Bile

These eventually collect at the inferior border of the liver in two larger ducts and exit the liver. Both unite after a short distance to form the common bile duct, which at one point gives off the connection to the gallbladder. Further on, the common bile duct passes over the head of the pancreas to the duodenum.

There, together with the pancreatic duct, it enters the intestine. At this transition into the intestine, the papilla of Vater (lat. papilla vateri), a critical bottleneck of the biliary system, is located as the closure of the bile duct system. In front of this bottleneck, smallest stones can often remain. From the close spatial relationship of the two outlets at the bile duct and the pancreas, it is understandable that certain diseases of the bile ducts can lead to pancreatitis.

In addition to the production of gastric juice, this also includes the secretion of bile from the gallbladder. This process is controlled by a highly complex system of nerve impulses and messenger substances that, among other things, cause the gallbladder to contract and empty its contents into the duodenum via the common bile duct.

Fortunately, most of the stones, which are often quite large, are located in the gallbladder, where they can remain for years without ever becoming noticeable. However, in about 20% of all stone carriers, gallstones are also found in the bile ducts. There, the small stones that “migrate” from the gallbladder into the narrow common bile duct and become trapped or, if they are small enough, leave the bile duct via the duodenum are most noticeable.

Inflammation of the bile ducts can occur when there is a slow flow of bile in the system over a long period of time, giving bacteria from the duodenum an opportunity to move backward into the common bile duct and infect the bile. Finally, two rather rare diseases of the bile ducts should be mentioned: The malignant tumors and the diseases that can cause delayed bile flow due to inflammation in the ducts.

The highly rare malignant bile duct tumors of the common bile ducts occur in three different “floors” outside the liver: Where the two main bile ducts leave the liver at the lower edge of the liver, up to the point where the two bile ducts just unite (hepatic fork), in the area of the middle third of the main bile duct, and at the final stretch of the main bile duct that extends from the upper edge of the pancreas to the duodenum.

Inflammation can cause the bile ducts to become narrowed. These inflammatory constrictions are the result of infections of the gallbladder and pancreas (with or without stone disease) or the result of previous surgery in this area, which damage the bile ducts in the blood flow or directly and can therefore lead to a stricture (narrowing).

If this causes bile to back up into the liver, a yellow discoloration of the eyes and skin as well as brown urine and discolored stool may occur. If the patient is feverish, has chills and feels seriously ill, it must also be assumed that there is inflammation of the bile ducts, which can sometimes extend to the pancreas.

A doctor should be consulted already in case of a permanent intolerance of food, in case of accompanying nausea, but at the latest in case of the occurrence of collic-like complaints in the upper abdomen, in order to clarify whether the cause is gallstones or another disease of organs of the right upper abdomen.

This is followed by a comprehensive physical examination including the abdomen. Afterwards, a blood sample is taken to check the inflammatory signs and liver values. In doing so, one pays particular attention to those values that can signal a bile stasis.

One of the most important examinations is ultrasound examination of the upper abdomen. In most cases, it provides basic information about possible gallstones and bile duct stones, bile stasis (dilated bile ducts), and signs of inflammation.

Nevertheless, the examiner may not be able to see the smallest stones on ultrasound if the bile ducts are severely dilated, but the patient still has typical “stone complaints.” In this case, one will usually perform a CT scan and possibly bile duct imaging (ERCP). The latter involves X-ray contrast imaging of the bile ducts using duodenal endoscopy, and stone removal can also be performed in the same session.

Magnetic resonance imaging (MRI) as a further diagnostic option is reserved for special questions. Unfortunately, even today, despite many highly specialized procedures, there is still no procedure that can 100% prove the presence of gallstones. Therefore, the exact sequence of diagnostics for bile duct stones always requires a synopsis of all examination results and laboratory values, and it takes into account the patient’s symptoms and age. This is the only way to find an individualized and low-complication therapy for the rehabilitation of the bile ducts.

If a patient presents with colicky symptoms, perhaps already with yellowing of the skin, it is necessary to remove the bile duct stones and restore normal bile flow. For this purpose, the patient is given a sedative before the examination and is then placed on a couch. The throat is thoroughly anesthetized with a spray, as in a gastroscopy.

The examining specialist also inserts a thin tube, the end of which has an optic, through the patient’s mouth and advances it into the duodenum. At the point where the common bile duct enters the intestine, also called the papilla, the common bile duct is visited and initially imaged with contrast medium to show and assess local findings. The examiner then decides on a specific sequence of therapy, which can be performed immediately via the endoscope. Two examples:

The papilla is too narrow to allow good bile drainage and to allow small stones to pass. Therefore, it is dilated with a special knife or expanded with a small balloon. There are stones in the common bile duct. They are removed from the bile duct with the help of a small basket. Inflammation of the bile ducts, with or without stone disease, is also treated with incision dilation of the papilla, and the bile ducts are flushed.

Intravenous administration of antibiotics is a matter of course. Now 95% of all patients can be cleared of their bile duct stones using this procedure, and fortunately, complications of ERCP and EPT are rare. At most, there may be bleeding from the interface of the papilla, or inflammation of the pancreas. If the patient still has his gallbladder, it is removed by minimally invasive surgery after the bile duct stones have been removed and all liver values and clinical findings have normalized.

Thus, yellow bile belonged to fire and circumscribed the character of the choleric who exclaims, “My bile is running over!” Today, it is known that the development of gallstones is actually associated with an altered composition of the bile. Many accounts show that people have been plagued by gallstone disease for centuries, but there have been only non-surgical therapies to relieve their symptoms.

Wound physicians intervened only when gallstone-containing abscesses broke through to the outside. When the prerequisites for abdominal surgery were met with antisepsis and general anesthesia in the 19th century, there was a rapid increase in knowledge in the field of surgical therapy of gallbladder and bile duct stones as well as new diagnostic procedures, in that the aim was to visualize the biliary system via contrast medium administration in order to localize stones there.

In 1882, Karl Langenbuch succeeded in performing the first gallbladder removal, and in 1890, Ludwig Courvoisier became the first surgeon to dare to open the common bile duct to remove a stone and restore bile flow. The particular difficulty was to create a suture-tight closure of the bile duct. Many surgeons at that time discouraged surgical therapy of the biliary tract, knowing that a “bile leak” of the duct resulted in serious complications.

The saving idea to grant bile drainage came from Hans Kehr in 1895, who invented the T-drainage, which is still used today. This is a very thin plastic tube that is inserted into the common bile duct and passes through the abdominal wall, allowing bile to drain freely. Once wound healing in the bile duct area is complete, the drain can be removed without complications.

In the following decades, there were still various surgical and diagnostic improvements, but the basic surgical therapy hardly changed. The development of the ERCP examination (ERCP stands for Endoscopic Retrograde Cholangiopancreaticography) by Ludwig Demling in 1974, a special X-ray contrast imaging of the bile ducts that simultaneously offered therapeutic possibilities, was groundbreaking.

Last but not least, the development of minimally invasive surgery (keyhole surgery) since 1985 revolutionized surgical procedures in the area of the gallbladder and bile ducts and arguably offers patients a much more comfortable surgical therapy.

Gallstones vary widely in size, shape, and composition (Fig. 4). Cholesterol stones (80%) are most commonly found in the gallbladder and bile duct and often originate in the gallbladder and are light in color. Pigment stones (bilirubin stones) tend to be dark and are found in only about 20% of cases. Finally, there are also the so-called mixed stones, which are relatively common in any composition and in different shapes and colors.

Gallstones can linger in the gallbladder for years without causing any symptoms. They are therefore often called “silent gallstones”. The dangerous stones are the small ones, as they can enter the bile ducts and obstruct bile flow in the papilla area, for example.
The typical symptoms of gallbladder colic are due to a discharge of such a small stone. If a stone passes the narrow points (Fig. 5), colic results, but if it remains stuck at a narrow point in the common bile duct, the bile can no longer flow away and backs up into the liver. This backwater leads to a yellow discoloration of the eyes and skin. The urine becomes dark and the stool light in color because the bile pigments can no longer fully enter the duodenum.

Small, but also larger stones, which cannot leave the gallbladder, lead to irritation of the gallbladder mucosa and consequently to inflammation. This can occur quite acutely or be chronic. Such a process can take weeks and months, often years.

The typical symptoms of biliary colic are cramping, burning or probing pain in the right and middle upper abdomen that can last from a few minutes to several hours. Pain radiation to the right shoulder and/or back can often be observed. Colic may also be accompanied by nausea and transient yellowing of the skin. Some patients also have diarrhea. However, it is important to note that all of these signs can occur with other conditions and are not specific to gallstone colic.

In the case of cholecystitis, the patient suffers from fever, in the acute episode up to 38 or 39°C, sometimes also from chills. In general, patients feel unwell and suffer from loss of appetite. Thanks to their experience with these colics, many know precisely after which foods they occur and often avoid them for years. Fatty foods are well known, such as cheese, fried eggs or fried food.

One of the most important examinations today is that with ultrasound, which can be used with the greatest certainty to determine whether stones are present in the gallbladder, whether the bile ducts are obstructed, and whether the gallbladder wall is thickened as a sign of inflammation (Fig. 6).

This examination is somewhat less accurate for stones in the bile duct system. Other examination methods, such as radiographic imaging with contrast medium, CT (Fig. 7) or MRI, are only necessary for special questions.

• Gallstones detected by ultrasound with a history of colic or inflammation, after resolution of symptoms (operation “à froid”).
• Acute gallbladder inflammation that does not resolve after antibiotic administration.
• A previously experienced pancreatitis, which is due to gallstones.
• After removal of gallstones in the bile ducts by ERCP (Fig. 8).
• Among the surgical techniques available today, a basic distinction is made between the minimally invasive laparoscopic procedure and the open, conventional gallbladder removal.

In keyhole surgery, the patient lies supine on the operating table with the legs supported on props (Fig. 10). After thoroughly disinfecting the surgical field and covering it with sterile drapes, the surgeon opens the skin to the right of the navel or in the umbilicus about one to two centimeters and then sticks a special blunt needle (Veress needle) into the abdominal cavity.

A syringe and some saline solution are then used to test whether no blood vessel has been hit and whether there is actually air in the abdomen. Carbon dioxide is now pumped into the abdominal cavity via the Veress needle. This causes the abdominal wall to lift away from the internal organs, creating a space in which to work with the instruments.

Subsequently, a sleeve is advanced into the abdominal cavity through the skin incision at the navel and a small camera with light is inserted into the abdominal cavity through this sleeve. Three more such guide sleeves are inserted into three further small skin incisions of five to ten millimeters under camera control. The working instruments, such as forceps and current hooks, can now be inserted via these additional access points.

The camera is used to carefully check once again that no bleeding has occurred anywhere in the liver bed. All the sleeves are then removed and the skin incisions are sutured closed with one or two stitches.

There are cases that are not suitable for a minimally invasive method or in which open surgery must be continued after a laparoscopic start. This is the case, for example, if the patient has already had previous operations in the upper abdomen with extensive adhesions.
Sometimes a gallbladder is also so strongly caked with its surroundings due to acute or chronic inflammation that laparoscopic surgery would entail too great a risk of bile duct or vascular injury due to the lack of an overview. Therefore, each patient must be informed prior to a planned laparoscopic procedure that a switch from the laparoscopic method to the open technique may be necessary.

Carefully informing the patient about the surgery and making sure that the patient really understands the information should always be considered important tasks by the surgeon in charge.

The gallbladder at the lower edge of the liver is presented with hooks, and the small artery for the gallbladder as well as the gallbladder duct are visited, pierced around and cut. Subsequently, the abdominal wall is closed again layer by layer.

Whether laparoscopic or open gallbladder surgery is an option depends on a number of factors and can only be answered on an individual basis. In principle, the laparoscopic method should be used first. If this is not possible, the open method must be chosen. After previous operations in the upper abdomen (stomach or intestinal operations), often only the open method is possible due to adhesions. However, this usually only becomes apparent during the operation.

Patients with severe cardiac conditions may need to refrain from laparoscopic surgery because the pressure in the abdomen rises due to the distending gas, carries over to the diaphragms, and can have a disabling effect on cardiac function.

Increased physical activities can be started after one week, and the ability to work depends on the individual workload in each case.

Problems associated with gallbladder surgery are rare. Occasionally, bleeding from a vessel or leakage from the bile duct occurs when a clip is not perfectly placed. The main dangers of gallbladder surgery arise from the very different anatomical variants of bile ducts and vessels; there are innumerable such variants and many insidious courses of these structures, which demand a great deal of skill even from very experienced surgeons.

In both open and laparoscopic surgery, the common bile duct can be mistakenly injured, blocked with a clip, or partially severed – fortunately, this happens very rarely. The main risk is injury to the common bile duct, but this occurs in only 0.3 to 0.9% of cases.

Today, we know that the development of gallstones is actually associated with an altered composition of the bile. Many accounts show that people have been plagued by gallstone disease for centuries, but there were only non-surgical therapies available to relieve their symptoms.

Wound physicians intervened only when gallstone-containing abscesses broke through to the outside. When the prerequisites for abdominal surgery were created with antisepsis and general anesthesia in the 19th century, there was a rapid increase in knowledge in the field of surgical therapy of gallbladder and bile duct stones as well as new diagnostic procedures: Via administration of a contrast medium, imaging of the biliary system was sought in order to localize any stones.

In 1882, Karl Langenbuch succeeded in performing the first gallbladder removal, and in 1890, Ludwig Courvoisier became the first surgeon to dare to open the common bile duct to remove a stone there and restore bile flow. The particular difficulty was to create a suture-tight closure of the bile duct. Many surgeons at that time refrained from surgical therapy of the bile ducts, knowing that a “biliary leak” of the duct would result in serious complications.

The saving idea to ensure bile drainage came from Hans Kehr in 1895, who invented the T-drainage, which is still used today. This is a very thin plastic tube that is inserted into the common bile duct and passes through the abdominal wall, allowing bile to drain freely. Once wound healing in the bile duct area is complete, the drain can be removed without complications.

In the following decades, there were still various surgical and diagnostic improvements, but the basic surgical therapy hardly changed. The development of the ERCP examination by Ludwig Demling in 1974 (ERCP stands for Endoscopic Retrograde Cholangiopancreaticography), a special X-ray contrast imaging of the bile ducts that simultaneously offered therapeutic possibilities, was groundbreaking (Fig. 8).

Last but not least, the development of minimally invasive surgery (Figs. 9 to 15) since 1985 revolutionized surgical procedures in the area of the gallbladder and bile ducts and has since made it possible to offer patients a much more comfortable surgical therapy.