6 gall blader & biliary tree diseases

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6 gall blader & biliary tree diseases

  1. 1. GALL BLADER & BILIARY TREE DISEASES BY TEMESGEN G/MARIAM(MD) FEB.04/2013
  2. 2. Lecture Out line  Anatomy & Physiologic highlights  Clinical presentation of a patient with biliary ds  Specific disease entities :  CHOLELITHIASIS  Acute cholecystitis  Obstructive jaundice  Gall bladder Ca
  3. 3. Anatomy OF THE Gallbladder  The gallbladder is a pear- shaped sac  7 to 10 cm long, with an average capacity of 30 to 50 Ml  It has four parts
  4. 4. Anatomy of The Bile Ducts • Cystic duct Tortouse course,acute angle of insertion ≈2-4cm long,3mm wide •CHD •CBD •Variable length •Upto 1cm in diameter
  5. 5. BLOOD SUPPLY
  6. 6. Anomalies  The classic description of the extrahepatic biliary tree and its arteries applies only in about one third of patients  The gallbladder may have abnormal positions, be intrahepatic, be rudimentary, have anomalous forms, or be duplicated
  7. 7. Physiologic highlights
  8. 8. • Storage • Concentration (reabsoption ) • Secretion of mucus •coordinated motor response of gallbladder contraction and sphincter of Oddi relaxation mediated by CCK
  9. 9. Clinical presentation of a patient with biliary ds  Pain  typical  (RUQ,epigastric)  Biliary colic  Jaundice  Associated symptoms  Fever,chills & rigor  Tightness/dullness  Urine/stool discoloration  Radiation  pruritus  Nausea/vomiting  Atypical  Indigestion,flatulence  Dyspepsia,retrostern al pain  Constitutional symptoms  Wt loss,anorexia,back pain
  10. 10. CHOLELITHIASIS/GALL STONE DS  Epidemiology  one of the most common problems affecting the digestive tract  Varies depending on  Age  Sex  Stone types  Overall prevalence  Western  Asia  Africa
  11. 11. Risk factors/etiology Major risk factors for pigmented stones • Infection • Sickle cell anemia • Hemolysis • Stasis • Parasitic infestation 5f:Fat, fertile, flatulent, female of fourty
  12. 12. Pathogenesis/ pathophysiology  Super saturation of bile  Drop in phospholipid  Decrease in bile acid pool  Increase cholesterol secretion  Biliary stasis(drainage)  Biliary dyskinesia/motility,TV,DM,pregnancy…  Infection  Predisposing factors
  13. 13. Composition of Bile
  14. 14.  Impaired GB function  Supersaturated bile • Age • Sex • Absorption • Genetics • Excretion • Obesity • Diet • Emptying Absorption/EHC Nucleating agents •Mucus •Glycoprotein •Infection •Deoxycholate •SBS •Fecal flora •Ileal resection
  15. 15. Clinical presentation of uncomplicated gallstone  Silent/incidental finding  Typical /classical      Biliay “colic” RUQ/ epigastic post prandial (50%) + nausea/vomiting Radiation to  Atypical     Dyspepsia/indigestion Flatulence Belching Atypical sites(retrosternal)
  16. 16.  Physical Examination  Ultrasound  No remarkable  Most important modality  May mild tenderness in  First line of investigation RUQ/epigastric area  Laboratory  CBC  LFT  Sensitive/specific()  Superior to CT scan  Characteristic finding  Echogenic  Acoustic shadow  Move when pt change position  May  Polp/stone in the cystic duct  Stone<5mm ,sluge  Obese,ascitic,bowel gas
  17. 17. Ultrasound pictures
  18. 18. Management  Surgery the almost only option(cholecystectomy)  Based on ultrasound finding & symptoms four categories  Category I = stone+ asymptomatic  Category II = stone+ typical symptoms  Category III = stone+ atypical symptoms  Category IV =no stone + typical symptoms
  19. 19. Category I  Indication for surgery  Porcelain  Total parenteral nutrition  Large stone(> 2.5cm)  GB polp > 1cm  Chronic  No immediate access to immunosuppresion  Sickle cell anemia  Bariatic surgery  Small multiple stone  Child  ?DM health care facility  Incidental(intra operative)  Non functional GB
  20. 20.  Category II  Category III  cholecystectomy  Other causes IBS , PUD ,  Good outcome (all Diverticulosis , hiatal hernia,…)should be R/o  Endoscopic evaluation  What if the service is not there?  Only sub groug of patient relieved from their symptoms after cholecystectomy relieved from their symptom)
  21. 21. Category IV  Further work for underlying causes •Missed stone •Sluge •Biliary diskinesia •choledocholelithiasis
  22. 22. Acute cholecystitis  Secondary to gallstones in 90 to 95% of cases  Acute acalculous cholecystitis  In <1% of acute cholecystitis, the cause is a tumor obstructing the cystic duct
  23. 23. Pathophysiology  Impaction of stone at the cystic duct/ hartman’s pouch  Chemical inflammation  Secondary bacterial infection
  24. 24. Bacteriologic profiles  Secondary bacterial contamination is documented in 15 to 30%
  25. 25. Clinical presentation  Abdominal pain  Similar to biliary colic but longer duration/severity (greater than four to six hours)  Fever  Nausea/vomiting  Physical exam  GA: ill appearing, and lie still on the examining table  Vital signs: febrile, and tachycardic  RUQ tenderness/ Murphy sign
  26. 26. Investigation  CBC  Mild leukocytosis  (15x103)  WBC > 18x103  Ultrasound  Sensitivity/specificity(80)  Evidences  stone  Empyema  Thicken (edematous)wall  perforationm  Perichlecystic fluid  Mild elevation of LFT  bil , alk phospha  Sonographic murphy sign  HIDA (97 and 90%)  highly sensitive and specific for acute cholecystitis
  27. 27. Treament  Conservative followed by interval /delayed cholecystectomy  Intravenous hydration and correction of any associated electrolyte disorders  NPO/NGT/ maintaince fluid  ANALGESIC  Antibiotic  Choice/duration/route of administration  Monitor response  Early cholecystectomy
  28. 28. Obstructive jaundice  Due to obstruction to the excretion of bilirubin  Confirmation that is obstructive is essential  Most frequent causes varies depending on age,geography,sex,..  Choledocholethiasis is most common(benign lesion) in many countries  Pancreatic head tumor commonest malignant
  29. 29. Classification of causes I. Excessive production (hemolytic jaundice):- A. Inherited hemolytic anemia's B. Acquired hemolytic anemia's II. Impaired transport to liver:- -Gilbert’s syndrome III. Impaired hepatic conjugation:- A. Inborn errors B. Immaturity of enzymes IV Impaired excretion(hepatocellular jaundice) A. Acquired liver diseases B.Intrahepatic cholestasis
  30. 30. V. Bile duct obstruction(obstructive jaundi) A. Extra hepatic:1.Stone 2.Neoplasms 3.Stricture 4.Atresia,ect B. Intrahepatic
  31. 31.  Pain similar to biliary colic  Associated symptoms: fever/chills , pruritus , darken urine , pale/ clay colored stool  Physical exam  No remarkable finding  Jaundice,  Vital signs  Scratch marks  Tenderness  Corvesouires law  Stigma for malignancy/liver disease
  32. 32. Laboratory
  33. 33. Imaging  Abdominal ultrasound  Important first line  Sensitivity varies(55-91%)  CBD Dilation > site> causes  Combination of clinical ,biochemical & U/S  Jaundice + biliary + gall stone + increased LFTS + Dilated CBD  As the No of criteria increases probability of stone in the CBD increases
  34. 34. Other imaging (not routinely used)  MRCP  ERCP  Highly sensitive & specific  PTC  EUS  Helical CT scan  HIDA
  35. 35. Management  Endoscopic removal/drainage(ERCP  Open/lap  Choledochotomy  Spincterotomy/ plasty  Drainage  Choledochduedunostomy  choledochjejunostomy
  36. 36. Candidates for drainage  Irremovable, impacted, distal CBD stones  Markedly dilated CBD, >1.5cm  Distal duct obstruction from tumor or stricture  Recurrence after previous duct exploration
  37. 37. Gall bladder Ca  Incidence –Un common (2-3 % of GI malignancies) –Incidence varies –Ethnicity , geographic –High incidence in Israel ,chili ,native Americans –M:F 1:3 –1% of cholecystectomy for gall stone. –>75% of cases> 60 years
  38. 38. Risk factors  Cholithiasis is the most important risk factor for     gallbladder carcinoma, and up to 95% of patients with carcinoma of the gallbladder have gallstones Porcelain gall bladder Primary sclerosing cholangitis Chledochal cyst Association with gall stone
  39. 39. Pathology  > (90%) adenocarcinoma – Scirrhous (60%) – Papillary(25%) – Mucoid(15%)  Spread  Hemato  Lymphatic  direct
  40. 40.  Table 54-2 -- TNM Staging for Gallbladder Cancer •T –T1 lamina propria (T1a) or muscular (T1b) layer –T2 perimuscular connective tissue, no extension beyond the serosa or into the liver –T3 perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts –T4 main portal vein or hepatic artery or invades multiple extrahepatic organs and/or structures •N –N0 No lymph node metastases –N1 Regional lymph node metastases •M –M0 No distant metastases –M1 Distant metastases
  41. 41. Stage Grouping  IA T1 N0 M0  IB T2 N0 M0  IIA T3 N0 M0  IIB T1 N1 M0  T2 N1 M0  T3 N1 M0  III T4 Any N M0  IV Any T Any N M1
  42. 42. clinical features
  43. 43. Diagnostic work up  Management/progosis  Diagnostic work up  •Abdominal U/S  •CT SCAN  •MRI/MRC  •ERCP •Surgery the only hope •Incidental cholecystectomy –Early stage , better outcome – The 5-year survival rate of all patients with gallbladder cancer is <5%
  44. 44. THANK U
  45. 45. References  Schwartz's Principles of Surgery,9th ed  Sabiston Textbook of Surgery, 18th ed  Maingot's Abdominal Operations  Upto date,18.2

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