Biliary stricture

IT CAN OCCUR AS A RESULT OF A TECHNICAL MISHAP......

DURING CHOLECYSTECTOMY IF IGNORED CAN DRIVE  LIFE- THREATENING COMPLICATIONS

STRICTURE OF BILE DUCT 
  

A bile duct stricture is caused by narrowing of the bile duct. The narrowing bile duct prevents the bile from draining into the intestine. The bile then backs up in the liver and spills over into the blood feat obstructive jaundice  ,it crapper cause through Surgical trauma ( postoperative ) ,Stones ,Primary sclerosing cholangitis ,Carcinoma of bile funiculus Carcinoma of head of pancreas.

Bile duct pathology (biliary stricture) is an uncommon but hard clinical condition that requires a integrated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma , Bile duct strictures (biliary strictures) may be well but, if ignored, can drive life-threatening complications, such as ascending cholangitis,  liver abscess, and secondary biliary cirrhosis

POSTOPERATIVE STRICTURE it is the result of a preventable non achievement in technique , during the performance of cholecystectomy ;Blind plunge application of a hemostat to a bleeding cystic or accessory cystic artery ,or to right hepatic artery.Should cholecystectomy be performed by dissecting from fundus ,too such traction applied to freed gall sac may so tent the bile funiculus that some forceps witting for cystic funiculus apprehension angulated main channel .Failure to identify anatomy in Calot's polygon when there is such inflammation .Common hepatic funiculus is tied instead of cystic duct.Ignorance of anatomical anomalies o bile ducts.Laceration of bile patch explration for stones.Injury to bile funiculus during partial gastrectomy.

CLINICAL PRESENTATION OF POSTOPERATIVE STRICTURE

Bile funiculus injuries may be rcognized at the instance of surgery .

Postoperatively by profuse and persistent discharge of bile if evacuation has been provided.Bile peritonitis if evacuation

has not been provided.Deepening obstructive jaundice.

In the absence of symptoms of the primary disease, most patients with bile funiculus strictures (biliary strictures) rest asymptomatic until the lumen of the bile funiculus is sufficiently narrowed to drive position to the flow of bile. Occasionally, patients may hit intermittent episodes of right upper line pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often inform with features of obstructive jaundice. On occasion, a patient may inform dramatically with sepsis and hypotension due to ascending cholangitis.

Cholangitis occurs in the proximity of partial or complete obstruction of the common bile funiculus , with accumulated intraluminal pressures, bacterial infection of the bile with procreation of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can apace embellish a life-threatening condition. Clinical show varies, with the Charcot set of fever and chills, jaundice, and right upper line abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also hit altered mental position and hypotension (ie, Reynold pentad). In the epilepsy of previous instrumentation, cholangitis is uncommon with malignant strictures.

Tests that shows stricture in the bile duct: ERCP (endoscopic retrograde cholangiopancreatography) , PTC (percutaneous transhepatic cholangiogram)  ,MRCP (magnetic kinship cholangiopancreatography)

Blood tests that indicate deviant function of biliary system:

Bilirubin level is higher than normal
ALP (alkaline phosphatase) is higher than normal

TREATMENT 

PREOPERATIVE TREATMENT temporary external biliary drainage ,by passing a cather percutaneously into an intrahepatic duct ,or by passing a cather through stricture at ERCP and left to drain through mouth.

OPERATIONS

Roux-en-Y choledochojejunostomy

Cholecystojejunostomy

Choledochoduodenostomy

Insertion of a stent  

COMPLICATIONS 

Recurrent inflammation of the biliary duct and stricture can occur in whatever patients. Patients are at risk for infection developing above the stricture. Long-standing strictures can advance to cirrhosis.

Complications of bile duct strictures (biliary strictures) include development of stones in the gallbladder and bile ducts proximal to the stricture, pyogenic liver abscess due to recurrent episodes of ascending cholangitis, secondary biliary cirrhosis, and weight loss and malnutrition from steatorrhea with fat-soluble vitamin deficiency.

Diverticulum common birth defect in about 2% of all infants

MECKLE'S DIVERTICULUM  The vitello-intestinal funiculus is the remnant of the yolk cover which is attached to the primitive midgut in the first some weeks of embryonic development .

It was first described by FABRICIUS HILDANUS in the sixteenth century and later named after Jhann friedrich meckle , who described the embryological origin of this type of diverticulum in 1809.

It should completely obliterate during the six week ,but haw persist completely or in conception .if it persist completely , there is a diverticulum ,the Meckle's diverticulum ,which arises from the terminal ileum .The classical description in adults is that it is present in 2% of he population , is 2 inches ( 5 cm ) daylong and 2 feet (60 cm )from the ileocaecal valve .

The diverticulum is usually supplied by the omphalomesenteric artery (a remnant of the vitelline artery), which arises from the ileal branch of the superior mesenteric artery. Usually, the artery terminates in the diverticulum; however, it has been reported to continue up to the abdominal wall in some cases. Rarely, these blood vessels persist in the form of fibrous remnants that run between the Meckel diverticulum and the abdominal wall or small bowel mesentery.

Meckel's diverticulum occurs on the antimesenteric abut of the ileum, commonly 40-60 cm proximal to the ileocecal valve. On average, the diverticulum is 3 cm long and 2 cm wide. Slightly more than one half include ectopic mucosa. Meckel diverticulum is typically lined by ileal mucosa, but another paper types are also institute with varied frequency.

The heterotopic membrane is most commonly gastric. This is important because peptic ulceration of this or conterminous membrane can lead to painless bleeding, perforation, or both. In one study, heterotropic viscus membrane was institute in 62% of cases, pancreatic paper was institute in 6%, both pancreatic paper and viscus membrane were institute in 5%, jejunal membrane was institute in 2%, Brunner paper was institute in 2% and both viscus and duodenal membrane were institute in 2%.2 Rarely, colonic, rectal, endometrial, and hepatobiliary tissues have been noted.

A persistent vitello-intestinal funiculus can present at birth , as a swelling at the base of the umbilical cord ,or as a fistulous connection to the umblicus ,or as an umblical polyp, which does not move like simple granulation tissue to cautery , because it has a mucosal surface , Surgical excision is required .It haw be lined by ileal membrane ,or contain ectopic gastric membrane ,which haw unergo peptic lesion with ensuant bleeding .

Most people who have a Meckel's diverticulum have no symptoms or problems. Only about 1 in 25 persons who are born with it will have problems. These problems vary by age. In infants and children, the problem is commonly injury from the rectum. Sometimes blood stained stool can be seen .

In adults, the gut may become blocked. If this happens, the mortal may have breadbasket pain and vomiting. Other symptoms allow fever, degradation and swelling of the stomach.

It haw present with

SEVERE HAEMORRHAGE blood is passed per rectum , and is blakish red in colouration.


INTUSSUSCEPTION ,MECKALIAN DIVERTICULITIS ( Without Perforation ) clinical features simulate those of acute appendicitis ,(With Perforation ) clical features simulate those of cut ulcer  .

CHRONIC PEPTIC ULCERATION symptomatic peptic ulcer pain , related to meals , but is felt around the umblicus ( because diverticulum is conception of midgut ).


INTESTINAL OBSTRUCTION a adornment present between apex of diverticulum and umblicus , haw cause obstruction either by adornment itself or by a volvulus around it .


LITTER's HERNIA meckle's diverticulum is found in an inguinal or femoral hernial cover .


SILENT MECKLE's DIVERTICULUM encouraged in barium meal follow-through or during an abdominal operation . 

DIAGNOSTIC INVESTIGATIONS 1 . X-RAY with BARIUM MEAL  may demonstrate Meckle's diverticlum  ,and failure to visualize is of no significance ,because so often the entrance of diverticulum is blocked by edema .

TECHNETIUM (Tc ) SCANNING may localize heterotopic gastric mucosa in a diverticulum .There is no definitive scan or investigation to confirm the existence of a Meckle's diverticulum .A radiolabelled technetium  scan looking for ectopic gastric mucosa ( that is outside the stomach ) is only positive in about 70 % of patients with a Meckle's diverticulum who present with rectal bleeding .

TREATMENT : management is by excision after the diagnosis has been made - which is often only at laparotomy , although it may be suspected beforehand.

MECKELIAN DIVERTICULECTOMY a broad base Meckle's diverticulum is resected with invagination technique in the same way as a vermiform appendix ,If the base of Meckle's diverticulum is indurated  and especially .when such induration  extends into neighboring ileum ,resect a short segment  of ileum containing the Meckle's diverticulum ,and restore the continuity of bowel by end-to-end anastomosis .

FREQUENCY

The figure of Meckel diverticulum is usually noted to be approximately 2% of the population,3 but publicised program arrange from 0.2-4%.4 Complications are only seen in about 5% of those with the anomaly.

Abscesses - Subphrenic abscess is a pus filled cavity and misdiagnosis lead sepsis and death

SUBPHRENIC ABSCESS 

 

There are a number of spaces below the diaphragm in relation to the liver which may become the site of abscess formation ( a subphrenic abscess ).Abscess may arise from such lesions as perforated peptic ulcer ,perforated appendicitis ,or perforated diverticulitis .Only two of the spaces are in fact directly subphrenic , the other two being subhepatic.The right and left subphrenic spaces lie between the diaphragm and the liver and are separated from one another by the falciform ligament. The right subphrenic space ( pouch of Rutherford Morrison ) is bounded by the posterior abdominal wall behind and by the liver above.The gall bladder, duodenum and right kidney are immediate relations. 

The left subphrenic space is the lesser sac itself.It may distend with fluid as a result of a perforated posterior gastric ulcer or as a result of acute pancreaitis ( pseudocyct of the pancrease ).At the present time most subphrenic abscess are drained percutaneously under the ultrasound control . However , the occasional one still requires open surgery and may be accessed if they are posteriorly placed by an incision below or through the bed of the twelfth rib. If they are placed anteriorly they can be drained through an incision below and parallel to the costal margin.

Any anastomosis leakage or another harm contamination tends to advance to a subphrenic abscess. The pressures from the diaphragmatic movements with respirations are such that there is a movement of the ascitic fluid of the cavum into the subphrenic space and with it travel any bacteria that strength be present, which facilitates abscess formation.

Patients are ofttimes elderly. Symptoms can be very impalpable and start perhaps with a fever and a loss of appetite approximately 1 month after the surgery. There might be a non-productive cough due to an atelectasis in the lung of the strained side or a pleural effusion (fluid in the chest cavity) on that side. Abdominal pain on the strained side in the upper cavum is common, which is severe on deep palpation by the physician. Blood tests exhibit a leukocytosis, there haw also be a lack of red blood cells (anemia).

 

Plain abdominal X-ray films haw exhibit the abscess decay with gas in it from gas producing bacteria. Chest X-rays ofttimes exhibit abnormalities in the lungs (atelectases, lower lobe pneumonia) and pleural effusions as well as an immobile diaphragm. Other tests are useful much as an ultrasound for a right- sided subphrenic abscess and a CT scan for a left-sided subphrenic abscess. The unification here shows a subphrenic abscess before (upper image) and after (lower image) drainage. Because it can be rather arduous to become to a diagnosis, hot isotope scanning much as an indium-111-labeled leukocyte scan could be useful in sleuthing a hidden intra-abdominal or subphrenic abscess.

 

TREATMENT

PERCUTANEOUS DRAINAGE insert a percutaneous drainage tube blindly, under combined ultrasonic and fluroscopic control. Same tube can be used to instill antibiotic solutions into abscess cavity.

SURGICAL DRAINAGE

INCISION if a swelling can be detected , incision is made over the site of maximum tenderness , or over any area where edema or redness is present. If no swelling is apparent , subphrenic spaces should be explored either by anterior subcostal approach or from behind after removal of outer part of 12th rib.

CLEANSING AND DRAINAGE When the cavity is reached ,all the fibrinous loculi must be broken down with finger .One or two drains or drainage tubes must be fully inserted.Drains are withdrawn gradually during next 10 days and closure of the cavity checked by x-ray sinograms.

X-ray shows sub-phrenic abscess

Tuberculous peritonitis

A bacterial contamination from spillage an intraabdominal viscus it could be life threatening event


TUBERCULOUS PERITONITIS
Infection occurs most commonly mass reactivation of latent tuberculous foci in the peritoneum that were established from hematogenous spread from a primary lung focus , It can also become via hematogenous spread from active pulmonary or miliary TB. Much less frequently, the organisms enter the peritoneal cavity transmurally from an infected diminutive intestine or contiguously from tuberculous salpingitis .


Peritoneal T.B. is an uncommon site of extrapulmonary infection caused by Mycobacterium T.B. (TB). The venture is accumulated in patients with cirrhosis, retrovirus infection, diabetes mellitus, underlying malignancy, mass treatment with anti-tumor necrosis factor (TNF) agents, and in patients undergoing continuous ambulatory peritoneal dialysis.


As the disease progresses, the visceral and parietal peritoneum become progressively studded with tubercles. Ascites develops alternative to "exudation" of proteinaceous fluid from the tubercles, similar to the mechanism leading to ascites in patients with peritoneal carcinomatosis. More than 90 percent of patients with TB rubor have ascites at the time of presentation, while the remainder present with a more advanced "dry" phase, representing a fibroadhesive modify of the disease.


Pathologically Gastrointestinal tuberculosisis characterized by rousing and fibrosis of the bowel surround and the regional lymph nodes. Mucosal lesion results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this stage of the disease, the changes are rechargeable and healing without scarring is possible. As the disease progresses, the lesion becomes confluent, and extensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral accumulation lesions. Strictures and fistulae formation may occur.


ORIGIN OF INFECTION from tberculous mesentric lymph nodes .from tuberculosis of ileocecal region ,from tuberculous pyosalpinx ,Blood-borne infection from pulmonary tuberculosis ,usually milliary.


CLINICAL TYPES


ASCITIC FORM peritoneum is studded with tubercles and peritoneal cavity becomes filled with pale ,straw colored fluid .its onset is insidious .with loss of energy , facial pallor and some loss of weight ,enlargement of abdomen ,pain often completely absent ,but there may br abdominal discomfort ,usually associated wih constipation or diarrhea . Even pyrexia and night sweats.


Dilated veins can be seen coursing beneath the skin of abdominal wall. shifting dullness and fluid thrill present , congenital hydrocele sometimes appear in male child .Umblical hernia may develop .A transverse solid mass can often be palpated per abdominally ,( this is rolled up greater omentum infiltrated with tubercles )


ENCYCTED ( LOBULATED ) FORM pathologically it is similar to ascitic form , but one part of abdominal cavity alone is involved .clinical features also resemble to ascitic form ,but there is a localized intraabdominally lump . .localized intraabdominally swelling .fluid thrill and shifting dullness may or may not be present ,depending upon the site of collection .


FIBROUS ( PLASTIC FORM ) there is widespread intraperitoneal adhesions .which causes coils of intestine especially the ileum , to become matted together and distended.These distended coils act as a blind loop. There are symptoms of steatorrhea , loss of weight , attacks of abdominal pain ,Evening pyrexia and night sweats ,and some symptoms of acute and subacute intestinal obstruction , with signs of wasting ,a palpable swelling or swellings per abdominally ( this is adherent intestine with omentum attached ,together with thickened mesentry ).


PURULENT FORM pathlogically there is mass of adherent intestine and omentum ,is surrounded by tuberculous pus to form a cold abscess .This may point to the surface ,commonly near umblicus ,or burst into bowel . In clinically it shows loss of weight ,abdominal pain .discharge from an opening on abdominal skin .evening pyrexia and night sweats ,with signs of discharge from a sinus or fistula ,the opening of which is often wide ,with thin blue and undermined margin. A swelling may be palpated per abdominally ( consisted of adherent intestine and omentum )


ACUTE FORM pathologically resemble with ascitic form and clinically resembles acute bacterial peritonitis .


Some investigations can reveal this lesion such as


PERITONEAL ASPIRATION fluid is pale yellow .usually clear , rich in lymphocytes and have a high specific gravity.1.020 or more .Mycobacterium tuberculosis can be demonstrated by culture and microscopy with Ziehl-Neelsen staining.
MANTOUX TEST a positive test is strongly suggestive ,in non immunized patients .
CHEST X-RAY may reveal pulmonary tuberculosis
LAPROSCOPY can demonstrate the clinical type
PERITONEAL BIOPSY reveal characteristic tuberculous granuloma.


TREATMENT


CHEMOTHERAPY initial phase ethambutol .plus isoniazid plus rifampin plus pyrazinamide for two months .and in continuation phase ethambutol plus isoniazid plus rifampin for four to seven months .


SURGICAL TREATMENT


IN CASES OF FLUID COLLECTION laparotomy is performed ,fluid is evacuated and abdomen is closed without drainage .
IN FIBROUS FORM
On laparotomy ,bands of adhesion are divided. if adhesions are accompanied by fibrous strictures of ileum ,then excise the affected bowel, if adhesions only are present , a plication may be performed.
IN PURULENT FORM
On laparotomy ,cold abscess are evacuated ,fecal fistula is closed , combined with some form of anastomosis between segment of intestine above the fistula and an unobstructed area below.