 percent o+ cases s b/ected to cholecystectomy" 'ost common d ct calc li are +ormed #ithin the *allbladder and mi*rate do#n the cystic d ct into the common bile d ct" ?ess commonly- stones are tho *ht to +orm #ithin the d cts" These are classi+ied as primary stones- in contradistinction to the secondary stones +ormed in the *allbladder" Primary stones are s ally so+t- non+aceted- yello#ish bro#n- and +riable" !n patients in+ected #ith tropical parasites s ch as Clonorchis sinensis and in the Asian pop lation o+ the 3ar East- stones may +orm #ithin the hepatic d cts or the common bile d ct itsel+" Altho *h small stones may pass ,ia the common d ct into the d oden m- the distal d ct #ith its narro# l men 22 to 0 mm5 and thic@ #all +re. ently obstr cts their passa*e" Edema- spasm- or +ibrosis o+ the distal d ct secondary to irritation by the calc li contrib te to biliary obstr ction" Both

extrahepatic and intrahepatic bile d cts become dilated- and there is e,idence o+ la@in* in the biliary radicles o+ the li,er" There is also thic@enin* o+ the d ct #alls and in+lammatory cell in+iltration" Chronic biliary obstr ction may ca se secondary biliary cirrhosis #ith bile thrombi- bile d ct proli+eration- and +ibrosis o+ the portal tracts" Also associated #ith chronic obstr ction is the de,elopment o+ in+ection #ithin the bile d ct- *i,in* rise to ascendin* cholan*itis and occasionally extendin* p to the li,er- res ltin* in hepatic abscesses" The o++endin* or*anism is almost al#ays E" coli" Gallstone pancreatitis is *enerally associated #ith the presence or passa*e o+ common bile d ct stones" The best e,idence +or this is the +re. ency #ith #hich stones can be +o nd i+ the stool is +iltered at the time o+ an attac@" The +re. ency #ith #hich stones are +o nd in the common d ct ,aries +rom 4 percent to C9 percent- dependin* on the time o+ the operation" At the time o+ exploration- the pancreas may appear entirely normal- or it may demonstrate edema and rarely necrosis 2necroti$in* pancreatitis5" Clinical 'ani+estations The mani+estations o+ calc li #ithin the common d ct are ,ariable" Stones may be present #ithin the extrahepatic d ct system +or many years #itho t ca sin* symptoms" Characteristically- the symptom complex consists o+ colic@y pain in the ri*ht pper . adrant radiatin* to the ri*ht sho lder #ith intermittent /a ndice accompanied by pale stools and dar@ rine" Biliary obstr ction is s ally chronic and incomplete b t may be ac te or complete" !+ obstr ction is complete- /a ndice pro*resses b t is rarely intense" !n contrast to patients #ith neoplastic obstr ction o+ the common bile d ct or the amp lla o+ :ater- the *allbladder is s ally not distended beca se o+ associated in+lammation 2Co r,oisier>s la#5" ?i,er + nction tests demonstrate the pattern o+ obstr cti,e /a ndice- and the al@aline phosphatase le,el s ally becomes ele,ated earlier and remains abnormal +or lon*er periods than the ser m bilir bin le,el" The prothrombin time is +re. ently prolon*ed beca se the absorption o+ ,itamin F is dependent on bile enterin* the intestine- b t a normal le,el can s ally be achie,ed #ith parenteral ,itamin F" Tests o+ hepatocell lar + nction *enerally ha,e normal res lts" !n patients #ith ascendin* cholan*itis- Charcot>s intermittent +e,er accompanied by abdominal pain and /a ndice is characteristic" The dia*nosis may be established by ERCP or PTC" Treatment The indications +or the remo,al o+ common d ct stones are< 245 their presence as de+ined preoperati,ely in a symptomatic patient or by palpation or cholan*io*raphically at the time o+ operation= 225 a dilated extrahepatic d ct= 205 /a ndice= 215 rec rrent chills and +e,ers s **esti,e o+ cholan*itis= and 275 *allstone pancreatitis" Common d ct stones can be remo,ed by ERCP- and the per+ormance o+ an ade. ate destr ction o+ the sphincter o+ &ddi #ill permit stones that #ere not extracted or +orm at a later date to pass into the d oden m #itho t obstr ction in the extrahepatic d cts" !n a patient nder*oin* an electi,e cholecystectomy in #hom common d ct stones are tho *ht to be present- a preoperati,e ERCP and sphincterotomy can be +ollo#ed by laparoscopic cholecystectomy" !n some elderly patients ERCP and sphincterotomy ha,e constit ted de+initi,e treatment and the *allbladder #as not remo,ed"

!+ common d ct stones are detected d rin* laparoscopic cholan*io*ram- they can be remo,ed by s bse. ent ERCP or d rin* the proced re by trans-cystic d ct retrie,al or p shin* them into the d oden m" Alternati,ely- the common d ct can be opened- the stones extracted- and a T t be inserted" !+ common d ct stones are s spected or detected d rin* open cholecystectomy- the same alternati,es apply" The se o+ the choledochoscope and reteral bas@ets +acilitates the proced re" !n the patient pop lation as a #hole- concomitant choledochostomy at the time o+ cholecystectomy increases the operati,e mortality by less than 4 percent" !n addition- in the +ace o+ dilated common d ct and m ltiple stones- a choledochod odenostomy can pro,ide de+initi,e treatment" Retained Common ) ct Stones !+ stones are noted to be present #hen a T-t be cholan*io*ram is per+ormed postoperati,ely 23i*" 29-415- se,eral approaches can be entertained" Small stonespartic larly those located in the branches o+ the hepatic d ct- may be disre*arded= the ma/ority #ill remain asymptomatic- and +or those that do *enerate symptoms operati,e extraction is not associated #ith si*ni+icantly increased morbidity" Another approach employs either +l shin* or chemical dissol tion" Capm l 6249- a monooctanoin- is the a*ent o+ choice" The se o+ heparin- 279-999 nits in a 279-m? sol tion in+ sed e,ery 6 h +or 7 days- has been s ccess+ l" The mechanical extraction o+ the retained stone can be per+ormed nder radio*raphic control" 'a$$ariello reported a 98 percent s ccess rate +or 4968 cases- and B rhenne and associates reported a 94 percent s ccess rate +or 842 patients mana*ed at 06 hospitals- #ith no deaths and no si*ni+icant complications" The T t be is *enerally le+t in place +or at least 1 #ee@s a+ter the operation= it is then extracted and a polyethylene catheter is sed to instill radiopa. e material into the common d ct" A )ormia bas@et is then ad,anced thro *h the catheter to entrap the stone 23i*" 29-475" The most commonly sed approach is transd odenal papillotomy #ith extraction o+ the stone nder endoscopic ,is ali$ation 23i*" 29-485" The s ccess rate +or extraction or spontaneo s passa*e a+ter this proced re #as 68 percent +or C04 collected cases" A complication rate o+ C percent #as noted- b t t#o-thirds o+ complications #ere treated conser,ati,ely" The mortality rate related to the techni. e #as 4"27 percent" &perati,e inter,ention is indicated in some cases i+ there is e,idence o+ obstr ction or cholan*itis- or i+ nonoperati,e methods +ail" Some calc li remain #ithin the li,er and may ca se irre,ersible dama*e" The most common location is a le+t main hepatic d ct that +orms a cisterna- and s ccess+ l treatment is best achie,ed in this circ mstance by resection o+ the le+t lobe o+ the li,er" !n occasional patients #ith rec rrent hepatic d ct stones- a Ro x-en-( limb can be anastomosed to the hepatic d ct 2 s ally the le+t main d ct5 and positioned so that it can be entered nder radio*raphic * idance to permit stone extraction" Biliary Enteric 3ist la and Gallstone !le s A stone in the amp lla o+ the *allbladder 2Hartmann>s po ch5 can encroach pon and erode the common bile d ct" This is @no#n as 'iri$$i>s syndrome" &perati,e mana*ement depends on the extent to #hich the common d ct has been compromised" !+ there is only a press re e++ect- cholecystectomy is s ++icient" !+ the common d ct se*ment is partially or completely destroyed- a reconstr cti,e proced re

is mandated and may re. ire a Ro x-en-( limb anastomosis to the proximal normal d ct" Dhen biliary enteric +ist las de,elop- they s ally r n bet#een the *allbladder and the d oden m- b t 47 percent are cholecystocolic +ist las" 'echanical obstr ction o+ the *astrointestinal tract ca sed by *allstones is a relati,ely in+re. ent occ rrence" Gallstone ile s ca ses 4 to 2 percent o+ mechanical small-intestine obstr ctions= the mortality rate is less than 49 percent" Since cholelithiasis occ rs three to six times more commonly in the +emale than in the male- a hi*her incidence o+ *allstone ile s in the +emale is to be anticipated" Preponderance in the +emale is act ally hi*her than one #o ld expect- and in se,eral series all patients #ere +emale" !t is characteristically a disease o+ the a*ed- #ith an a,era*e a*e o+ sixty-+o r- and is n s al nder the a*e o+ +i+ty" The process s ally be*ins #ith +ormation o+ the stone #ithin the *allbladder- b t cases ha,e been reported in #hich the *allbladder #as not present- ha,in* been remo,ed se,eral years prior to the intestinal obstr ction" A+ter the *allstone has le+t the *allbladder- it may obstr ct the alimentary tract in one o+ t#o #ays" Typicallyintral minal obstr ction is prod ced by the entrance o+ the stone into the *astrointestinal tract" Rarely- the stone enters the peritoneal ca,ity- ca sin* @in@in* or in+lammation and extrinsic obstr ction o+ the intestine" The stone may enter the d oden m ,ia the common d ct- b t this is n s al- and almost al#ays the o++endin* calc l s enters thro *h a cholecystenteric +ist la" The +ist lo s tract may connect the *allbladder #ith the stomach- d oden m- /e/ n m- ile m- or colon" !n additioninternal biliary +ist las may comm nicate #ith the ple ral or pericardial ca,itiestracheobronchial tree- pre*nant ter s- o,arian cyst- renal pel,is- and rinary bladder" !n a series o+ 4C8 +ist las ca sed by *allstones- the d oden m #as in,ol,ed in 494the colon in 00- the stomach in C- and m ltiple sites in44" The +ist la probably ori*inates #ith a stone obstr ctin* the cystic d ct- ac te cholecystitis- empyema- and the +ormation o+ adhesions bet#een the *allbladder and ad/acent ,iscera" Per+oration then occ rs bet#een the intimately adherent or*ans- and the stone tra,erses the +ist la" The cholecystenteric +ist la then +re. ently closes- and only a +ibro s remnant remains" Ha,in* entered the alimentary tract- the *allstone#hich is s ally sin*le- may be ,omited or passed spontaneo sly ,ia the rect m" The si$e o+ the stone is important- since stones smaller than 2 to 0 cm s ally pass" Dhen obstr ction occ rs- the site is s ally at the terminal ile m- #hich is the narro#est portion o+ the small intestine" &+ 471 cases- the d oden m #as obstr cted in 8- the /e/ n m in 41- the proximal ile m in 8- the middle ile m in 04- the terminal ile m in 66- the colon in 0- and the rect m in 2" Dhen a *allstone bloc@s the small intestinethe morbid anatomic and physiolo*ic e++ects o+ a mechanical obstr ction obtain" There are ,ery lar*e losses o+ +l id into the intestine" Edema- lceration- or necrosis o+ the bo#el may occ r- and per+oration may res lt" Clinical 'ani+estations A past history s **esti,e o+ cholelithiasis is present in 79 to C7 percent o+ patients" Symptoms o+ ac te cholecystitis immediately precedin* the onset o+ *allstone ile s occ r in one-. arter to one-third o+ the cases" A history o+ /a ndice is present in abo t 49 percent o+ the cases" &ccasionally- there may be an initial episode o+ pain s **esti,e o+ biliary colic- b t ma/or pain is s ally not experienced ntil the intestinal colic res lts" There is associated crampin*- na sea- and ,omitin*- #hich

may be intermittent" Dhen complete small intestinal obstr ction occ rs- the ,omitin* increases and obstipation res lts" :omitin* is present in almost 499 percent- cramps in 99 percent- distention in 99 percent- obstipation in C6 percent- and +ec lent ,omitin* in 8C percent" Ser m electrolyte le,els re,eal the pattern o+ lo#er intestinal obstr ction #ith mar@ed hypochloremia- hyponatremia- hypo@alemia- and an ele,ated carbonate le,el" The correct preoperati,e dia*nosis is in+re. ently made- ran*in* bet#een 40 and 09 percent in se,eral series" The s al dia*nosis is that o+ intestinal obstr ction o+ n@no#n ca se" Radiolo*ic examination may be dia*nostic i+ *as is demonstrated #ithin the biliary tract 23i*" 29-4C5" 3lat- pri*ht- and lateral +ilms pl s spot +ilms o,er the li,er are indicated i+ the dia*nosis is considered" The plain x-ray +ilm re,eals the pattern o+ small-intestine obstr ction- and a stone is ,is ali$ed in less than 29 percent o+ the cases" The dia*nosis has also been based on the mi*ration o+ a pre,io sly obser,ed radiopa. e *allstone" Treatment Biliary enteric +ist las are mana*ed by cholecystectomy and clos re by primary repair o+ the intestinal openin*" The patient #ith *allstone ile s o+ten re. ires +l id and electrolyte replacement in order to correct de+iciency- and a naso*astric t be is sed to decompress the stomach" )e+initi,e therapy consists o+ locatin* the stone or stonesenterotomy proximal to the stone- and remo,al o+ the o++endin* calc li #ith clos re o+ the intestine" The rec rrence rate o+ *allstone ile s is 7 to 9 percent- and it is important to palpate the entire small intestine- *allbladder- and common d ct +or retained stones- partic larly i+ the obstr ctin* stone is +aceted" Either concomitant or planned inter,al cholecystectomy and clos re o+ the +ist la- i+ patent- is indicatedsince rec rrent symptoms or complications de,elop in one-third o+ the patients" Carcinoma o+ the *allbladder has also been present or de,eloped 7 to 48 years a+ter remo,al o+ the obstr ctin* *allstone" Per+ormance o+ concomitant cholecystectomy is determined by the patient>s *eneral condition" 'any o+ these patients are extremely ill and depleted- and prolon*ation o+ the operati,e proced re may be contraindicated" !%3?A''AT&R( A%) &THER BE%!G% ?ES!&%S Ac te Cholecystitis Ac te cholecystitis is s ally associated #ith an obstr ction o+ the nec@ o+ the *allbladder or cystic d ct ca sed by stones impacted in Hartmann>s po ch" )irect press re o+ the calc l s on the m cosa res lts in ischemia- necrosis- and lceration #ith s#ellin*- edema- and impairment o+ ,eno s ret rn" These processes in t rn increase and extend the intensity o+ the in+lammation" The lceration may be so extensi,e that the m cosa is +re. ently hard to de+ine on microscopic examinationand se*mented le @ocytes are +o nd in+iltratin* all layers" The res lts o+ necrosis are per+oration #ith pericholecystic abscess +ormation- +ist li$ation- or bile peritonitis" !n the past- ac te cholecystitis secondary to systemic in+ection occ rred most commonly #ith typhoid +e,er- b t this is no# rare" A bacterial ca se has been proposed and positi,e bile c lt res ha,e been noted in 89 percent o+ patients" E" coli- Flebsiella species- streptococci- Enterobacter aero*enes- salmonellae- and clostridia ha,e all been implicated" Ac te cholecystitis- ca sed by *enerali$ed sepsis or by stasis or impaction o+ a calc l s- may occ r #hile the patient is reco,erin* +rom tra ma or an operation"

Amon* other ca ses o+ ac te cholecystitis are the ,asc lar e++ects o+ colla*en diseaseterminal states o+ hypertensi,e ,asc lar disease- and thrombosis o+ the main cystic artery" Ac te cholecystitis in #hich the *allbladder is de,oid o+ stones is @no#n as acalc lo s cholecystitis" ?ess than 4 percent o+ ac tely in+lamed *allbladders contain a mali*nant t mor that may play a role in ca sin* obstr ction" The incidences o+ common d ct calc li are similar in ac te and in chronic cholecystitis- a,era*in* C to 47 percent" Clinical 'ani+estations 'ost attac@s o+ ac te cholecystitis occ r in patients #ho *i,e a history compatible #ith chronic cholecystitis and cholelithiasis" Ac te cholecystitis can occ r at any a*eb t the *reatest incidence is bet#een the +o rth and ei*hth decades- and patients o,er the a*e o+ sixty comprise bet#een one- . arter and one-third o+ the *ro p" Ca casians are a++licted more +re. ently than blac@s- and #omen more than men" The onset o+ ac te symptoms is +re. ently related to a ,i*oro s attempt o+ the *allbladder to empty its contents- s ally a+ter a hea,y- +atty- or +ried meal" 'oderate to se,ere pain is experienced in the ri*ht pper . adrant and epi*astri m and may radiate to the bac@ in the re*ion o+ the an*le o+ the scap la or in the interscap lar area" The patient is o+ten +ebrile- and ,omitin* may be se,ere" Tenderness- s ally alon* the ri*ht costal mar*in- o+ten associated #ith rebo nd tenderness and spasm- is characteristic" The *allbladder may be palpable- or a palpable mass in the re*ion may be the res lt o+ oment m #rapped aro nd the *allbladder" 'ild icter s may be present and may be ca sed by calc li #ithin the amp lla and edema encroachin* on the common d ct" 'oderate to mar@ed /a ndice- partic larly #ith a ser m bilir bin le,el *reater than 8 m*Ed?- s **ests the presence o+ associated choledocholithiasis b t can occ r #ith isolated cholecystitis" The di++erential dia*nosis incl des per+oration or penetration o+ peptic lcerappendicitis- pancreatitis- hepatitis- myocardial ischemia or in+arction- pne moniaple risy- and herpes $oster in,ol,in* an intercostal ner,e" The hemo*ram s ally demonstrates le @ocytosis #ith a shi+t to the le+t" Radio*raphs o+ the chest and abdomen are indicated to r le o t pne monia" A radiopa. e calc l s is noted in less than 29 percent o+ cases" The ser m bilir bin le,el may determine the presence o+ common d ct obstr ction" Altho *h an ele,ated amylase le,el is *enerally re*arded as e,idence o+ ac te pancreatitis- le,els as hi*h as 4999 Somo*yi nits ha,e been associated #ith ac te cholecystitis ncomplicated by pancreatitis" To r le o t myocardial ischemia- an electrocardio*ram sho ld be per+ormed on any patient o,er the a*e o+ +orty-+i,e bein* considered +or s r*ical treatment" Ac te cholecystitis may be responsible +or some electrocardio*raphic chan*es" &ral cholecysto*raphy is o+ limited ,al e beca se o+ impaired absorption o+ dye" An ltrasono*ram may demonstrate calc li andEor a thic@ened #all o+ the *allbladder and is the dia*nostic proced re o+ choice" Radion clide scannin* #ith )!S!)A 2diisopropyl iminodiacetic acid5 or P!P!)A 2%-para-isopropyl-acetanilideiminodiacetic acid5 is the most e++ecti,e dia*nostic st dy in this sit ation" Treatment There ha,e been con+lictin* opinions on the mana*ement o+ ac te cholecystitispartic larly on the optimal time +or s r*ical inter,ention" 3or the p rposes o+

disc ssion- early operation is de+ined as one per+ormed #ithin C2 h a+ter the onset o+ symptoms= intermediate operation is one carried o t bet#een C2 h and the cessation o+ clinical mani+estations= delayed operati,e mana*ement permits the ac te in+lammatory process to s bside= and sched led electi,e s r*ery is per+ormed a+ter an inter,al o+ 8 #ee@s to 0 months" 'ost s r*eons no# +a,or early operation- i"e"- #ith 21 to 16 h" The mortality rate +or emer*ent cholecystectomy ran*es +rom 9 to 7 percent" !n the ma/ority o+ cases- laparoscopic cholecystectomy is s ccess+ l- b t the incidence o+ con,ersion to open cholecystectomy is *reater in this *ro p o+ patients #hen compared to those #itho t ac te in+lammation" !n rare instances o+ extremely ill patients- cholecystostomy nder local anesthesia is applicable" Emphysemato s Cholecystitis Emphysemato s cholecystitis is a rare +orm o+ ac te- s ally *an*reno scholecystitis- associated #ith the presence o+ *as in the *allbladder 23i*" 29-465" Hnli@e ordinary ac te cholecystitis- #hich is more pre,alent amon* #omenemphysemato s cholecystitis is more o+ten +o nd in men- #ith incidences o+ C7 percent +or males and 27 percent +or +emales" Patho*enesis is related to ac te in+lammation o+ the *allbladder- #hich o+ten be*ins aseptically- complicated by a secondary in+ection #ith *as- +ormin* bacilli" These may reach the *allbladder by bile d cts- bloodstream- or lymphatic channels and *ro# in an anaerobic en,ironment" The clinical mani+estations are similar to those o+ ac te cholecystitis" !n approximately hal+ the patients- a history o+ pre,io s *allbladder attac@s can be elicited" Cholelithiasis is also present in hal+ the patients- #ho are +re. ently diabetic" The dia*nosis is s ally made on the basis o+ radio*raphs that sho# a *lob lar- *as+illed shado# in the re*ion o+ the *allbladder" ?ater- intram ral or s bm cosal *as may appear- and *as may also appear in the pericholecystic area- denotin* extension o+ the patholo*ic process o tside the con+ines o+ the *allbladder" The treatment o+ choice is early operation- since the incidence o+ +ree per+oration is reported to be 19 to 89 percent" Cholecystectomy is indicated- b t i+ it is not +easible- cholecystostomy sho ld be per+ormed" !n 9 percent o+ cases- choledocholithiasis is present- and exploration o+ the common d ct may be re. ired" Altho *h positi,e bile c lt res are +o nd in only hal+ the cases- antibiotics directed to#ard the clostridial and coli+orm or*anisms are indicated" The mortality rate is si*ni+icantly *reater than that +or nonemphysemato s cholecystitis" Chronic Cholecystitis Chronic in+lammation o+ the *allbladder is *enerally associated #ith cholelithiasis and consists o+ ro nd cell in+iltration and +ibrosis o+ the #all" B ried crypts o+ m cosa 2Ro@itans@y-Ascho++ sin ses5 may be seen dippin* into the m cosa 23i*" 29-495" &bstr ction by *allstones o+ the nec@ o+ the cystic d ct may prod ce a m cocele o+ the *allbladder 2hydrops5" The bile is initially sterile b t may be secondarily in+ected #ith coli+orm bacilli- Flebsiella species- streptococci- and occasionally clostridia or Salmonella typhi" Secondary e++ects o+ cholecystitis incl de obstr ction o+ the common d ct- cholan*itis- per+oration o+ the *allbladder #ith +ormation o+ a pericholecystic abscess or a cholecystenteric +ist la- bile peritonitis- and pancreatitis" There may be associated carcinoma o+ the *allbladder" Clinical 'ani+estations

The patients *enerally present #ith moderate intermittent abdominal pain in the ri*ht pper . adrant and epi*astri m- occasionally radiatin* to the scap la and interscap lar re*ion" There is s ally a history o+ intolerance o+ +atty or +ried +oodsand the patient may ha,e noted intermittent na sea and anorexia" !+ the patient is not experiencin* ac te pain- there may be no dia*nostic +indin*s on physical examination" &ccasionally tenderness is elicited o,er the *allbladder" )ia*nosis is s ally established by ltraso nd scannin* or an oral cholecysto*ram- #hich demonstrates either the absence o+ +illin* o+ the *allbladder or the presence o+ stones" Hyperplastic Cholecystoses Hyperplastic cholecystoses are characteri$ed by the proli+eration o+ normal tiss e elements" The t#o most common o+ these lesions are cholesterolosis and adenomyomatosis" !n patients #ith cholesterolosis there is e,idence o+ cholesterol deposition #ithin the epithelial cells o+ the lamina propria" The bile o+ these patients contains si*ni+icantly more cholesterol than that o+ normal ad lts- and the abnormality pres mably arises +rom some aberration in cholesterol transport and absorption by the *allbladder epitheli m" The deposition o+ cholesterol #ithin the #all *i,es rise to the *ross description o+ the Astra#berry *allbladder"B Adenomyomatosis is characteri$ed by hyperplasia o+ the m scle and m cosa o+ the *allbladder" 'ali*nant de*eneration is n s al- and it is nclear #hether these disorders can tr ly be the so rce o+ symptoms" Cholecystectomy sho ld be o++ered to these patients only i+ #arranted by symptoms" Treatment The treatment o+ chronic cholecystitis and cholelithiasis is cholecystectomy- and the res lts are s ally excellent" ?aparoscopic cholecystectomy is the proced re o+ choice" Early cholecystectomy is partic larly important +or the diabetic patient" &perati,e mortality o+ less than 4 percent has been reported +or lar*e series" Se,enty+i,e percent o+ patients nder*oin* cholecystectomy +or cholelithiasis are completely relie,ed o+ all preoperati,e symptoms- and the remainin* 27 percent ha,e only mild symptoms that are apparently nrelated to the biliary system" Acalc lo s Cholecystitis Ac te and chronic in+lammatory disease o+ the *allbladder can occ r #itho t stones" Ac te acalc lo s cholecystitis +re. ently is a complication o+ b rns- sepsis- m ltiple system +ail re- cardio,asc lar disease- diabetes- prolon*ed illness- or a ma/or operation" The incidence o+ chronic acalc lo s cholecystitis is di++ic lt to establish" !t is present in o,er 79 percent o+ children and 07 percent o+ %i*erians #ith *allbladder diseaseand the accepted incidence o+ ad lts in the Hnited States is less than 7 percent o+ cases o+ cholecystitis" Possible ca ses incl de 245 anatomic conditions s ch as @in@in*+ibrosis- and obstr ction o+ the cystic d ct by t mor or anomalo s ,essels= 225 thrombosis o+ ma/or blood ,essels- prod cin* ischemia and *an*rene= 205 spasm or +ibrosis o+ the sphincter o+ &ddi in patients #ith a Acommon channelB #ith or #itho t associated pancreatitis= 215 systemic diseases s ch as diabetes mellit s and colla*en diseases= 275 speci+ic in+ections s ch as typhoid +e,er- actinomycosis- and parasitic in+estation= and 285 scarlet +e,er and a #ide ,ariety o+ +ebrile illnesses in yo n* children" The )!S!)A or P!P!)A scan and the ltraso nd scan are occasionally normal in these patients- b t characteristically the ltraso nd demonstrates thic@enin*

o+ the #all" Perc taneo s cholecystostomy has been sed s ccess+ lly 269 percent5 +or dia*nosis and treatment o+ acalc lo s cholecystitis" Treatment Cholecystectomy is pre+erable- b t in one series the patient>s condition mandated cholecystostomy in 41 o+ 48 cases" !n children #ith ac te +ebrile illnesscholecystostomy has been partic larly e++ecti,e- and s bse. ent cholecystectomy has not been re. ired in many o+ these patients" Cholan*itis !n+ection #ithin the biliary d ct system is most +re. ently associated #ith choledocholithiasis b t also has accompanied choledochal cysts and carcinoma o+ the bile d ct- and has +ollo#ed sphincteroplasty" !n+ection and in+lammatory chan*es may extend p the d ct system into the li,er and *i,e rise to m ltiple hepatic abscesses" Clinically- the condition is characteri$ed by intermittent +e,er- pper abdominal painexacerbation o+ /a ndice- pr rit s- and at times ri*or" !n patients #ith common d ct stones in #hom there is ascendin* cholan*itis- a broadspectr m antibiotic directed partic larly at E" coli- #hich is the most common o++endin* or*anism- sho ld be *i,en +or se,eral days be+ore s r*ical treatment" Antibiotics s ally control the in+ection- b t i+ the patient>s temperat re does not +alls r*ical draina*e sho ld not be delayed" This can be accomplished perc taneo sly by the transd odenal or transhepatic ro tes or operati,ely" Ac te S pp rati,e Cholan*itis S pp rati,e cholan*itis- in #hich there is *ross p s #ithin the biliary tract- constit tes one o+ the most r*ent ca ses +or laparotomy in patients #ith obstr cti,e /a ndice" The condition #as +irst described in 46CC by Charcot- #ho s **ested a dia*nostic triad o+ /a ndice- chills and +e,er- and pain in the ri*ht pper . adrant" To theseReynolds and )ar*an added shoc@ and central ner,o s system depression as speci+ic identi+yin* +eat res o+ the condition" The disease occ rs almost excl si,ely in patients o,er C9 years o+ a*e" All patients are +ebrile- and a ma/ority are /a ndiced" Hypotension- con+ sion- or lethar*y occ rs in abo t 29 percent o+ cases" A #hite blood cell co nt o+ less than 42-999Emm0 has been reported in o,er hal+ the patients- probably related to the a*e and lac@ o+ marro# response" Bilir bin- SG&T- and al@aline phosphatase le,els are characteristically ele,ated- b t the ser m amylase le,el is s ally normal" The correct dia*nosis has been made in less than one-third o+ the patients" Patients ha,e been mana*ed emer*ently by establishin* initial draina*e ,ia ERCP or PTC +ollo#ed by de+initi,e operation" At operation- all patients demonstrate *ross distention o+ the common bile d ct- #ith +ran@ p s- +re. ently nder considerable press re- and choledocholithiasis or a t mor obstr ctin* the distal bile d ct" !+ the *allbladder is present- it is in,ariably distended and in+lamed" Spontaneo s per+oration o+ the bile d cts has been reported" S r*ical treatment is directed at rapid decompression o+ the d ct system and is combined #ith lar*e doses o+ antibiotics- partic larly those that achie,e hi*h le,els in the bile" !n a re,ie# o+ the literat re- it #as reported that all patients #ho #ere not operated on

died- and mortality +ollo#in* draina*e or s r*ical proced res ran*ed +rom $ero to 66 percent- a,era*in* 00 percent" Cholan*iohepatitis Cholan*iohepatitis- #hich is also @no#n as rec rrent pyo*enic cholan*itis- is +o nd almost excl si,ely amon* the Chinese- #ith the lar*est n mber o+ cases seen amon* Cantonese li,in* in the Pearl Ri,er delta in China" !n Hon* Fon* it is the most commonly enco ntered disease o+ the biliary passa*es and is the third most common abdominal s r*ical emer*ency a+ter appendicitis and per+orated lcer" !t has also been enco ntered in Great Britain- in A stralia- and in the Chinese pop lation in the Hnited States" Cholan*iohepatitis occ rs most +re. ently in the third and +o rth decades b t has been reported at all a*es and occ rs #ith e. al +re. ency amon* men and #omen" The etiolo*y o+ cholan*iohepatitis is s mmari$ed in 3i*" 29-29" The pyo*enic element probably ori*inates +rom the bo#el and is ca sed by E" coli- Flebsiella species- Bacteroides species- or Enterococc s +aecalis" !n most instances- positi,e c lt res are obtainable +rom the bile and the portal ,eno s blood" The Chinese li,er +l @e- C" sinensis- #as tho *ht to be an important contrib tin* +actor" &ther +actors that ha,e been implicated as contrib tin* ca ses o+ cholan*iohepatitis incl de ascariasis and hemolysis associated #ith malaria" Patholo*y The *allbladder #all is thic@ened b t not *rossly in+lamed" The common bile d ct is also s ally *rossly distended and contains lar*e stones" The stones are prod ced by precipitation o+ bile pi*ments- des. amation o+ epitheli m- and prod cts o+ in+lammation= the n cle s o+ the stone may contain an ad lt Clonorchis #orm- an o, m- or an ascarid" Ac te or hemorrha*ic pancreatitis occ rs in less than 4 percent o+ cases" The most mar@ed chan*es occ r in the li,er- #here the intrahepatic bile d cts are both dilated and constricted" !n+lammatory chan*es are present in the perid ctal tiss e and may pro*ress to +ran@ abscess +ormation" Clinical 'ani+estations !n hi*hly endemic areas- cholan*iohepatitis is the +irst consideration in patients #ith /a ndice- pain- and pyrexia" Pain is s ally located in the ri*ht pper . adrant and epi*astri m and may be colic@y or constant" !n most ac te attac@s there is +e,er accompanied by chills and ri*ors- and 79 percent o+ the patients are /a ndiced- #hile the remainder ha,e an ele,ation o+ the ser m bilir bin le,el" Rec rrence o+ symptoms is one o+ the most characteristic +eat res o+ the disease" 'ost patients appear to be in a toxic condition- #ith temperat res p to 19JC" There is tenderness and * ardin* in the ri*ht pper . adrant" The #hite blood cell co nt is s ally abo t 47-999Emm0- and the ser m bilir bin le,el is *enerally abo,e 2m*Ed?#ith accompanyin* bilir bin ria" There may be e,idence o+ impairment o+ hepatocell lar + nction" !n the ma/ority o+ cases calc li are not demonstrable on ro tine x-ray +ilms" An occasional +indin* o+ si*ni+icance is the presence o+ *as in the biliary tree- #hich may be d e to a secondary *as-+ormin* or*anism or a +ist la bet#een the d ct and d oden m" ERCP or PTC may establish the dia*nosis" 'ani+estations o+ portal hypertension may be present"

Treatment Patients are *enerally prepared #ith antibiotics" S r*ical therapy- ho#e,er- sho ld not be delayed +or the patient #ho is /a ndiced and has pain and pyrexia" The operation consists o+ remo,al o+ the stones and debris +rom the extrahepatic bile d cts +ollo#ed by establishment o+ open draina*e bet#een the in,ol,ed d cts and intestine- s ally #ith a Ro x-en-( limb" Anchorin* the Ro x-en-( limb to the anterior abdominal #all +acilitates s bse. ent repeated dilatation and stone extractions" !+ lar*e hepatic abscesses are noted- draina*e sho ld be per+ormed" ?e+t hepatic lobectomy has been carried o t on occasion- #hen there has been *ross dilatation o+ the d cts and abscess +ormation in the le+t lobe #hile the ri*ht #as apparently normal" The pro*nosis is *enerally * arded- since rec rrence is not ncommon" !n one st dycommon d ct exploration- transhepatic int bation- and hepatotomy #ere associated #ith rec rrence rates o+ 21- 0C- and C7 percent- respecti,ely" Hepatic resection had a +ail re rate o+ only 1 percent- and none o+ the patients had rec rrent stones" !n ad,anced cases- partic larly #ith m ltiple abscesses- the pro*nosis is poor- and the patient e,ent ally s cc mbs to li,er +ail re- septicemia- or cholan*iocarcinoma" Sclerosin* Cholan*itis Sclerosin* cholan*itis is an ncommon disease that in,ol,es all or part o+ the extrahepatic biliary d ct system and o+ten a++ects the intrahepatic biliary radicals as #ell" The disease has also been called obliterati,e cholan*itis and stenosin* cholan*itis- in re+erence to a pro*ressi,e thic@enin* o+ the bile d ct #alls encroachin* pon the l men" !t may be associated #ith *allstones- b t se,eral series ha,e been presented in #hich there #ere no stones in the *allbladder or the common d ct" A si*ni+icant n mber o+ cases ha,e been associated #ith lcerati,e colitis- Crohn>s disease- Riedel>s str ma- retroperitoneal +ibrosis- and porphyria c tanea tarda" The ca se o+ sclerosin* cholan*itis is n@no#n" Histolo*ic sections in se,eral cases +ailed to re,eal any *ran lomato s lesion- metaplasia- or neoplasia" !n se,eral seriesnone o+ the patients had pre,io s s r*ical treatment- and there+ore local tra ma #as excl ded as an etiolo*ic a*ent= irritation o+ the common d ct by passa*e o+ calc li is nli@ely *i,en that there are s ally no stones present in either the common d ct or the *allbladder" !t has been s **ested that the disease may be ca sed by local response to ,iral in+ection- since a relati,e lymphocytosis #ith atypical lymphocytes has been noted" !mm ne response and colla*en disease ha,e also been considered as possible ca ses" A positi,e cell lar imm ne response to biliary anti*ens has been demonstrated" The disease has been noted in patients #ith H!: in+ection" Patholo*y Grossly- there is di++ se thic@enin* o+ the #all o+ the extrahepatic biliary tract and sometimes o+ the intrahepatic d cts- #ith a concomitant encroachment on the l menres ltin* in mar@ed l minal narro#in*" The d ct system may be completely in,ol,edor the hepatic d cts may be spared and the disease restricted to the entire len*th o+ the common d ct" The *allbladder is s ally not in,ol,ed- b t the lymph nodes in the re*ion o+ the common d ct and +oramen o+ Dinslo# are s ally mar@edly enlar*ed and s cc lent" 'icroscopic analyses o+ the a++ected d ct sho# that the #alls are as m ch as ei*ht times thic@er than normal" The areas o+ in+lammation and +ibrosis are in the s bm cosal and s bserosal portions- #ith an edemato s +ield bet#een them" The

m cosa is intact thro *ho t" Biopsy examination o+ the li,er may re,eal bile stasis orin lon*-standin* cases- biliary cirrhosis" The histolo*ic e,al ation is critical- since it is di++ic lt to di++erentiate this disease +rom sclerosin* carcinoma o+ the bile d cts" Clinical 'ani+estations The dia*nosis is to be considered in patients 2partic larly middle-a*ed men5 #ith a clinical and laboratory pict re o+ extrahepatic /a ndice" Ga ndice is s ally associated #ith intermittent pain in the ri*ht pper . adrant- na sea- ,omitin*- and occasionally chills and +e,er" !n lon*-standin* cases #ith biliary cirrhosis- the mani+estations o+ portal hypertension- s ch as bleedin* ,arices and ascites- may be apparent" The dia*nosis has been established by ERCP" At operation a dense in+lammatory reaction in the re*ion o+ the *allbladder and *astrohepatic li*ament is noted" Palpation o+ the d ct re,eals a cordli@e str ct re that may +eel li@e a thrombosed blood ,essel- b t the #all o+ the common d ct is ob,io sly thic@ened and c ts #ith di++ic lty" The ed*es o+ the incision characteristically po t o t" Hs ally only a +ine probe or small Ba@es dilator can be inserted into the l men" Cholan*io*raphy may ,i,idly demonstrate the extensi,e narro#in* o+ the l men 23i*" 29-245" Treatment The appropriate mana*ement o+ sclerosin* cholan*itis remains nclear" %o dr * therapy has achie,ed consistent- or e,en s al- s ccess" The asymptomatic anicteric patient is not treated and is not st died #ith repeated cholan*io*rams i+ /a ndice or cholan*itis does not de,elop" The pr ritic and icteric patient is treated +or 1 to 8 #ee@s #ith prednisone= i+ there is no impro,ement- or i+ cholan*itis is present or de,elops- an operation is per+ormed #ith a preoperati,e cholan*io*ram as a * ide" !+ there is minimal intrahepatic in,ol,ement and dilatation o+ a se*ment o+ the common d ct or common hepatic d ct proximal to mar@ed stenosis- the stenotic se*ment is excised as a biopsy section to r le o t cholan*iocarcinoma- and a direct m cosa-to-m cosa anastomosis is e++ected bet#een the dilated se*ment o+ d ct and a Ro x-en-( limb o+ /e/ n m- pre+erably #itho t a stent" Strict re o+ the con+l ence o+ the hepatic d cts is mana*ed by excision o+ the distal d cts +or patholo*ic e,al ation and anastomosis o+ the hepatic d cts to the Ro x-en-( limb o+ /e/ n m by the m cosa-to-m cosa techni. e" !+ the hepatic d cts are s ++iciently dilated- no stent is sed" !+ these d cts are small- transhepatic stents are sed- b t no attempt is made to dilate intrahepatic d cts" )ata +rom se,eral lar*e centers s **est that selected patients #ith primarily extrahepatic disease can be s ccess+ lly mana*ed #ith hepatico/e/ nostomy and lon*term stentin*" !n patients #ith more di++ se or ad,anced parenchymal disease- hepatic transplantation has become the proced re o+ choice" The role o+ transplantation mi*ht be extended as #e be*in to nderstand more + lly the ris@ o+ cholan*iocarcinoma de,elopin* in patients #ith sclerosin* cholan*itis" 3ibrosis or Stenosis o+ the Sphincter o+ &ddi !n 4661 ?an*enb ch- only 2 years a+ter reportin* the +irst s ccess+ l remo,al o+ a *allbladder- s **ested transd odenal di,ision o+ the Adi,ertic l mB o+ :ater in cases o+ cicatricial stenosis +or chronic in+lammation" !n 4994 &pie called attention to the Acommon channelB theory as the ca se o+ pancreatitis- and in 4940 Archibald s **ested sphincteroplasty as the treatment +or pancreatitis"

The patho*enesis o+ +ibrosis or stenosis o+ the sphincter o+ &ddi and the papilla o+ :ater is not + lly nderstood" ?on*-standin* spasm may play an important role- and in+ection o+ the biliary tract or pancreas has also been implicated" !rritation +rom stones #ithin the common d ct may also lead to +ibrosis" !n a series o+ 79 patients in #hom sphincteroplasty #as per+ormed beca se a small Ba@es dilator co ld not be passed thro *h the sphincter o+ &ddi- biopsy analysis re,ealed no abnormalities in 46#hile 46 sho#ed in+lammatory in+iltration- 4C had minimal +ibrosis- and 2 had di++ se +ibrosis" %o de+inite correlation co ld be +o nd bet#een the ,ario s mani+estations o+ biliary tract disease and the histolo*ic chan*es" Clinical 'ani+estations The main symptom o+ +ibrosis or stenosis o+ the sphincter o+ &ddi is abdominal pains ally colic@y and +re. ently associated #ith na sea and ,omitin*" The pain be*ins in the ri*ht pper . adrant and radiates to the sho lder- and it may be intermittent" &,er hal+ the patients *i,e a history o+ intermittent /a ndice- and many indicate that they ha,e had pre,io s cholecystectomy #itho t relie+ o+ symptoms" Treatment The dia*nosis is *enerally made #hen there is di++ic lty in passin* a %o" 0 Ba@es dilator thro *h the amp lla o+ :ater" Cholan*io*raphy and press re st dies on the common bile d ct ha,e theoretical application" !+ a 0-mm dilator cannot be easily passed thro *h the amp lla- a transd odenal exploration sho ld be carried o t" Thomas and associates compared the res lts o+ transd odenal sphincteroplasty and choledochod odenostomy in 09 patients #ith stenosis or strict re o+ the sphincter" The proced res #ere e. ally and hi*hly e++ecti,e- and neither #as associated #ith a si*ni+icant incidence o+ s bse. ent cholan*itis" Sphincteroplasty is pre+erable i+ the common d ct is small- and a transd odenal approach is indicated i+ an amp llary t mor is s spected" Endoscopic papillotomy has been sed s ccess+ lly- partic larly in E rope- #here the disorder is more +re. ently dia*nosed" Papillitis !n 4928 )el:alle +irst described a beni*n in+lammatory and +ibro s process o+ the amp lla o+ :ater and indicated that it #as a +actor in prod cin* stenosis" !t #as post lated that ac te and s bac te in+lammatory chan*es occ r and that stenosis is the +inal and irre,ersible res lt o+ these chan*es" Acosta and %ardi ha,e presented 84 cases o+ papillitis- 24 o+ #hich #ere chronic lcerati,e papillitis- 29 chronic sclerosin* papillitis- 47 chronic *ran lomato s papillitis- and 7 chronic adenomato s papillitis" The ac te sta*e- #hich is characteri$ed by edema- papillary dilatationhemorrha*e- and in+iltration- may be re,ersible- #hereas sclerosin* papillitis and chronic *ran lomato s papillitis are considered irre,ersible in ,ie# o+ their ine,itable e,ol tion into scar tiss e" The clinical and patholo*ic +eat res associated #ith papillitis incl de the postcholecystectomy syndrome in 09 percent- dilatation o+ the common d ct in 79 percent- biliary disease #itho t stones in 27 percent- obstr cti,e /a ndice in 89 percent- pancreatitis in C9 percent- and li,er dama*e in 27 percent" There has been no correlation bet#een the speci+ic clinical syndromes and the patholo*ic chan*es" A pancreatic e,ocati,e test- sin* morphine-neosti*mine or secretin-CCF- has been sed" Ele,ation o+ at least one ser m pancreatic en$yme le,el by a +actor o+ +o r o,er

the normal le,el- co pled #ith reprod ction o+ the patient>s pain- is considered a positi,e test res lt" The e++icacy o+ this test has been disp ted" Since the ma/ority o+ patients #ith papillitis ha,e irre,ersible lesions- sphincteroplasty is *enerally employed" TH'&RS Carcinoma o+ the Gallbladder Carcinoma o+ the *allbladder acco nts +or 2 to 1 percent o+ *astrointestinal mali*nancies" !ts occ rrence in random a topsy series is abo t 9"1 percent- and approximately 4 percent o+ patients nder*oin* biliary tract operations ha,e carcinoma either as an anticipated dia*nosis or +o nd incidentally" Etiolo*y Approximately 99 percent o+ patients #ith carcinoma o+ the *allbladder ha,e cholelithiasis- b t the patho*enesis has not been de+ined" There is also an association #ith polypoid lesions o+ the *allbladder" Areas o+ dysplasia ha,e been noted in / xtaposition to lar*er 2*reater than 2"7 cm5 stones and in adenomas" 'ali*nant chan*es ha,e been noted more +re. ently in polypoid lesions *reater than 49 mm" The calci+ied AporcelainB *allbladder is associated #ith a 29 percent incidence o+ *allbladder carcinoma" Patholo*y Approximately 69 percent o+ the t mors are adenocarcinomas 2C7 percent o+ these are scirrho s- 47 percent polypoid- and 49 percent m coid5" S. amo s carcinomasadenoacanthomas- and melanomas occ r rarely" The ro tes o+ metastasis incl de spread alon* the lymphatics to the choledochal- peripancreatic- and perid odenal nodes" There is o+ten locali$ed in,asion o+ ,essels #ithin the #all o+ the *allbladderand the t mor +re. ently extends transm rally into the parenchyma o+ the li,er" Dhen metastases are present- the li,er is in,ol,ed in t#o-thirds o+ patients- the re*ional lymph nodes in abo t one-hal+- and the oment m- d oden m- colon- or porta hepatis in abo t one-+o rth" Early reports s **est more +re. ent and rapid rec rrences o+ carcinomas o+ the *allbladder a+ter laparoscopic cholecystectomy" By 4997- 47 cases o+ trocar-site metastases +rom ns spected *allbladder carcinoma +ollo#in* laparoscopic cholecystectomy #ere reported" Clinical 'ani+estations Si*ns and symptoms o+ carcinoma o+ the *allbladder are *enerally indistin* ishable +rom those associated #ith cholecystitis and cholelithiasis" These incl de abdominal discom+ort- ri*ht pper . adrant pain- na sea- ,omitin*- and #ei*ht loss" Hal+ the patients are /a ndiced- and t#o-thirds o+ those #ith clinical mani+estations ha,e a palpable mass" ?aboratory +indin*s are not dia*nostic" Hltraso nd or CT scan may s **est the dia*nosis" Treatment 'ost lon*-term s r,i,ors are patients #ho nder#ent cholecystectomy +or cholelithiasis and in #hom the mali*nancy #as an incidental +indin*" The mana*ement o+ these patients is contro,ersial" There is some s **estion that T2 or more ad,anced t mors ha,e a better pro*nosis i+ a radical second proced re- #hich incl des lymphadenectomy and partial hepatic resection +or lesions located ad/acent to the li,er- is per+ormed" 3or lesions that are apparent at operation- remo,al o+ the

hepatod odenal nodes- resection o+ se*ment !:E: or extended ri*ht hepatectomy andin some cases- pancreaticod odenectomy has been reported to impro,e s r,i,al" By contrast- other reports ha,e indicated that there has been no impro,ement associated #ith these proced res" Some *ro ps ha,e reported that ad/ ,ant radiation therapy or chemotherapy impro,es s r,i,al" Pro*nosis ?ar*e c m lati,e series report 7-year s r,i,al rates o+ 7 percent" The o,er#helmin* ma/ority o+ s r,i,ors are in the *ro p that had incidentally dia*nosed t mors" T4 lesions ha,e a 7-year s r,i,al rate o+ approximately 499 percent" T2 lesions ha,e a s r,i,al rate o+ 19 percent #hen s b/ected to the more radical operations" !n some series- no di++erence #as noted #hen node-ne*ati,e and node-positi,e patients #ere compared" Bile ) ct Carcinoma Patholo*y The a topsy incidence o+ bile d ct carcinoma is abo t 9"0 percent" Hnli@e *allbladder carcinomas- bile d ct t mors occ r more +re. ently in men" There is no e,idence that bile d ct stones ha,e a role- and the relationship bet#een the t mors and sclerosin* cholan*itis remains ill-de+ined" Approximately t#o-thirds o+ the lesions are located in the proximal d cts- o+ten at the con+l ence o+ the ri*ht and le+t main hepatic d cts 2Flats@in t mors5" The t mors are *enerally small b t in,ol,e the #hole thic@ness o+ the d ct- *ro#in* in a scirrho s concentric manner and res ltin* in d ctal obstr ction" The proximal lesions o+ten extend into the hepatic parenchyma" Rarely- the d ctal t mors are polypoid t mors- #hich are associated #ith a more +a,orable pro*nosis- as is the case #ith carcinomas o+ the amp lla o+ :ater" ) ctal lesions are cholan*iocarcinomas o+ the adenocarcinoma type" 'ost t mors are #ell di++erentiated and associated #ith a mar@ed +ibro s reaction" Perine ral in,ol,ement is common" !ntraoperati,e +ro$en-section dia*nosis is o+ten di++ic lt" The li,er and re*ional lymph nodes are the most +re. ent sites o+ metastasis" The incidence o+ metastasis at operation is 79 percent" !n some cases m lticentric d ctal t mors ha,e been reported" Clinical 'ani+estations Characteristically- patients present #ith the recent onset o+ /a ndice- acholic stoolsand dar@ rine" The /a ndice is o+ten preceded by pr rit s" Almost all patients ha,e had si*ni+icant #ei*ht loss associated #ith loss o+ appetite" Hal+ the patients ha,e abdominal pain= cholan*itis may res lt +rom the obstr ction" The *allbladder is palpable in one-third o+ the patients #ho ha,e distal lesions and is not +elt #ith proximal t mors" The laboratory +indin*s are compatible #ith the dia*nosis o+ obstr cti,e /a ndice #ith ele,ation o+ the bilir bin and al@aline phosphatase and mild increase o+ the transaminases" !ncreased le,el o+ carcinoembryonic anti*en 2CEA5 can be detected in the bile" Hltraso nd scannin* demonstrates intrahepatic d ctal dilatation and distention o+ the extrahepatic d cts proximal to the point o+ obstr ction" CT scannin* #ill also de+ine the extent and location o+ d ctal dilatation= it rarely demonstrates the t mor itsel+" Precise demonstration o+ the site o+ obstr ction is achie,ed by PTC or ERCP" !n the +ace o+ isolated intrahepatic d ctal dilatation- the +ormer is pre+erable-

and #hen there is e,idence o+ distention o+ the *allbladder or extrahepatic d ctsERCP is more re#ardin* 23i*" 29-225" Treatment Treatment is directed at resectin* the t mor- i+ possible- or palliation by relie,in* the obstr ction" C re can be achie,ed only by s r*ical remo,al o+ the lesion- #hile palliation can be e++ected by operation- radiolo*ic inter,ention- or endoscopic decompression" C rati,e resection *enerally entails remo,al o+ the common d ct and the common hepatic d ct p to and sometimes incl din* the con+l ence o+ the ri*ht and le+t hepatic d cts- +ollo#ed by anastomosis o+ the proximal dilated system to a Ro x-en-( limb o+ small intestine 23i*" 29-205" The resectability o+ proximal t mors is abo t 29 percent- and the c re rate remains nder 47 percent" !+ a proximal lesion extends into the li,er parenchyma- ,aryin* amo nts o+ the li,er are remo,ed en blocand proximal intrahepatic d cts are anastomosed to the intestine 23i*" 29-215" &rthotopic li,er transplants ha,e been per+ormed +or intrahepatic t mors #ith some lon*-term s r,i,ors" The c re o+ distal bile d ct t mors has been impro,ed by radical lymphadenectomy and pancreaticod odenectomy 2Dhipple proced re5" S r*ical palliation is per+ormed by anastomosin* the dilatated d ctal system proximal to the point o+ obstr ction to the limb o+ intestine" !n more proximal lesions- this can be achie,ed by sin* the extrahepatic portion o+ the le+t main hepatic d ct 23i*" 29275" Transection o+ the li,er to the le+t o+ the +alci+orm li*ament and anastomosin* the intestine to the dilated hepatic d ct 2?on*mire proced re5 rarely pro,ides lon*-term relie+ o+ /a ndice" Hsin* PTC or ERCP- a stent can be passed thro *h the t mor to pro,ide draina*e o+ the dilated d cts" These re. ire +re. ent chan*es" E++ort sho ld be directed to pro,idin* draina*e into the intestine rather than externally beca se external draina*e o+ bile pre,ents an enterohepatic circ lation and is accompanied by loss o+ appetite" There ha,e been con+lictin* reports re*ardin* the e++icacy o+ ad/ ,ant radiotherapy and chemotherapy +or either c re or palliation" &PERAT!&%S &3 THE B!?!AR( TRACT Perioperati,e Considerations Prophylactic antibiotics are not indicated +or patients nder*oin* electi,e cholecystectomy nless there are speci+ic ris@ +actors" These incl de /a ndicecommon d ct stones- diabetes- and a*e *reater than 87 years" !nter,entional proced res s ch as PTC or ERCP- especially in patients #ith biliary tract obstr ctionsho ld be co,ered #ith prophylactic antibiotic therapy" The antibiotic s ally is selected #ith the ass mption that the most li@ely in,ol,ed or*anisms are E" coliFlebsiella species- and enterococci" A second-*eneration cephalosporin is appropriate" The dr * is administered be+ore the operation or inter,ention- and t#o s bse. ent doses are *i,en at 8-h inter,als" Preoperati,e decompression o+ the proximal distended d cts in patients #ith obstr cti,e /a ndice does not si*ni+icantly impro,e the o tcome and has been associated #ith an increased incidence o+ complications" Short- term draina*e may be indicated as a brid*e to an operation in a patient #ith cholan*itis and sepsis" The preoperati,e placement o+ catheters transhepatically may +acilitate dissection o+ proximal t mors- and they can be le+t in place as stents that tra,erse anastomoses" Cholecystostomy

Cholecystostomy accomplishes decompression and draina*e o+ the distendedhydropic- or p r lent *allbladder" !t is partic larly applicable i+ the patient>s *eneral condition is s ch that it precl des prolon*ed anesthesia- since the operation may be per+ormed nder local anesthesia" !t is also per+ormed in cases in #hich mar@ed in+lammatory reaction obsc res the anatomic relation o+ critical str ct res" Cholecystostomy may be a de+initi,e proced re- partic larly i+ a postoperati,e t be cholan*io*ram is normal" Techni. e 23i*" 29-285" A circ m+erential p rse-strin* s t re is placed in the + nd s o+ the *allbladder- and a small incision is made thro *h the serosa #ithin the s t re" A trocar is inserted into the l men o+ the *allbladder- #hich is then decompressed" A+ter the *allbladder has been emptied- a stone +orceps may be introd ced to the / nction o+ the amp lla and cystic d ct- and obstr ctin* calc li may be remo,ed" A m shroom or 3oley catheter is inserted into the l men o+ the *allbladder- and a second p rse-strin* s t re is placed concentrically to the +irst one" The s t res are tied- in,ertin* the serosa" Hnless a small- obli. e incision #as sed initially- the draina*e t be sho ld be bro *ht o t thro *h a stab #o nd" !+ the + nd s o+ the *allbladder is necrotic- the *an*reno s portion sho ld be excised and the remainder o+ the *allbladder closed aro nd the catheter- sin* p rse-strin* s t res" &pen Cholecystectomy A principal aim o+ open cholecystectomy is to a,oid in/ ry to the common d ct close to its / nction #ith the common bile d ct to ob,iate a lon* cystic d ct remnant" A more conser,ati,e approach to#ard electi,e cholecystectomy is indicated +or cirrhotic patients" !+ an operation is per+ormed- increased bleedin* sho ld be anticipated= extensi,e intrahepatic dissection sho ld be a,oided" !ntraoperati,e in+ sion o+ ,asopressin and an anti+ibrinolytic a*ent sho ld be considered" Techni. e 23i*" 29-2C5" The *allbladder may be approached thro *h an obli. e ri*ht pper . adrant incision 2Focher or Co r,oisier5- thro *h a ,ertical ri*ht paramedian incision- or thro *h the pper midline" There are +re. ently adhesions bet#een the *allbladder- partic larly the amp lla- and the d oden m and colon" These sho ld be lysed by sharp dissection" By applyin* traction laterally to the amp lla and retractin* the d oden m medially- the ,eil o+ peritone m r nnin* +rom amp lla to hepatod odenal li*ament may be accent ated and incised" The cystic d ct is identi+ied and a sil@ li*at re passed aro nd it" Traction is applied to the li*at re to pre,ent passa*e o+ a stone do#n the cystic d ct d rin* dissection o+ the *allbladder" )issection is contin ed craniad in this peritoneal +old- and the cystic artery is identi+ied" The co rse o+ this artery to the *allbladder sho ld be demonstrated to a,oid li*atin* the ri*ht hepatic artery" The cystic artery sho ld be do bly li*ated and transected" !+ bleedin* occ rs +rom the cystic artery- it is best controlled by applyin* press re on the hepatic artery #ithin the hepatod odenal li*ament" The artery is compressed bet#een the index +in*er- #hich is inserted into the +oramen o+ Dinslo#and the th mb anteriorly" The peritone m o,erlyin* the *allbladder is then incised close to the li,er- and dissection is be* n +rom the + nd s o+ the *allbladder do#n to an ltimate pedicle o+ cystic d ct" ) rin* this dissection- blood ,essels co rsin* +rom

the li,er may re. ire li*ation- and the *allbladder bed sho ld be inspected +or lar*e drainin* d cts- #hich sho ld also be li*ated" Attention is then directed to#ard ,is ali$ation o+ the / nction o+ the cystic d ct and the common d ct" The cystic d ct is transected and li*ated 0 to 7 mm +rom the common bile d ct" !t is not necessary to close the bed o+ the *allbladder" A drain may be bro *ht o t +rom the hepatorenal po ch- #hich is the most dependent portion o+ the pper abdomen #ith the patient in the s pine positon- ,ia a separate stab #o nd i+ there is any concern that blood #ill acc m late or i+ there is mar@ed pericholecystic in+lammation and edema" Se,eral series ha,e sho#n that in the absence o+ speci+ic indications- draina*e is not re. ired" This method is directed at +acilitatin* demonstration o+ the / nction bet#een the cystic d ct and the common bile d ct" The *allbladder may also be remo,ed in the socalled retro*rade +ashion- in #hich the cystic d ct is li*ated close to the / nction #ith the common d ct as the initial part o+ the proced re" Then- a+ter the cystic d ct and artery ha,e been transected- dissection is be* n +rom the cystic d ct and contin ed o t#ard to#ard the + nd s 23i*" 29-265" ?aparoscopic Cholecystectomy The application o+ minimally in,asi,e s r*ical techni. es to remo,al o+ the *allbladder has emer*ed as the pre+erred #ay o+ treatin* symptomatic *allstone disease" Altho *h a s bcostal incision is a,oided- these operations sho ld be ,ie#ed #ith the same respect +or s r*ical principles as are the open proced res" Trocars are introd ced a+ter the instillation o+ a pne moperitone m- and the *allbladder and li,er can be retracted so as to pro,ide optimal ,is ali$ation" !t is essential that the d ctal str ct res be care+ lly identi+ied be+ore di,ision" Beca se o+ the nat re o+ this proced re- bleedin* is a partic larly #orrisome problem and sho ld be * arded a*ainst" This proced re be*ins by retractin* the *allbladder p o,er the ed*e o+ the li,er so as to +acilitate expos re o+ the trian*le o+ Calot 23i*" 29-295" The cystic d ct and artery are then identi+ied- and d ctal anatomy is con+irmed" &perati,e cholan*io*raphy can be sed to selecti,ely de+ine anatomy as #ell as to search +or common bile d ct stones" The cystic d ct is then di,ided" The *allbladder is dissected +rom this area p to#ard the + nd s" Be+ore complete separation o+ the *allbladder +rom the li,er bed- the *allbladder +ossa sho ld be care+ lly inspected +or bleedin*" A+ter this has been mana*ed- the *allbladder is care+ lly #ithdra#n thro *h one o+ the ports and the pne moperitone m released" As #ith open cholecystectomy- bile d ct in/ ry and hemorrha*e can and sho ld be a,oided" &perations o+ the Extrahepatic Bile ) ct Exploration +or Choledocholithiasis 23i*" 29-095" Exploration +or choledocholithiasis is indicated #hen d ctal stones ha,e been identi+ied by palpation or cholan*io*raphy or #hen the ca se o+ obstr ction has not been de+ined" The proced re is o+ten +acilitated by per+ormin* a Focher mane ,er 2+reein* the lateral and posterior attachments o+ the second portion o+ the d oden m5" Common d ct dissection can be +acilitated by traction on the cystic d ct" A+ter the anterior aspect o+ the d ct has been ,is ali$ed- aspiration o+ bile #ith a +ine needle pro,ides con+irmation" A+ter a +ixation s t re has been placed laterally and medially and traction applied- a ,ertical incision is made bet#een these thro *h the anterior #all" A choledochoscope can be introd ced at this time to ,is ali$e the l men and determine #hether any stones are present"

) ctal stones can be remo,ed by irri*ation- balloon-tipped catheters- scoops- or +orceps" These proced res sho ld be applied initially to the distal common d ct and s bse. ently proximally to each o+ the main hepatic d cts" A+ter the stones ha,e been remo,ed- a %o" 0 Ba@es dilator is passed into the d oden m and the tip is ,is ali$ed thro *h the anterior #all" Dhen the d ct is clear o+ stones- a T t be is inserted into the d ct" The limbs o+ the T t be sho ld be short so that the distal limb does not pass thro *h the amp lla- and the proximal limb does not obstr ct either o+ the hepatic d cts" The incision in the d ct is closed aro nd the lon* limb o+ the t be- and saline is in/ected to demonstrate the absence o+ lea@s" A completion cholan*io*ram con+irms the absence o+ stones and the passa*e o+ dye into the d oden m" The latter can be +acilitated by the in/ection o+ *l ca*on" The T t be sho ld be bro *ht o t thro *h a stab #o nd" A postoperati,e cholan*io*ram is per+ormed abo t 4 #ee@ postoperati,ely- and i+ absence o+ stones and clear passa*e o+ opa. e medi m into the d oden m are demonstrated- the t be is remo,ed" The common d ct can be explored and cleared o+ stones laparoscopically 2see Chap" 115" Transd odenal Sphincteroplasty 23i*" 29-045" )i,ision o+ the sphincter o+ &ddi is occasionally indicated +or a stone impacted at the amp lla- a strict re- or a + nctional disorder" The proced re is also applicable +or m ltiple or rec rrent d ctal stones" A *enero s Focher mane ,er sho ld be per+ormed initially- +ollo#ed by a lon*it dinal anterior d odenotomy" The passa*e o+ a Ba@es dilator or cathether do#n the d ct +acilitates identi+ication o+ the sphincter- #hich sho ld be incised at the 44-o>cloc@ position to a,oid dama*in* the pancreatic d ct" A pie-shaped se*ment is remo,ed +rom the sphincter and the d odenal and d ctal m cosa are coapted #ith +ine absorbable s t res" A T t be is inserted into the common d ct- and the d odenotomy is closed either lon*it dinally or hori$ontally- #ith care bein* ta@en not to compromise the l men" Choledochod odenostomy 23i*" 29-025" This proced re is applicable to patients #ith m ltiple common d ct stones to ob,iate the se o+ a T t be" The sine . a non +or the per+ormance o+ this proced re is a dilated common d ct" A Focher mane ,er is per+ormed to relie,e any tension on the anastomosis" The distal common d ct is incised lon*it dinally- as is the anterior portion o+ the d oden m- and a one-layer- lar*e-diameter anastomosis is made" Choledocho/e/ nostomy 2Ro x-en-(5 2see 3i*" 29-205" Altho *h an occasional transection o+ the common d ct #ith a sharp instr ment can be repaired by end-to-end anastomosis o,er a T t be- most d ctal in/ ries and strict res are pre+erably repaired #ith choledocho/e/ nostomy or- more o+ten- a hepatico/e/ nostomy- sin* a 17-cm de+ nctionali$ed Ro x-en-( limb o+ /e/ n m to ob,iate re+l x o+ intestinal contents into the biliary tree" A precise m cosato-m cosa anastomosis sho ld be per+ormed sin* the antimesenteric side o+ the /e/ n m #ith interr pted absorbable s t res" !n most instances- a stent is not necessary" 2Biblio*raphy omitted in Palm ,ersion5