Gb hbt

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Gb hbt

  1. 1. Gallbladder and Biliary system<br />NEIL MENDOZA, MD, FPCS, FPALES<br />Department of Surgery<br />
  2. 2. The Gallbladder<br />
  3. 3. Functions of Bile<br />Contains bile acids for fat digestion and absorption<br />Emulsification of fat <br />Aids in absorption of digested fat<br />For excretion of wastes from the blood<br />Bilirubin<br />Excess cholesterol<br />
  4. 4. Bile Flow<br />Hepatocyte<br />BileCanaliculi<br />Perilobularductules<br />Lobar ducts<br /> R & L hepatic ducts<br /> Common hepatic duct<br /> Common bile duct<br />Gall bladder Cystic duct<br />
  5. 5. Bile Flow<br />
  6. 6. Bile Flow<br />x<br />INTRA-HEPATIC DUCTS<br />EXTRA-HEPATIC DUCTS<br />
  7. 7. Hepatic Bile vs. GB bile<br />
  8. 8. Gallstone formation<br />Too much water extraction from the bile<br />Too much bile salt extraction from the bile<br />Inflammation of the gallbladder wall<br />Stasis<br />
  9. 9. Regulation of Bile Flow<br />Presence of bile acids<br />More bile acids = more bile production<br />Prevention of atherosclerosis<br />Secretin<br />Affects 2nd stage of bile production<br />
  10. 10. Entero-Hepatic Circulation<br />Liver Cholesterol<br />Cholic Acid + Chenodeoxycholic Acid<br /> Conjugation with glycine or taurine<br />Glyco- or Tauro- bile acids<br /> + NaCl<br /> Bile Salts<br /> Ileum<br />SMV<br />PV<br />
  11. 11. Gallbladder<br />pear-shaped sac<br />7 to 10 cm long<br />average capacity of 30 to 50 mL<br />When obstructed<br />up to 300 ml<br />Shared lymph and vascular drainage with liver<br />
  12. 12. Gallbladder<br />The gallbladder is divided into four anatomic areas:<br />fundus<br />corpus (body)<br />infundibulum<br />neck<br />
  13. 13. GALLBLADDER <br />Functions<br />Concentrate bile<br />Temporary storage of bile<br />
  14. 14. GALLBLADDER<br />4 parts<br />Hartmann’s pouch<br />Cystic duct<br />1-5cm long<br />3-7mm diameter<br />Spiral valves of Heister<br />Junction with CHD<br />Angular=70%<br />Spiral =30%<br />
  15. 15. Triangle of Calot<br />3 margins<br />3 contents<br />
  16. 16. Triangle of Calot<br />the area bound by the:<br />cystic duct<br />common hepatic duct<br />liver margin <br />
  17. 17. Cystic artery<br />usually a branch of the right hepatic artery (>90% of the time)<br />course of the cystic artery may vary, but it nearly always is found within the hepatocystic triangle<br />it divides into anterior and posterior divisions<br />
  18. 18. Cystic Artery Anomalies<br />Most variable structure<br />90% from RIGHT hepatic artery<br />88% single, 12% double<br />
  19. 19. Gallbladder<br />mucus secreted into the gallbladder originates in the tubuloalveolar glands found in the mucosa lining the infundibulumand neckof the gallbladder, but are absent from the body and fundus<br />histologically differs from the rest of the gastrointestinal tract i.e. lacks a muscularis mucosa and submucosa<br />
  20. 20. Common Bile Duct (CBD)<br />5-17cm long<br />3-8mm diameter<br />
  21. 21. Physiology<br />Fasting<br />Postprandial<br />Bile production<br />Extrahepatic bile duct<br />
  22. 22. PHYSIOLOGY<br />During fasting cyclic emptying<br />Amount of bile produced<br />GB reabsorbs 90% of bile water<br />Bile lithogenicity<br />Cholesterol, phospholipids, bile salts<br />Post-prandial<br />Bile ejection GB, canaliculi<br />CCK stimulants vs. inhibitors<br />Extrahepatic bile duct no smooth muscle<br />
  23. 23. GB Disease: Clinical Presentation<br />Causes of Symptoms<br />Infection<br />Obstruction<br />Extramural<br />Intramural<br />Intraluminal<br />Obstruction + Infection<br />
  24. 24. SYMPTOMS<br />Abdominal pain <br />biliary colic vs. cholecystitis<br />Jaundice <br />direct vs. indirect<br />Fever <br />Charcot’s triad vs. Reynold’s pentad<br />Hypotension, Neurologic symptoms<br />Nausea and Vomiting<br />Weight loss, Anorexia<br />
  25. 25. Abdominal Pain<br />Biliary colic<br />Functional disease<br />Negative Murphy’s sign<br />Negative laboratory exams<br />Cholecystitis<br />Positive Murphy’s sign<br />Systemic manifestation<br />Irreversible GB injury<br />
  26. 26. DIFFERENTIAL DIAGNOSIS<br />Peptic ulcer<br />Hepatitis<br />Pancreatitis<br />Diverticulitis<br />
  27. 27. DIAGNOSTIC STUDIES<br />Laboratory exams<br />Bilirubin ( B1, B2 )<br />SGPT, SGOT <br />ALP<br />5’ aminopeptidase<br />GGT<br />Protime<br />Albumin<br />
  28. 28. Obstructive Jaundice<br />
  29. 29. Laboratory Exams<br />
  30. 30. Laboratory Exams<br />
  31. 31. Laboratory Exams<br />
  32. 32. Laboratory Exams<br />
  33. 33. DIAGNOSTIC IMAGING<br />Abdominal x-ray<br />Ultrasound<br />CT scan<br />Cholangiography<br />ERCP<br />PTC<br />IOC<br />MRCP<br />Scintigraphy<br />Oral Cholecystogram<br />
  34. 34. DIAGNOSTIC IMAGING<br />Abdominal x-ray<br />
  35. 35. DIAGNOSTIC IMAGING<br />Ultrasound<br />
  36. 36. DIAGNOSTIC IMAGING<br />CT scan<br />
  37. 37. DIAGNOSTIC IMAGING<br />
  38. 38. DIAGNOSTIC IMAGING<br />CHOLANGIOGRAPHY<br />
  39. 39. CALCULOUS DISEASE<br />Types of stones<br />Cholesterol<br />Pigment<br />Mixed<br />Gallbladder sludge, microcalcification<br />
  40. 40. Cholesterol Stones<br />
  41. 41. Cholesterol Gallstones<br />Unifying hypothesis<br />Risk factors<br />Age > 40 years old<br />Female<br />Race<br />First degree relatives with gallstones<br />Obesity<br />Crohn’s disease<br />Rapid weight loss<br />Stasis<br />Exogenous estrogen<br />
  42. 42. Pigment Gallstones<br />Predominant variety in the world except in the U.S.<br />High bilirubin content<br />Black or brown coloration<br />
  43. 43. Types of Gallstones<br />
  44. 44. CLINICAL SYNDROMES<br />Asymptomatic Gallstones<br />Acute Cholecystitis<br />Hydrops of the Gallbladder<br />Choledocholithiasis<br />Cholangitis<br />Gallstone ileus<br />Acalculouscholecystitis<br />Oriental Cholangio-hepatitis<br />Biliary colic, cholecystitis in pregnancy<br />Mirizzi syndrome<br />
  45. 45. CLINICAL SYNDROMES<br />1. Asymptomatic Gallstones<br /><ul><li>10% Biliary colic
  46. 46. 1-3% each year Acute cholecystitis
  47. 47. 0.5-1% mortality
  48. 48. Treatment Observe
  49. 49. Indications for surgery</li></ul>Clinical symptoms<br />“Porcelain” gallbladder<br />Gallbladder polyps <br />
  50. 50. CLINICAL SYNDROMES<br />2. Acute cholecystitis<br />Cystic duct obstruction<br />Pain characteristic<br />P.E. <br />Murphy’s sign<br />Laboratory exams<br />Leukocytosis<br />↑ LFT’s<br />Diagnosis<br />Ultrasound<br />
  51. 51. CLINICAL SYNDROMES<br />2. Acute cholecystitis<br />Complications<br />Empyema of the gallbladder<br />Emphysematous gallbladder<br />Perforation, sepsis<br />
  52. 52. CLINICAL SYNDROMES<br />2. Acute cholecystitis<br />Complications<br />Empyema of the gallbladder<br />Emphysematous gallbladder<br />Perforation, sepsis<br />
  53. 53. CLINICAL SYNDROMES<br />2. Acute cholecystitis<br />Treatment<br />Avoid morphine and opioid analgesics<br />Cholecystectomy<br />Early vs. Late cholecystectomy<br />Open vs. Lap Chole<br />
  54. 54. Laparoscopic vs. Open Cholecystectomy<br />
  55. 55. CLINICAL SYNDROMES<br />Hydrops<br />
  56. 56. CLINICAL SYNDROMES<br />4. Choledocholithiasis<br />Complications<br />Jaundice<br />Cholangitis<br />Pancreatitis<br />Sepsis<br />
  57. 57. CLINICAL SYNDROMES<br />4. Choledocholithiasis<br />Sources<br />Primary vs. secondary CBD stones<br />Retained vs. recurrent CBD stones<br />
  58. 58. CLINICAL SYNDROMES<br />4. Choledocholithiasis<br />Indicators<br />SENSITIVE<br /> ALP, Bilirubin<br />SPECIFIC<br />CBD stone on USG 100%<br />Cholangitis100%<br />Pre-op jaundice 97%<br />Dilated CBD on US 96%<br />Pancreatitis 95%<br /> Amylase 95%<br />Bilirubin 88%<br /> ALP 85%<br />
  59. 59. CLINICAL SYNDROMES<br />4. Choledocholithiasis<br />Diagnosis<br />Ultrasound<br />Cholangiography<br />Intra-operative/IOC<br />Routine vs. selective<br />4 indications <br />ERCP<br />PTC<br />MRCP<br />Treatment<br />Size<br />Timing of discovery<br />
  60. 60. Choledocholithiasis<br />
  61. 61. CLINICAL SYNDROMES<br />5. Cholangitis<br />Charcot’s triad<br />Abdominal pain<br />Fever<br />Jaundice<br />Bacterial reflux via canaliculi<br />Treatment<br />Antibiotics, supportive measures<br />CBD decompression: Endoscopic vs. operative<br />
  62. 62. CLINICAL SYNDROMES<br />6. Gallstone Ileus<br />Cholecysto-enteric fistula<br />Elderly female<br />Cholecystectomy not advised<br />
  63. 63. Gallstone Ileus<br />
  64. 64. CLINICAL SYNDROMES<br />7. Acalculouscholecystitis<br />Ischemia<br />Critically ill, fasting, septic patient, ICU<br />Higher gangrene, empyema, perforation than in AC<br />Cholecystectomy vs. cholecystostomy<br />
  65. 65. CLINICAL SYNDROMES<br />8. Oriental Cholangiohepatitis<br />Intrahepatic, extrahepatic BD with pigment stones<br />Normal GB<br />Hongkong<br />Parasites in BD<br />Ascarislumbricoides, Clonorchissinensis<br />Segmental, hence, rare jaundice<br />CBD exploration, biliary bypass<br />
  66. 66. CLINICAL SYNDROMES<br />9. Cholecystitis and Biliary Colic in Pregnancy<br />Ultrasound<br />Historically, operate during 2nd trimester<br />Currently, anytime during pregnancy <br />Adequate tocolysis<br />Open vs. laparoscopic cholecystectomy in pregnancy<br />
  67. 67. CLINICAL SYNDROMES<br />10. Mirizzi Syndrome<br />Type I- external CHD compression<br />Cholecystectomy<br />Type II- GB-CHD fistula<br />Partial chole + biliary-enteric anastomosis<br />Long cystic duct<br />Painless jaundice, Cholangitis<br />
  68. 68. TREATMENT<br />Goals <br />Remove biliary calculi<br />Prevent stone-related complications<br />Medical Treatment<br />Oral dissolution therapy<br />Contact dissolution therapy<br />ESWL<br />
  69. 69. Medical Treatment<br />Oral dissolution therapy<br />Urso- vs. chenodeoxycholic acid for 6-12 months<br />For small, non-calcified cholesterol stones<br />50-60% response if <1cm<br />50% recur in 5 years<br />
  70. 70. Medical Treatment<br />Contact dissolution therapy<br />MTBE directly to GB <br />Mono-octanoin directly to CBD<br />Dissolves in hours or days<br />
  71. 71. Medical Treatment<br />ESWL<br />Criteria: biliary colic, <3 stones, functioning GB<br />12-18 months therapy= 91% clearance<br />Experimental (2002)<br />Complications<br />Colic (20-40%), hemobilia (8-14%), mild AP (1-2%)<br />Recurrence<br />33% in 5 years<br />15% with symptoms<br />
  72. 72. Surgical Treatment<br />Open Cholecystectomy<br />Laparoscopic Cholecystectomy<br />
  73. 73. Open Cholecystectomy<br />
  74. 74. Laparoscopic Cholecystectomy<br />Advantages<br /><ul><li>Short hospitalization
  75. 75. Early return to work
  76. 76. Less pain
  77. 77. Cosmesis
  78. 78. Less trauma</li></ul>Disadvantage<br /><ul><li>Expense
  79. 79. Availability of technology
  80. 80. Availability of expertise</li></li></ul><li>Gallbladder Polyps<br />
  81. 81. Galbladder Cancer<br />
  82. 82.
  83. 83. Other Diseases<br />Duct anomalies<br />Choledochal cyst<br />Biliary strictures<br />Courvoisier’s law<br />Periampullary malignancies<br />

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