Transabdominal ultrasound and liver function tests to be done.
Unlike gallbladder stones, common bile duct stones can be difficult to visualise on transabdominal ultrasound. However, a combination of biliary colic with a dilated bile duct on ultrasound and/or abnormal LFTs is suggestive of the diagnosis.
Alkaline phosphatase (ALP) is often raised, normal levels can be seen. In the context of acute biliary obstruction, the dominant abnormality can be an alanine transferase (ALT) of several hundred international units or higher.
When there is a persistent suspicion of common bile duct stones and results are non-diagnostic, further investigation may be necessary.
For patients requiring assessment before or after gallbladder removal, other options include magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound. Both are sensitive and specific tests which avoid the risks associated with the gold standard investigation endoscopic retrograde cholangiopancreatography (ERCP), which is now generally reserved for therapeutic intervention.
Stones in the gallbladder can be managed conservatively if they are not causing the patient pain, but most clinicians would offer to remove stones in the common bile duct regardless of presenting symptoms.
In patients who have already undergone cholecystectomy, the treatment of choice is ERCP. This can typically be performed as a day case procedure, either under conscious sedation or general anaesthetic.
Therapeutic ERCP entails identifying the orifice of the common bile duct, it enters the duodenum, using a flexible video endoscope passed via the oesophagus.
The duct is then cannulated and cholangiography is undertaken. Following this, a biliary sphincterotomy is performed, whereby the papilla is cut using electrocautery. Stones can then be removed using a balloon catheter or metal basket.
ERCP is associated with some significant risks. Acute pancreatitis is historically the most common complication and occurs more frequently in young female patients. However, the incidence can be reduced by the use of non-steroidal anti-inflammatory medications at the time of intervention. Other complications include bleeding, perforation and sepsis.
Although most adverse events settle with supportive management, there is a small mortality rate associated with the procedure of <0.5%.
This means that careful case selection, good operator technique and thorough discussion with the patient are essential. Sometimes patient may require multiple sessions of treatment for removal or large stones.
At repeat ERCP is usually done after 1 month following cholecystectomy, the stent is generally removed if the CBD clearance is achieved, in small percentage of patients re do stenting is desired.
It is very import to remove the stent placed after ERCP in due time because after longer period the stent itself can act as nidus for stones and there will be stone formation around it.
Spontaneous passage of calculi occurs in up to 10% of patients, with 80% requiring removal of stone fragments during repeat ERCP. Although recurrence of bile duct calculi is estimated at 14% after one year, most of these are amenable to endoscopic treatment.
Gallbladder cancer is cancer that begins in the gallbladder.
Gallbladder cancer is uncommon in western and southern part of India. When gallbladder cancer is discovered at its earliest stages, the chance for a cure is very good. But most gallbladder cancers are discovered at a late stage, when the prognosis is often not good. Geographically it is seen more common in northern part of India.
Gallbladder cancer is difficult to diagnose because it often causes no specific signs or symptoms. Also, the relatively hidden nature of the gallbladder makes it easier for gallbladder cancer to grow without being detected.
Tests and procedures used to diagnose gallbladder cancer include:
•Blood tests: Blood tests to evaluate your liver functions as well as tumour markers like CA 19.9.
•Procedures to create images of the gallbladder: Imaging tests that can create pictures of the gallbladder include ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI).
•PET Scan: If needed could also be ordered to see for the distant extents of the disease.
It is best done with high speed Multi slice CT Scan to look for local spread of disease.
Second thing is presence of jaundice and distant lymph node spread.
Presence of jaundice makes it very difficult for surgeon to operate and reduction of jaundice has to be done with either ERCP /PTBD. This procedure
can lead to reduction in jaundice but at the same time the disease can progress and make the tumour unresectable.
The stages of gallbladder cancer are:
•Stage I. At this stage, gallbladder cancer is confined to the inner layers of the gallbladder.
•Stage II. This stage of gallbladder cancer has grown to invade the outer layer of the gallbladder.
•Stage III. At this stage, gallbladder cancer has grown to invade one or more nearby organs, such as the liver, small intestine or stomach. The gallbladder cancer may have spread to nearby lymph nodes.
•Stage IV. The latest stage of gallbladder cancer includes large tumors that involve multiple nearby organs and tumors of any size that have spread to distant areas of the body.Treatment
What gallbladder cancer treatment options are available to you will depend on the stage of your cancer, your overall health and your preferences.
The initial goal of treatment is to remove the gallbladder cancer, but when that isn't possible, other therapies may help control the spread of the disease and keep you as comfortable as possible.
Surgery may be an option if you have an early-stage gallbladder cancer. Options include:
•Surgery to remove the gallbladder. Early gallbladder cancer that is confined to the gallbladder is treated with an operation to remove the gallbladder (cholecystectomy). Only for stage T1a.
•Surgery to remove the gallbladder and a part of the liver and lymph nodes. Gallbladder cancer that extends beyond the gallbladder and into the liver is sometimes treated with surgery to remove the gallbladder, as well as portions of the liver and bile ducts that surround the gallbladder.
It's not clear whether additional treatments after successful surgery can increase the chances that your gallbladder cancer won't return. Some studies have found this to be the case, so in some instances, your doctor may recommend chemotherapy, radiation therapy or a combination of both after surgery.
•As said ahead this is one of the deadliest cancers of all kind, one is because of its late presentations and secondly because of its virulence and aggressive disease nature.
•Even despite surgery the chances of recurrence rate of ca GB is very high.
•Only papillary type of GB Cancer has some better and favourable prognosis.
•Rest all tend to have poorer outcome and nearly 10% five-year survival rate.
Surgery can't cure gallbladder cancer that has spread to other areas of the body. Instead, doctors use treatments that may relieve signs and symptoms of cancer and make you as comfortable as possible.
Options may include:
•Chemotherapy. Chemotherapy is a drug treatment that uses chemicals to kill cancer cells.
•Radiation therapy. Radiation uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells.Procedures to relieve blocked bile ducts
Advanced gallbladder cancer can cause blockages in the bile ducts, causing further complications. Procedures to relieve blockages may help. For instance, surgeons can place a hollow metal tube (stent) in a duct to hold it open or surgically reroute bile ducts around the blockage (biliary bypass).
Supportive and pain killer treatment.
Treatment for nutrition and vomiting.
Treatment for ascites or bleeding from vomitus.
Your gallbladder is a small organ in your upper abdomen. It lies just bellow liver on right upper part of abdomen.
The gallbladder collects and stores bile that helps your body break down food. Small, hard deposits called gallstones can form in the gallbladder. This is a common condition. It usually arises out of malfunction of gall bladder. Whenever it loses its ability to effectively concentrate bile or whenever there is increase in the solutes of bile - this leads to formation of Gall bladder stones. If your gallstones cause health problems, doctors might do surgery to remove it. For example, you might need surgery if your gallbladder is no longer working correctly and you have pain. Your doctor will talk with you about this.
Anatomy: gallbladder, liver, pancreas In the past, GB Surgery was an open surgery. Today, surgeons can do this surgery with tiny instruments and just a few small cuts. This is called laparoscopic or minimal invasive surgery.
Gallstones are often the cause but not all the times. Patient can have simply biliary colicky pain to long term post prandial pain to persistent severe pain. Many times, its noted that a thick concentrated bile can also lead to similar symptoms and even acute cholecystitis or pus within the gall bladder.
It can lead to pus formation and empyema.
It can even lead to gangrene of the organ which can life threatening situation.
If the stones migrate in common bile duct it can lead to Jaundice or infection within liver
If the stones stuck at the lower end of bile duct it can lead to pancreatitis which is even more disastrous situation.
• Are a woman,
• Have had children,
• Are overweight, or
• Are over 40.
You might also get gallstones if other people in your family had them.
What are the symptoms of gallbladder problems?
• Sharp pain in your abdomen, in upper part on right side or in central upper part.
• Nausea and vomiting sometimes only once,
• Fever, and
• Yellow skin – Jaundice is the medical term for skin and eyes that look yellow. You might get jaundice if gallstones block your bile duct.
The best test called an ultrasound is usually done.It is even better to CT scan for detection of Stones in GB
If you need more tests, you might have a CT scan / MRI-MRCP /EUS
Taking the gallbladder out is usually the best way to treat gallbladder problems. You might get some relief from changing your diet to some extent. For example, eating less fat can help.
You might have heard about treatments to break up gallstones or make them melt away (dissolve). Unfortunately, these do not usually work well.
There are no ayurvedic / homeopathic /unani medicine to dissolve gall stones till date.
• Smaller incisions – mostly holes.
• Almost NIL pain than open surgery.
• Quicker recovery than open surgery – You might go home the same day OR may in a day or so. You can also go back to regular activities more quickly.
• Less rest is needed, light work can be resumed in 2 days following surgery.
• Travelling is also possible following surgery.
• Take a shower on the same morning.
• Stop eating and drinking at the time your doctor tells you before surgery. mostly a night before for morning surgery.
• The morning of your surgery, you may take medications your doctor told you are allowed (usually the blood presser or thyroid medicines). Take them with just a sip of water. Avoid diabetes medicines.
• You might need to stop taking certain medicines before surgery. These include blood thinners, supplements, and medicines that affect your immune system. Talk to your surgeon when you schedule your laparoscopic gallbladder removal.
You will be given general anaesthesia for your laparoscopic gallbladder removal. This means you are asleep during surgery.
Three or four ports are generally inserted for gall bladder removal surgery.
Incisions after minimally invasive (laparoscopic) surgery
We – at SIDS Hospital have highest experience of gall bladder removal surgery in entire South Gujarat, including most complex and most difficult cases are also done with laparoscopy.
In an extremely rare situations or in very difficult conditions laparoscopic gallbladder removal surgery is done with open technique.
Such chances could be there in case of
• You have multiple scares on your tummy with obesity.
• The surgeon cannot see very well inside your body through the laparoscope.
• You have bleeding problems during surgery.
It is not a complication (problem) if your surgeon decides to switch to open surgery. They will switch if open surgery is the safest option for you.
Complications are problems that happen during medical care or after it. Most people who have laparoscopic gallbladder removal have very less complications or none at all.
Complications of laparoscopic gallbladder removal (cholecystectomy) do not happen often.
They can include bleeding, infection in the surgery area, hernias, blood clots, and heart problems.
You should also know that any surgery has the risk of hurting other body parts. This is not likely, but it is possible. Gallbladder surgery could hurt nearby areas such as the common bile duct, large intestine (colon), or small intestine. You might need another surgery if this happens. It is also possible that bile might leak into the abdomen after gallbladder surgery.
You will feel some pain after surgery. A minorpain at the incision sites and in your abdomen especially at naval site is common. You might also have pain in your shoulders. This is from the CO2 put into your abdomen during the operation. The shoulder pain should go away in 24 to 48 hours.
You might feel sick to your stomach (nauseated) or throw up (vomit) after your surgery. Having surgery and anaesthesia can make this happen. You should feel better in a day or two. Tell your doctor or nurse if you keep vomiting or feeling nauseated.
You should be as active as your body allows. Doctors recommend walking. You can go up and down stairs on the day of your surgery. The next day, you can take a shower with the dressings. You can expect to feel a little better each day after going home. If not, please call your doctor.
You can probably go back to normal activity within a week after laparoscopic gallbladder removal.
If you do a physical job with heavy lifting, ask your doctor when you can go back to work. You can drive 24 hours after you had anesthesia if you are not taking narcotic pain medicines.
Light exercises and aerobics including swimming is usually permitted after a week. Heavy weight lifting is usually warranted will 2-3 months.
If you had an open surgery with a large incision, you need more time to recover. You will probably need to stay in the hospital for a few days after surgery. Expect to go back to full activities in 4 to 6 weeks. You will probably recover more slowly in other ways, too.
You need to see your surgeon 7 to 10 days after surgery, sutures are usually removed on the follow up visit, and don’t forget to collect the biopsy report in the follow up visit.
Be sure to call your surgeon or family doctor if you have any of problems below.
• Fever over 101 degrees F.
• Severe pain or swelling in the belly
• Yellow skin (jaundice)
• Feeling sick and persistent nausea or vomiting.
• Blood or pus coming from any of the small cuts in the surgery area – Or redness that spreads or gets worse.
Pain that your medicines do not help
Breathing problems or a cough that does not get better.
This brochure is intended to provide a general overview of a surgery. It is not intended to serve as a substitute for professional medical care or a discussion between you and your surgeon about the need for a surgery. Specific recommendations may vary among health care professionals. Every individual is different and every human body behaves differently.
Choledochal cysts (CC) are a rare congenital cystic dilation of the biliary tract. They present primarily in female infants and young children and are more prevalent in East Asian populations.
Although benign, CC can be associated with serious complications including malignant transformation, cholangitis, pancreatitis, and cholelithiasis.
Approximately 80% of CC are diagnosed in infants and young children within the first decade of life. The incidence of CC ranges from 1 in 100,000 to 1 in 150,000 individuals in Western countries to one in 13,000 individuals in Japan.
The exact etiology is unknown, anomalous pancreaticobiliary duct junction (APBDJ) is seen in 30% to 70% of all CC where the common bile duct (CBD) and pancreatic duct junction occurs outside the duodenum, allowing reflux of pancreatic fluid into the biliary tree. The exposure of biliary epithelium to digestive and caustic pancreatic enzymes may contribute to CC formation.
Choledochal cysts are usually diagnosed in childhood, although in utero and adult diagnosis is also common.
Common presentations include abdominal pain, jaundice, and right upper quadrant mass and are most commonly seen in paediatric patients.Cholangitis, pancreatitis, portal hypertension, and liver function test abnormalities are common and are thought to be a result of ABPDJ or stone obstruction. Biliary amylase levels can be elevated in CC patients, and clinical features correlate with degree of elevation.
The classic triad of abdominal pain, right upper quadrant mass, and obstructive jaundice is mainly seen in the paediatric population.
Adults are more likely to present with biliary or pancreatic symptoms and abdominal pain; children are more likely to present with an abdominal mass and jaundice.Adults with CC are more likely to have symptomatic gallstones (45% to 70% of patients) or acute cholecystitis, both of which are attributed to biliary stasis. As a result, adult patients with CC are more likely to have undergone previous biliary procedures including surgery and stenting.
The best way to diagnose the cc is have USG followed by MRCP examination.
In case of mass within the CC one may be subjected to CECT abdomen or an EUS FNAC for the material confirmation of diagnosis.
Biliary malignancy is seen in 10% to 30% of CC. Malignancy is rarely seen in pediatric CC; however, CC-associated biliary malignancy carries a dismal prognosis.
Malignancy is most commonly associated with types I and IV cysts, while types II, III, and V have minimal neoplastic risk.
Now a days this surgery can be carried out with minimally invasive laparoscopic and robotic techniques. These techniques have made the recovery and outcome of the surgery very good in recent times. Three dimensional laparoscopy and robotic surgery has made this surgery very easy for the operating surgeon.
Type 1 – Surgical excisioin and RYHJ
Type 2 – Surgical excisioin and RYHJ OR Stenting
Type 3 – ERCP and papillotomy with close monitoring
Type 4 – Surgical excisioin and RYHJ +/- Liver resection
Type 5 – Liver transplantation. (The risk of neoplasia in Caroli's disease is less than 7%, but surgical management is usually indicated secondary to cholangitis and liver complications)
Postoperative morbidity and mortality are typically very low in children, while postoperative complications are more commonly seen in adult patients. Late complications (greater than 30 days postoperatively) occur in up to 40% of adult patients if surgery is not done in properly. At times it can lead to stricture formation of RYHJ as well as post-operative hepatolithiasis.
Although malignancy is rare, CC resection does not reduce it to baseline levels, so long-term surveillance is indicated given the increased likelihood of developing postexcision biliary malignancy.
Benign biliary strictures (block) (BBSs) may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bile-duct injury (after gall bladder surgery), or at biliary anastomoses following liver transplantation.
Most of the times patients are presented with slowly rising bilirubin may or may not be associated with fever, pain always negligible or mild, may or may not be associated with weight loss and associated with clay coloured stool and darkening of urine. Presentation is almost always mild and gradual. The signs and symptoms are progressive or in some cases it may be episodic.
The causes in brief could be
|Liver transplantation||Vasculitis: SLE- and ANCA-associated|
|Bilioenteric anastomosis||Portal biliopathy|
Is best done with complete assessment of liver function testes. The treating doctor may order other associated blood tests and tumour markers test as well. USG is the primary line of investigation for liver and later on MRCP is usually needed to classify the type and its extents.
Bismuth class Location
I >2 cm distal to hepatic confluence
II <2 cm distal to hepatic confluence
III At the level of the hepatic confluence
IV Involves the right or left hepatic duct
V Extends into the left or right hepatic branch ducts
Treatment aims to relieve symptoms of biliary obstruction, maintain long-term drainage, and preserve liver function.
Endoscopic therapy, including stricture dilatation and stenting, is effective in most cases and the first-line treatment of BBS. For severe fibrotic strictures, initial balloon or bougie dilatation may be required, followed by placement of one or more plastic stents or an FCSEMS
Response to treatment is dependent upon the technique and accessories used, as well as stricture etiology.
Recommended endoscopic treatments for causes of benign biliary strictures
|Condition||Dilatation||≥1 plastic stent||FCSEMS|
|Primary Sclerosing Cholangitis||Yes||–||–|
Although SEMSs are more expensive than plastic stents, they have significantly wider diameters (10 vs 3.3 mm, respectively), and are technically easier to insert than placing multiple plastic stents. Even the results are also better for the FCMS.
Surgery may be required for patients with refractory BBS or those who are noncompliant with endoscopic therapy. For example, patients with CP found those with pancreatic head calcifications were 17-times more likely to have failure of response to endoscopic stenting.
Surgical treatment may provide better long-term outcomes for patients with persisting CP-associated BBS after more than three endoscopic procedures.Post-liver-transplantation nonanastomotic BSs also have lower treatment success following endoscopic drainage than those with anastomotic strictures.
Surgical alternatives to repair of BBS include excision of strictures with end-to-end repair, Roux-en-Y hepaticojejunostomy (RYHJ), choledochojejunostomy, and choledoduodenostomy. The choice of repair depends on such variables as extent and location of BBS. However, choice of treatment remains RYHJ.
Surgery lasts typically between 2 to 4 hours and the recovery time is usually 4-6 days of hospital stay followed by couple of weeks rest at home.
Radiological therapies are reserved for patients whose strictures are refractory to endoscopic and surgical interventions.
The procedure is safe and durable, with a rate of success of 80%–99% in the hands of experienced surgeons.
Cholangiocarcinoma is cancer that forms in the tubes (bile ducts) that carry the bile from liver to intestine. This condition, also known as bile duct cancer, is an uncommon form of cancer that occurs mostly in people older than age 50, though it can occur at any age.
Doctors divide cholangiocarcinoma into different types based on where the cancer occurs in the bile ducts:
• Intrahepatic cholangiocarcinoma occurs in the parts of the bile ducts within the liver and is sometimes classified as a type of liver cancer. We shall discuss there.
• Hilar cholangiocarcinoma occurs in the bile ducts just outside of the liver. This type is also called perihilar cholangiocarcinoma.
• Distal cholangiocarcinoma occurs in the portion of the bile duct nearest the small intestine or within the intra pancreatic part of bile duct. The presentation & management as well as the outcomes are similar to that of the pancreatic head tumours, hence shall be discussed in pancreatic head cancer region.
Signs and symptoms of cholangiocarcinoma include:
Yellowing of your skin and the whites of your eyes (jaundice)
Intensely itchy skin
Unintended weight loss
See your doctor if you have persistent fatigue, abdominal pain, jaundice, or other signs and symptoms that bother you.
Liver function tests. Blood tests to measure your liver function can give your doctor clues about what's causing your signs and symptoms. It checks Bilirubin and liver enzymes levels as well as coagulation parameters.
• Tumor marker test. Checking the level of cancer antigen (CA) 19-9 in your blood may give your doctor additional clues about your diagnosis. A high level of CA 19-9 in your blood doesn't mean you have bile duct cancer, though. This result can also occur in other bile duct diseases, such as bile duct inflammation and obstruction. Value of such marker does not corelate with the severity of disease.
• MRI with MRCP- This is a test for the visualization of bile duct intra hepatic and extra hepatic area. One of the best tests to delineate the duct size and its anatomy.
• CECT Whole abdomen- This is the test to see the vessels involvement for the tumour and surrounding area. It also determines the extents of the disease as well as spread in surrounding area.
• A test to examine your bile duct with a small camera. During endoscopic retrograde cholangiopancreatography (ERCP), a thin tube equipped with a tiny camera is passed down your throat and through your digestive tract to your small intestine. The camera is used to examine the area where your bile ducts connect to your small intestine. Your doctor may also use this procedure to inject dye into the bile ducts to help them show up better on imaging tests.
• A procedure to remove a sample of tissue for testing. A biopsy is a procedure to remove a small sample of tissue for examination under a microscope.If the suspicious area is located very near where the bile duct joins the small intestine, your doctor may obtain a biopsy sample during ERCP. If the suspicious area is within or near the liver, your doctor may obtain a tissue sample by inserting a long needle through your skin to the affected area (fine-needle aspiration – EUS- FNAB).
If your doctor confirms a diagnosis of cholangiocarcinoma, he or she tries to determine the extent (stage) of the cancer. Often this involves additional imaging tests. Your cancer's stage helps determine your prognosis and your treatment options.
The results of your imaging tests will help guide your treatment. Treatments for cholangiocarcinoma (bile duct cancer) may include:
• Surgery. When possible, doctors try to remove as much of the cancer as they can. For very small bile duct cancers, this involves removing part of the bile duct and joining the cut ends. For more-advanced bile duct cancers, nearby liver tissue, pancreas tissue or lymph nodes may be removed as well.
• Liver transplant. Surgery to remove your liver and replace it with one from a donor (liver transplant) may be an option in very much selective & certain cases for people with hilar cholangiocarcinoma.• For many, a liver transplant is a cure for hilar cholangiocarcinoma, but there is a risk that the cancer will recur after a liver transplant.
• Chemotherapy. Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be used before a liver transplant. It may also be an option for people with advanced cholangiocarcinoma to help slow the disease and relieve signs and symptoms.
• Radiation therapy. Radiation therapy uses high-energy sources, such as photons (x-rays) and protons, to damage or destroy cancer cells. Radiation therapy can involve a machine that directs radiation beams at your body (external beam radiation). Or it can involve placing radioactive material inside your body near the site of your cancer (brachytherapy).
• Photodynamic therapy. In photodynamic therapy, a light-sensitive chemical is injected into a vein and accumulates in the fast-growing cancer cells. Laser light directed at the cancer causes a chemical reaction in the cancer cells, killing them. You'll typically need multiple treatments. Photodynamic therapy can help relieve your signs and symptoms, and it may also slow cancer growth. You'll need to avoid sun exposure after treatments.
• Biliary drainage. Biliary drainage is a procedure to restore the flow of bile. It can involve bypass surgery to reroute the bile around the cancer or stents to hold open a bile duct being collapsed by cancer. Biliary drainage helps relieve signs and symptoms of cholangiocarcinoma.
Because cholangiocarcinoma is a very difficult type of tumor to treat, don't hesitate to ask about your doctor's experience with treating the condition. If you have any doubts, get a second opinion.
Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing aggressive treatments, such as surgery.
When palliative care is used along with other appropriate treatments — even soon after your diagnosis — people with cancer may feel better and may live longer.
Palliative care is provided by teams of doctors, nurses and other specially trained professionals. These teams aim to improve the quality of life for people with cancer and their families. Palliative care is not the same as hospice care or end-of-life care.