Anatomy of the biliary system.
Fig. 1
Bile canaliculi unite to form segmental bile ducts which drain each liver segment.
The segmental ducts combine to form sectional ducts with the following pattern:
· Segments VI and VII: right posterior duct (RPD), coursing more horizontally
· Segments V and VIII: right anterior duct (RAD), coursing more vertically
· Right posterior and anterior ducts unite to from the right hepatic duct (RHD)
· Segmental bile ducts from II-to-IV unite to form the left hepatic duct (LHD)
The left and right hepatic ducts unite to form the common hepatic duct (CHD).
Bile duct(s) from segment I drain into the angle of their union. The ducts of the left hepatic lobe are more anterior than those of the right lobe; it is important particularly when contrast cholangiogram is performed because contrast may not opacify nondependent ducts
The common hepatic duct is joined by the cystic duct to form the common bile duct. The common bile duct travels initially in the free edge of the lesser omentum,
then courses posteriorly to the duodenum and pancreas to unite with the main pancreatic duct to form the ampulla of Vater,
which drains at the major duodenal papillae on the medial wall of the D2 segment of the duodenum.
Variations in the biliary system anatomy Fig. 2
The most common anatomic variation in the branching of the biliary tree involves the fusion of right posterior sectoral duct with the left hepatic duct.
Other variations encountered are right posterior sectoral duct opening into the common hepatic duct or cystic duct and trifurcation anomaly.
Causes of biliary obstruction: Fig. 3
- Neoplastic
- Post -inflammatory
- Inflammatory
Types of biliary interventions for biliary obstruction:
PTBD: Percutaneous transhepatic biliary drainage Fig. 4
-External drainage Fig. 5
-Internal drainage ( biliary stent insertion)
-Internal/external drainage Fig. 6
ERCP: Endoscopic Retrograde Cholangiopancreatograpy Fig. 7
Possible complications :
a)Pneumothorax Fig. 8
b)Duodenal perforation Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13
c)Liver trauma Fig. 14
d)Biliary tract injury Fig. 15
a)Biliary leakage: biloma Fig. 16 Fig. 17
b) Displaced/ dislogement of the draining catheter
-Outwards: Non-functioning
-Venous haemobilia
-Arterial haemobilia Fig. 18
-Peritoneal leakage
c)Acute pancreatitis: Fig. 19 Fig. 20 Fig. 21
Pancreatitis is the most frequent complication in cases of ERCP,
occuring in about 3 to 5 percent of people undergoing ERCP.
When it occurs,
it is usually mild,
causing abdominal pain and nausea,
which resolve after a few days in the hospital.
Rarely pancreatitis may be more severe.
d)Cholangitis
e) Sepsis
a)Abscess formation: Anywhere along the track of the biliary system: Liver Fig. 22 or abdominal wall abscess
b)Stent fracture: Fig. 23 Fig. 24 Fig. 25 Fig. 26
This is a female patient who underwent ERCP stenting with persistent jaundice.
CT of the abdomen showed intrahepatic biliary radicle dilatation with stent fracture with a broken stent,
explaining its dysfunction.
c) T-tube leakage Fig. 27 Fig. 28
d)Caudal stent migration: There are three illustrative cases all complaining with persistant jauncide after stent placement
This is a case of persistant obstructive jaundice after ERCP and stentting owing to caudal slipping of the stent till the 2nd part of the duodenum Fig. 29 Fig. 30 Fig. 31 Fig. 32 ,
This is a case with distal migration of the stent Fig. 33 Fig. 34 Fig. 35 Fig. 36 Fig. 37 )&
The last case is that of a caudal stent migration as shown in an MRCP study Fig. 38
e)Biliary stricture Fig. 39