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The Biliary System
The Gall bladder is a hollow organ in which bile is stored and concentrated before it is released into the small intestine. Humans can live without a gall bladder. Common problems that affect the gall bladder are gallstone disease and cancer. These often manifest with pain in the right upper abdomen or may be detected.
- Gallstone Disease: Laparoscopic cholecystectomy ( removal of the gall bladder through key hole surgery ).
- Gall bladder Cancer: Radical Cholecystectomy ( Removal of the gal bladder with the cancer and a part of the adjoining liver, removal of lymph nodes around the bile ducts and sometimes removal of the common bile duct as well ).
The Bile duct is a long tube like structure that carries bile from the liver to the small intestine ( duodenum ) . Bile is needed by our body for the digestion of food. If the bile duct is blocked by stones, injury/stricture, or cancer, then bile cannot reach the intestine. leads to obstructive jaundice. The patient complains of passing high coloured urine, pale clay-like stools , yellowing of the eyes & skinand also suffers from severe itching ( pruritis ).
Stones in the bile duct usually result from slippage of gallstones from the gall bladder into the common bile duct ( CBD ) . Bile duct stones may cause
- Fever with shivering (cholangitis).
- Upper abdomen pain (acute pancreatitis).
- Endoscopic ( ERCP ) stone clearance +/- stent placement into the bile duct.
- Laparoscopic / Open CBD Exploration.
- Choledocodudenostomy or hepaticojejunostomy ( joining the bile duct to the small intestine).
Bile duct injury/stricture
Bile duct injuries are rare but serious complications of gof operations on the gal lbladder. Bile duct properly. Ideally bile duct injuries should be managed at a centre with facilities & expertise in hepatopancreatobiliary surgery, endoscopy (ERCP) & interventional radiology.
- Endobiliary stenting by ERCP
- Percutaneous catheter drainage ( PTBD ).
- Roux en Y hepaticojejunostomy.
- Rarely even liver resection.
Choledochal cysts (Bile duct cysts) are abnormal cystic dilatations of all or part of extrahepatic and/or intrahepatic bile ducts. Most patients have symptoms in their childhood. The common problems are intermittent abdominal pain and jaundice. There is also an increased risk of cancer in the wall of the cyst. Choledochal cysts are mostly treated by complete surgical removal of the cyst with the formation of Roux-en-Y hepaticojejunostomy.
Biliary atresia is a disease of newborns, in which the bile ducts are abnormally narrow, blocked or completelyabsent. Most common symptoms include jaundice (dark urine, pale stools, yellow skin & eyes). If untreated, eventually patient develops swollen tummy (free fluid in the abdominal cavity) and liver cirrhosis. Kasai portoenterostomy ( by-pass operation ) and later liver transplantation is the best approach for infants/children with biliary atresia.
Bile duct cancer (cholangiocarcinoma)
Cancers of the bile ducts are called Cholangiocarcinomas. A hilar cholangiocarcinoma is a cancer of the biliary tree occurring at the junction of the right & left hepatic ducts. These cancers cause jaundice (dark urine, pale stools & yellow skin & eyes), generalized itching/pruritis, & weight loss.
Cholangiocarcinoma is considered to be lethal cancer unless fully removed by surgery. Surgical resection provides the only hope of cure for this disease; however, it is technically challenging & should be done by surgeons with expertise in HPB & living donor liver transplant surgery. Treatment options are right/left extended hepatectomy with caudate Lobe Resection +/- portal venous resection, depending on the location of the cancer.