PATOLOGIA DE LA VIA BILIAR Dr. Marcelo Victor D’Alessandro

VIA BILIAR Figure 1-1. The right hepatic duct (RHD) and left hepatic duct (LHD) emerge from the porta hepatis and in most instances join together after about 0.5 to 1 cm to form the common hepatic duct, which further descends in the free edge of the lesser omentum anterior to the foramen of Winslow. At a variable distance (from 1 to 5 cm) the cystic duct (CD) enters to form the common bile duct (CBD) (see Figure 1-4). The latter continues downward in the hepatoduodenal fold of the peritoneum, passes behind the first part of the duodenum and the pancreas, then curves or bends to the right to enter in an oblique way the second part of the duodenum on its posteromedical side [1] (see Figures 1-4, 1-6, and 1-7). CA-cystic artery; CHA-common hepatic artery; GA-gastroduodenal artery; GB-gallbladder; LHA-left hepatic artery; PV-portal vein; RHA-right hepatic artery. (Adapted from Frierson [1].) References: [1]. Frierson HF, The gross anatomy and histology of the gallbladder, extrahepatic bile ducts, Vaterian system, and minor papilla. Am J Surg Pathol 1989 13 146-162

PATOLOGIA DE LA VIA BILIAR De la Vesícula Biliar De los conductos Biliares

PATOLOGIA DE LA VIA BILIAR Asintomática Sintomática

ALGORITMO CLINICA LABORATORIO IMAGENES

SME. COLEDOCIANO ICTERICIA OBSTRUCTIVA ICTERICIA COLURIA ACOLIA ↑ bilirrubina ↑ FAL/ggt ↑ tgo/tgp ↓ quick

ICTERICIA OBSTRUCTIVA Dolor abdominal Fiebre, escalofríos Cirugía biliar previa Edad avanzada Masa palpable Aumento predominante de bi y FAL Quick normal o que se normaliza con vit K

IMAGENES ECOGRAFIA TAC CRMN EUS CTPH CIO ERCP

MRCP

VIA BILIAR ERCP

CIO

DUODENOSCOPIO

COLEDOCOSCOPIA

INDICACIONES DE ERCP ERCP, CRMN y EUS igual sensibilidad y especificidad para el diagnóstico de coledocolitiasis Pacientes sometidos a COLELAP NO requieren ERCP preoperatoria si tienen baja probabilidad de coledocolitiasis Exploración laparoscópica del colédoco y ERCP postoperatoria son ambas seguras y eficaces en evacuar el ducto biliar común ERCP con esfinterotomía y litoextracción, es una modalidad terapéutica valiosa en pac. con coledocolitiasis con ictericia, vía biliar dilatada o colangitis

INDICACIONES DE ERCP En pacientes con cáncer biliar o pancreático, la principal ventaja de la ERCP es la paliación de la obstrucción biliar ERCP es el mejor método para el diagnóstico de ampulomas Utilidad en Disfunción del esfínter de Oddi? No debe realizarse ERCP si existe baja probabilidad de estenosis o litiasis, sobretodo en mujeres con dolor recurrente y hepatograma normal, sin otros signos de enf. biliar

INDICACIONES DE ERCP ERCP debe ser realizada por endoscopistas con experiencia y entrenamiento apropiado La mejor forma de evitar complicaciones es NO realizar procedimientos innecesarios Con las nuevas tecnologías de diagnóstico por imágenes, la ERCP debe ser tomada como un procedimiento predominantemente TRAPEUTICO

Canulación

OBSTRUCCION DE LOS CONDUCTOS BILIARES COLEDOCOLITIASIS ENFERMEDAD de los DUCTOS BILIARES Inflamatorias Parasitarias Neoplásicas Anomalias congénitas COMPRESION EXTRINSECA del ARBOL BILIAR Vasculares Pancreatitis IATROGENICAS

CEP

CEP

CEP

ASCARIS

Ascaris

Ascaris

COLANGIOCARCINOMA

COLANGIOCARCINOMA

COLANGIOCARCINOMA

ESTENOSIS

COLANGIOCARCINOMA

CA DE PANCREAS

Ca. PANCREAS

LITIASIS BILIAR LITIASIS VESICULAR COLEDOCOLITIASIS

LITIASIS VESICULAR Asintomática Cólico biliar Colecistitis

ECOGRAFIA COLECISTITIS

Mirizzi

Universidad de Buenos Aires Sme. de Mirizzi Hospital de Clínicas Universidad de Buenos Aires Calculo vesicular

COLEDOCOLITIASIS ASINTOMATICA COLICO BILIAR SME. COLEDOCIANO PANCREATITIS COLANGITIS

COLANGITIS: clínica FIEBRE 95% DOLOR / HIPERSENS. EN HD 90% Bi+2 80% LEUCOCITOSIS 80% FAL elevada HEMOCULTIVOS gralmente. (+) Tríada de CHARCOT 70% Péntada de Reynolds Hiperamilasemia

COLANGITIS: conducta URGENCIA BILIAR INFECCIOSA Antibioticos Trastornos metabolicos y sosten DESCOMPRESION DEL CONDUCTO BILIAR

DRENAJE BILIAR QUIRURGICO PERCUTANEO ENDOSCOPICO

COLEDOCOLITIASIS TRATAMIENTO QUIRURGICO PERCUTANEO ENDOSCOPICO

MANEJO DE LA COLEDOCOLITIASIS Table 9-4. The diagnosis and management of choledocholithiasis in the era of laparoscopic cholecystectomy may be facilitated by determination of a patient's likelihood of harboring stones. Risk factors suggesting a high likelihood for common bile duct stones include bilirubin level greater than 2 mg/dL, alkaline phosphatase level greater than 150 units/L, jaundice or severe pancreatitis (or both), a dilated common bile duct or stone visualized on noninvasive imaging, and increasingly high results in serial liver function tests. This group of patients may benefit from endoscopic retrograde cholangiopancreatography (ERCP). Patients with an intermediate likelihood are those with bilirubin levels of 1.5 to 2.0 mg/dL, alkaline phosphatase levels of 110 to 150 units/L, transaminase levels more than twice normal, a remote history of jaundice or pancreatitis, and liver tests showing rapid improvement. This intermediate group may benefit from intraoperative cholangiography (IOC), but decisions about endoscopic stone removal versus laparoscopic or open surgical stone removal are guided by available local expertise. In patients whose liver test results are normal and there is no ductal dilatation, jaundice, or pancreatitis, neither ERCP nor IOC is recommended based on the low probability that common bile duct stones are present.

ERCP Diagnóstico Terapéutico

TRATAMIENTO ENDOSCOPICO PAPILOTOMIA LITOEXTRACCION COLOCACION DE STENT DRENAJE NASOBILIAR

CANULACION DE PAPILA DE VATER Endoscopic view of sphincterotomy and basket extraction of common bile duct stones. A, The sphincterotome is within the common bile duct. B, The sphincterotomy is performed using electrocautery and extended toward the 11 o`clock to 12 o`clock position. After completion of sphincterotomy, the basket catheter is deployed under fluoroscopic guidance (C) and withdrawn through the papilla along with several common bile duct stones (D).

CALCULO IMPACTADO Endoscopy in acute cholangitis. Stone disease remains the most common cause of cholangitis in most large series in the United States. Choledocholithiasis occurs in 8% to 15% of patients undergoing cholecystectomy; the incidence in patients more than 60 years of age is even higher, estimated at 15% to 60% in some series [22]. At endoscopy, the obstructing stone is often seen bulging from the papillary orifice, as in this figure. A recent randomized, controlled trial supports early endoscopic examination and intervention in cases of suspected stone-related acute cholangitis [23]

LITIASIS COLEDOCIANA Endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis. Cholangiography is the gold standard for the diagnosis of choledocholithiasis. A-C, Three examples of cholangiograms obtained by ERCP. The choledocholiths are visualized as filling defects as a column of contrast fills the common bile duct. Most stones that originate within the common bile duct are brown pigment stones. Electron microscopy has revealed that such stones are often associated with bacteria [24]. Periampullary diverticula also seem to increase the risk of choledocholith formation, perhaps by serving as a reservoir for intestinal bacteria [25]. The formation of a common bile duct stone around a surgical clip is shown in panel C. Foreign bodies, including suture material placed 30 years before the patient presented with common bile duct stones, have often been reported in association with choledocholithiasis [26]

LITIASIS COLEDOCIANA Endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis. Cholangiography is the gold standard for the diagnosis of choledocholithiasis. A-C, Three examples of cholangiograms obtained by ERCP. The choledocholiths are visualized as filling defects as a column of contrast fills the common bile duct. Most stones that originate within the common bile duct are brown pigment stones. Electron microscopy has revealed that such stones are often associated with bacteria [24]. Periampullary diverticula also seem to increase the risk of choledocholith formation, perhaps by serving as a reservoir for intestinal bacteria [25]. The formation of a common bile duct stone around a surgical clip is shown in panel C. Foreign bodies, including suture material placed 30 years before the patient presented with common bile duct stones, have often been reported in association with choledocholithiasis [26]

PAPILOTOMIA Endoscopic view of sphincterotomy and basket extraction of common bile duct stones. A, The sphincterotome is within the common bile duct. B, The sphincterotomy is performed using electrocautery and extended toward the 11 o`clock to 12 o`clock position. After completion of sphincterotomy, the basket catheter is deployed under fluoroscopic guidance (C) and withdrawn through the papilla along with several common bile duct stones (D).

LITOEXTRACCION CON CESTA DE DORMIA Figure 9-11. Radiographic view of the basket extraction of common bile duct stones shown in Figure 9-10. A, The biliary basket catheter has entrapped two common bile duct stones, each measuring approximately 18 mm. The proximal biliary tree is significantly dilated (27 mm). B, Delivery of one stone through the papilla is shown.

LITOEXTRACCION CON CESTA DE DORMIA Endoscopic view of sphincterotomy and basket extraction of common bile duct stones. A, The sphincterotome is within the common bile duct. B, The sphincterotomy is performed using electrocautery and extended toward the 11 o`clock to 12 o`clock position. After completion of sphincterotomy, the basket catheter is deployed under fluoroscopic guidance (C) and withdrawn through the papilla along with several common bile duct stones (D).

LITO EN DUODENO A, After sphincterotomy, a basket is advanced into the duct and maneuvered so that the stone is captured within it. The basket and stone are then gently pulled through the papillotomy. B, An extracted stone is seen within the duodenal lumen.

LITOEXTRACCION CON BALON

BALON

Balloon extraction of common bile duct stones after sphincterotomy Balloon extraction of common bile duct stones after sphincterotomy. A, The bile duct is cannulated using a sphincterotome. B, Electrocautery is applied and sphincterotomy is performed in a 12 o`clock direction. The balloon catheter is inserted under fluoroscopic guidance, then inflated and withdrawn towards the endoscope. C, When the catheter is withdrawn, stone debris is seen emanating from the papilla. D, After sphincterotomy and stone extraction, the biliary orifice is patent.

ME LA MUESTRA DR!

STENTS PLASTICOS

STENT BILIAR Endoscopic stents for treatment of common bile duct stones and cholangitis. An alternative to sphincterotomy and immediate stone extraction is placement of a stent at the time of endoscopic retrograde cholangiopancreatography. This allows free passage of bile around the choledocholith and decompression of the infected biliary tree. A, A stent bypassing a stone is seen on a cholangiogram. B, Active drainage of pus from the biliary tree after stent placement is shown. In 18 patients seen at Duke University Medical Center with stones that could not be removed after initial sphincterotomy, stent placement resulted in a significant decrease in the size of the retained stones. All patients in this series eventually had complete duct clearance by mechanical lithotripsy, laser lithotripsy, additional stenting, stricture dilation, or extension of sphincterotomy [41]

STENT DOBLE PIGTAIL Pigtail stent for stone disease. In addition to straight stents, pitail stents can be used to decompress the biliary tree in the setting of choledocholithiasis.

STENT EN COLANGITIS SUPURADA Endoscopic stents for treatment of common bile duct stones and cholangitis. An alternative to sphincterotomy and immediate stone extraction is placement of a stent at the time of endoscopic retrograde cholangiopancreatography. This allows free passage of bile around the choledocholith and decompression of the infected biliary tree. A, A stent bypassing a stone is seen on a cholangiogram. B, Active drainage of pus from the biliary tree after stent placement is shown. In 18 patients seen at Duke University Medical Center with stones that could not be removed after initial sphincterotomy, stent placement resulted in a significant decrease in the size of the retained stones. All patients in this series eventually had complete duct clearance by mechanical lithotripsy, laser lithotripsy, additional stenting, stricture dilation, or extension of sphincterotomy [41]

CATETER NASOBILIAR In patients with calculous cholangitis, initial management consists of stabilization with intravenous fluids and antibiotics. After the patient responds appropriately, endoscopic retrograde cholangiopancreatography (ERCP) is indicated. If the patient cannot be stabilized within 24 hours (or presents with shock or mental status change), emergency ERCP should be undertaken. Options at ERCP include placement of a nasobiliary tube or endoprosthesis to establish bile duct drainage. This elderly patient presented with acute suppurative cholangitis. ERCP revealed a faceted stone that was not easily removable. A nasobiliary tube was placed and copious pus was drained until the patient was stabilized. The patient then underwent successful sphincterotomy with stone extraction.

TUMORES VESICULA BILIAR VIAS BILIARES AMPOLLA

BIOPSIA

APULOMA

STENT METALICO

STENT METALICO AUTOEXPANDIBLE

BILIRRAGIA

CONDUCTO ABERRANTE

BILIRRAGIA Y LITIASIS RESIDUAL

ESTENOSIS

SECCION COMPLETA DEL DBP

ERCP RESUMEN Colangitis Aguda Coledocolitiasis Estricturas benignas Bilirragias Obstrucciones malignas

COMPLICACIONES DE CPRE Table 9-24. Endoscopic sphincterotomy has an overall rate of acute complications of 6% to 10% that is well documented in the literature [6]

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