Ministry of health of the Republic of Moldova

State University of Medicine and Pharmacy

Nicolae Testemitanu
FACULTY OF MEDICINE Nr.II
DEPARTMENT OF SURGERY Nr.II
DIPLOMA THESIS
Diseases of the biliary tract
Chief of department: Dr.
Scientific advisor: Dr.Borta Edward
Student: Masarwa Mahmud
6th Year, Group M1140
CHISINAU 2017
THE AIM OF THE STUDY :

To analyze the pathologies and treatment

approaches of the biliary tract diseases
THE OBJECTIVES :

To study the causes and the risk factors for biliary tract
diseases
To study the methods of diagnosis of biliary tract diseases
To study the methods of treatment in patients with biliary
tract diseases
To study the complication of biliary tract diseases
To study the screening methods for patients with biliary tract
diseases
To study the prevention of biliary tract diseases
 DEFINITION :
Biliary tract diseases are a group of disorders
that interfere with the normal function of the
biliary tract, which can be of infectious,
cancerous, traumatic, or any other origin.
Most common in incidence are, gallstone,
acute acalculous cholecystitis, and tumors.
(Adamsen, S., Hansen, O. H., Funch-Jensen, P., Sehulze, S., Stage, J. G., Wara )
,
ANATOMIC LOCATION OF CRC

Cecum 14 %
Ascending colon 10 %
Transverse colon 12 %
Descending colon7 %
Sigmoid colon 25 %
Rectosigmoid junct.9 %
Rectum 23 %
ETIOLOGY AND RISK FACTORS
Age more than 50 years old .
Adenomas, Polyps presence .
Sedentary lifestyle, Diet, Obesity
Family History of CRC
Inflammatory Bowel Disease (IBD)
Hereditary Syndromes (familial adenomatous polyposis (FAP))
CLASSIFICATION OF CRC (WHO)
Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma
TNM STAGING

T;TUMOR
T1:tumor invades submucosa
T2:tumor invades muscular layer
T3:tumor invades to muscular and peri rectal tissues
T4:tumor perforates the organ and other structures
NODE (N)

N0: No regional lymph node metastasis

N1:metastasis to 1 to 3 regional lymph nodes
N2: Metastasis in 4 or more regional lymph nodes

Metastasis (m)
M0:no metastasis
M1 :distant metastasis
HOW DOES COLORECTAL CANCER
DEVELOP

Colon cancers result from a series of pathologic changes that

transform normal epithelium into invasive carcinoma.
Specific genetic events, shown by vertical arrows,
accompany this multistep process.
SYMPTOMS ASSOCIATED WITH CRC
DIAGNOSIS AND CONFIRMATION TESTS

1. Physical exam and history

To check general signs of health

2. Digital rectal exam

inserts a lubricated gloved finger
into the rectum to feel for lumps
or anything else that seems
unusual.
3. Fecal occult blood test (FOBT)

Detects small amounts of blood in the feces which would not

normally see or be aware of.

4. Rectoromanoscopy and Sigmoidoscopy ( biopsy )

The rectum and lower colon are examined using a lighted
instrument called a sigmoidoscope

Fecal occult blood test (FOBT)

5. Colonoscopy
The rectum and entire colon are examined using a
lighted instrument called a colonoscope
. 6. Double contrast barium enema (DCBE)
A series of x-rays of the entire colon and rectum are taken
after the patient is given an enema with a barium solution
and air is introduced into the colon
The barium and air help to outline the colon and rectum
on the x-rays
7. Computed Tomography (CT Scan)
Combines special x-ray equipment with sophisticated
computers to produce multiple images or pictures of the
inside of the body
A CT scan may be used if colorectal cancer has
metastasized to other organs
8. Positron emission tomography (PET)
Help to determine whether an abnormal area seen on
another imaging test is a tumor or not.
For patients who have already been diagnosed with
cancer, this test help the doctor to see if the cancer has
spread to lymph nodes or other parts of the body.
MANAGEMENT
Medical management
1. chemotherapy
2. radiation
3. surgery
1. CHEMOTHERAPY
Use drugs to stop the growth of cancer cells
killing the cells
stopping them from dividing.

2 types :
i. Systemic chemotherapy
Taken orally or intravenously
ii. Regional chemotherapy
placed directly into the spinal column, an organ, or a body
cavity
2.RADIATION :
Use high-energy x-rays to kill cancer cells or keep them
from growing.
local therapy - affects the cancer cells only in the treated
area.

2 types :
External radiation therapy
uses a machine outside the body to send radiation
toward the cancer.
Internal radiation therapy
uses a radioactive substance sealed in needles or
3.SURGICAL MANAGEMENT
1.colectomy (right hemicolectomy-asending colon
Left hemi colectomy(decending colon)
Extended hemicolectomy(transeverse colon)
Sigmoidectomy ( resection of sigmoid colon)
Total colectomy
Subtotal colectomy
Hartmann operation
COLOSTOMY
A colostomy is a surgical procedure in which a stoma is
formed by drawing the healthy end of the large intestine
though the abdominal wall and suturing in to place (medical
encyclopedia)
Colostomy is a surgical procedure that allows intestinal
contents to pass from the bowel through an opening is called
STOMA .the stoma created when the intestine is brought
through the abdominal wall and sutured to the skin.
(colostomy nursing care)
 TYPES OF OSTOMIES

Hartmann operation
LOOP STOMA
DOUBLE-BARRELED STOMA
KNOCK POUCH
COLOSTOMY CARE
Emotional support as the patient cope with a radical body
change
Patient teaching about stoma care

Normal stoma
 COMPLICATIONS
Liver metastasis
Lung cancer
Intestinal obstruction
Intestinal perforation and bleeding
Prevention :
Colon cancer can be prevented and cured through early
detection
Changing your eating habits( more fiber and less fats)
Dont smoke and drink less
SCREENING :
All patients age 50 years and older, the asymptomatic general
population
Fecal occult blood test (FOBT) every year, or
Flexible sigmoidoscopy every 5 years, or
A fecal occult blood test every year plus flexible sigmoidoscopy
every 5 years (recommended by the American Cancer Society), or
Double-contrast barium enema every 5 to 10 years, or
Colonoscopy every 10 years (recommended by the American
College of Gastroenterology).
 Mortality
Test Reduction
Fecal occult blood testing 33%

Flexible sigmoidoscopy 66%

(in portion of colon examined)

FOBT + flexible sigmoidoscopy 43%

(compared to sigmoidoscopy alone)

Colonoscopy ~76-90%
(after initial screening and polypectomy)
CASE STUDY
HISTORY OF PRESENT ILLNESS:
70 year old white male
post resection of a stage III adenocarcinoma of the sigmoid colon (approx. 10 days)
2 weeks prior to surgery he had significant coronary artery disease and had underwent
a CABG

PATHOLOGY REPORT:
highly aggressive T3, N2 adenocarcinoma of the colon, stage III with angiolymphatic
invasion.
6 of 11 lymph nodes were positive .
He underwent adjuvant 5FU leucovorin chemotherapy
Recently he experience some vague abdominal pain.
 FAMILY HISTORY:

Mother died of cancer of unknown etiology

A son who died of lymphoma at age 46.

DIAGNOSIS:

A flexible sigmoidoscopy : negative.

Ultrasound of the liver showed calcifications

CT scan : negative.

PET scan : negative.

FINDINGS:

No areas of increased fludeoxy glucose (FDG) uptake to suggest recurrent or

metastatic disease.

Sensitivity of this study is decreased due to the patient's hyperglycemia. (Blood

glucose level was 175mg/dl)
ASSESSMENT AND PLAN:
A 70 year old white male with a history of Stage III colon cancer,
now with a rising cacinoemryonic antigen (CEA) level, negative CT
scan and negative PET scan.
Recheck his CEA in two months. If it continues to rise, should move
forward with a PET-CT scan follow-up.
FOLLOW-UP PET-CT SCAN:
Recurrence : Focal area of intense FDG uptake corresponding to
mildly enlarged left paraaortic lymph node
Hepatic metastasis : Additional area of intense FDG uptake
identified within the right lobe of the liver.
TREATMENT
Chemotherapy.
CLINICAL CASE

62 years old white male.

Diagnostic preoperative: rectosigmoid cancer .acute Low bowel obstruction.

Operation 26.03.2015: Hartmann operation. Apendectomy.

Operation team: T.Timi, V.Bendelic, L.Palii

Diagnostic postoperation: rectosigmoid cancer T4N2Mx with distraction and

gowns in posterior wall of urinary bladder .
POSTEOPERATIVE
The pts remain in the hospital 4 days for monitoring and fluid
resuscitation
The pts receive respiratory physiotherapy and diet consult.
chemoradiotherapy treatment its begin with the pts
The pts begin to feel more good and he start to back his health
He leave the hospital in healthy situation
follow-up :
Physical examination and CEA testing every three to six months
Abdominal and chest CT scan each year (every six to 12 months for
patients with a high risk of recurrence)
For patients with rectal cancer, pelvic CT scan every six to 12 months
Colonoscopy one year after surgery
Rectosigmoidoscopy every six months for patients with rectal cancer
who did not have radiation therapy to the pelvis.
CONCLUSION

Early diagnosis of colorectal cancer is key to its cure.

If found early, the disease is considered curable.
If the tumor spreads to lymph nodes, a patient's chance of living
at least five years drops to 40 - 60%.
If the cancer has already spread to distant organs, the long-term
survival may be lower.
Early and accurate detection is highly importance to improve
patient outcomes.
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Thank you usmf
chisinau