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Bile Ducts

 

Diseases of the Bile Ducts

 

Gall bladder - bile ducts - outlet of the bile ducts An integrated system

As already mentioned in the chapter on the gall bladder, the latter is located at the lower rim of the liver and serves as a reservoir of bile. The bile duct system belonging to it starts in the liver, where the liver cells produce bile and distribute it into very tiny bile ducts which then permeate the liver. They finally collect at the lower rim of the liver to form two bigger ducts that then leave the liver. After a short distance, the two unite and form the common bile duct, which branches off a connection to the gall bladder. The common bile duct continues to the duodenum, passing the head of the pancreas. There, it flows into the bowel, together with the secretory duct of the pancreas. Exactly at this place lies the papilla as the final part of the bile duct system. It is a critical narrow passage of the biliary system, where often tiny stones may be deposited. The two outlets are very close together, which makes it understandable that certain diseases of the bile ducts may result in pancreatitis.

Functions of the bile duct system

The bile, which is instrumental in the digestion of fats in the duodenum and the small bowel, consists of a great number of substances and is also a type of transport medium of the catabolic products of the liver. As the demand of bile depends on the food intake, and as the liver cannot increase the production of bile at once, bile is again and again stored in the gall bladder to be immediately pressed into the duodenum after a meal. During the passage of food through the stomach and the duodenum, various mechanisms of digestion are activated. Among them are the production of gastric juice and the release of bile from the gall bladder. This process is regulated by a highly complicated system of nerve impulses and messenger substances, which cause the gall bladder to contract and to empty its content through the common bile duct into the duodenum.

Incarceration of stones and acute inflammation of the bile ducts as the most common diseases of the bile duct system

A complicated system of the production of bile, its storage and distribution is of course prone to disorders. If the composition of the bile changes or if the discharge of the whole system is delayed, the most common disease of this area develops: the formation of gallstones. Fortunately, the greater number of the partly quite big stones is found in the gall bladder, where they may stay for years without ever making themselves felt. About 20% of the stones are, however, found in the bile ducts. There, it is especially the small stones that make themselves felt when they move from the gall bladder into the narrow main bile duct and get wedged. If they are small enough, they may leave the bile duct via the duodenum. An inflammation of the bile ducts may be caused if the bile flows too slowly through the system over a longer space of time, thus giving the bacteria from the duodenum an opportunity to move backwards into the common bile duct. Finally, two rarer diseases of the bile ducts should be mentioned: the malignant tumours and the diseases, in which inflammations of the ducts cause a retarded drainage of the bile. The very rare malignant tumours of the bile ducts occur on three levels outside the liver:
1. where the two main bile ducts leave the liver at its lower rim, up to the place in which the two unite (hepatic bifurcation)
2. around the middle of the main bile duct
3.around its final section, extending from the upper rim of the pancreas to the duodenum

How do I recognize a bile duct disease?

Many patients with gallstones or stones of the bile ducts do not have any complaints for their whole lives, and the most important laboratory values are also inconspicuous. Others may feel a slight indisposition and a minor pain on pressure in the upper abdomen or complain about the indigestibility of fat or flatulent food. However, if a stone is released from the gall bladder and moves into the ducts, the patient will suffer from strong colicky pains in the right side of the upper abdomen. They may last from a few minutes to some hours and sometimes radiate into the right shoulder and the back. If this causes a congestion of the bile as far as to the liver, a yellow colouring of the eyes may occur, but also brown urine and decolourized stool. If the patient is feverish, if he has got shivers, and if he feels badly ill, an inflammation of the bile ducts is most probable and may also affect the pancreas. If there is a continuous indigestibility of food accompanied by nausea, or if colicky discomforts in the upper abdomen occur, a doctor should be consulted. It has to be clarified whether the complaints are caused by gallstones or by an irritable stomach or bowel.

Necessary clarifications and diagnostic possibilities

The doctor will start with an intensive questioning of the patient: Has he been avoiding certain food for a longer space of time (fats, coffee, chocolate)? Does he take certain medicaments? What was the pain like and whereto did it radiate? Was there a yellow colouring of the eyes and of the skin? Was the stool discoloured and the urine dark? Had there been any fever attacks or shivers? In that case, the doctor carries out an intensive physical examination, especially of the abdomen, and takes a blood sample to check whether there are indications of an inflammation and to control the liver factors. Special attention must be paid to the factors, which might indicate a congestion of the bile. One of the most important examinations is the ultrasound of the upper abdomen. In most cases, it supplies fundamental information about possible gallstones and stones of the bile ducts, about a congestion of bile, and about indications of an inflammation. Nevertheless, it might happen that the examining doctor cannot make out very tiny stones if the bile ducts are widened, even if the patient has the typical complaints. Then, usually a CT¬-examination and perhaps a visualization of the bile ducts (ERCP) will be carried out. ERCP is a contrast radiography of the bile ducts by means of an endoscopy of the duodenum. During this process, the removal of stones is also possible. The nuclear spin tomography (MRI), another diagnostic possibility, is reserved for special problems. There are many highly specialized methods today, but unfortunately, there is none that could prove the existence of gallstones with 100% certainty. Therefore, the diagnosis of bile duct stones requires a complete and combined view of all findings and laboratory data, also taking the complaints and the age of the patient into account. Only that way, an individual therapy without complications for the healing of the bile ducts is possible.

How can a disease of the bile ducts be treated?

The removal of very tiny bile duct stones profits a lot from the era of endoscopy. The development of the endoscopic retrograde Cholangiopancreatography (ERCP) and the endoscopic papillotomy (EPT) in 1974 opened entirely new, non-surgical possibilities of diagnosis and therapy of the bile duct disease. How do these methods work? If there is a patient with colicky complaints, maybe already with a yellow colouring of the skin, his bile duct stones must be removed and a normal drainage of the bile must be restored. Before the examination, the patient receives a sedative and lies on a stretcher. His throat is thoroughly benumbed with a spray in the same way as prior to a gastroscopy. The doctor then inserts a thin pipe, the end of which is equipped with a camera, into the mouth of the patient, pushing it in as far as the duodenum. At the place where the common bile duct opens into the bowel, called the papilla, the main bile duct is found and visualized by the use of a contrast medium. Thus, the local findings can be shown and evaluated. After this, the examining doctor decides what sequence of therapy should be followed, and which can immediately be realized via the endoscope. Here are two examples:

The papilla is too narrow to allow good drainage of the bile and to allow the passage of small stones. Therefore, it is widened with a special knife or dilated with a small balloon.

There are stones in the main bile duct. They are removed from the bile duct with the help of a tiny basket. An inflammation of the bile ducts, whether there are stones or not, is also treated by widening the papilla with an incision. The bile ducts are flushed out if necessary.

It goes without saying that antibiotics are administered in this therapy. In the meantime, 95% of the patients can be relieved from their bile duct stones with this method, and complications with the ERCP and EPT are fortunately rare. There may, however, be bleedings at the papilla, where the incision was made, or an inflammation of the pancreas. Should the patient still have his gall bladder, it is removed in a minimally invasive operation, but only after the removal of the bile duct stones and after a normalization of all liver factors and clinical findings.

What happens after the treatment?

As soon as the patient has completely woken up after the operation, he is allowed to get up. He can drink and eat light food that same day, but antibiotics have still to be taken for some more days. By controlling the liver factors and by observation of the skin, the doctor finds out whether the congestion of the bile has diminished and the therapy has therefore been successful.

What has to be paid attention to in future everyday life?

The intervention is well tolerated and the disease normally heals without later secondary complaints. It happens only very rarely that new stones form in the common bile duct after the removal of the gall bladder and the treatment of the bile duct.

History

Bile as a liquid of the body has been known since antiquity. It was part of the ancient doctrine of the four juices, which mirrored the notion of that time how diseases developed. Until then, scientists and physicians had the opinion that man and matter consisted of only one element. But in the ancient doctrine of the four juices, the physician Empedocles of Akragas assigned the four elements of air, water, fire, and earth, which he had defined himself, to the four juices of the body: blood, mucus, yellow and black bile. It was thought that an unbalanced mixture of these juices of the body did not only evoke diseases, but they also determined characters. Thus, the yellow colour belonged to the fire and at the same time described the character of the choleric type who exclaims: "It galls me" (it makes me furious). Today, it is known that the formation of gallstones in fact goes along with a changed composition of the bile. Many descriptions prove that mankind has been suffering from gallstones for centuries, but also that there were only non-operative therapies to alleviate the pains. Surgeons only intervened if abscesses caused by gallstones broke through to the outside. When with the introduction of antisepsis and general anaesthesia in the 19th century the preconditions for abdominal surgery had been established, there was a rapid growth of knowledge as to the surgical therapy of stones of the gall bladder and of the bile ducts. There were also new diagnostic methods. Hence, by trying to visualize the biliary system through the application of contrast material, it became possible to localize stones. In 1882, Karl Langenbach succeeded in removing the first gall bladder, and in 1890, Ludwig Courvoisier was the first surgeon who dared to open the common bile duct in order to remove a stone and to re-establish the flow of the bile. The special difficulty to achieve a tight suture of the bile duct kept many surgeons of that time away from a surgical therapy because they knew that a leak of bile can cause grave complications. The idea of how to guarantee the drain of the bile came from Hans Kehr in 1895, who invented the T-drainage, which is still in use today: a very thin plastic pipe is inserted in the main bile duct that then passes through the abdominal wall to the outside, so that the bile can drain unimpeded. After the wound around the bile duct has healed, the drain can be removed without complication. In the following decades, there were several surgical and diagnostic improvements, but the fundamental surgical therapy did not change. The development of the ERCP-examination by Ludwig Demling in 1974 was pioneering. It is a special contrast radiography of the bile ducts, which at the same time offers therapeutic possibilities. It was also the development of the minimally invasive surgery since 1985, which revolutionized the surgical interventions of the gall bladder and the bile ducts, offering to the patients a more comfortable surgical therapy.

 

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