PPT

1. Functional gallbladder and
sphincter of Oddi disorders
(Rome IV, 2016)
E1. Diagnostic Criteria for Biliary Pain
Pain located in the epigastrium and/or right
uppe quadrant and all of the following:

2. • 1. Builds up to a steady level and lasting 30
minutes or longer
• 2. Occurring at different intervals (not daily)
• 3. Severe enough to interrupt daily activities
or lead to an emergency department visit
• 4. Not significantly (<20%) related to bowel
movements
• 5. Not significantly (<20%) relieved by
postural change or acid suppression

3. Supportive Criteria
The pain may be associated with:
• 1. Nausea and vomiting
• 2. Radiation to the back and/or right
infrasubscapular region
• 3. Waking from sleep

4. Diagnostic Criteria for Functional
Gallbladder Disorder
• 1. Biliary pain
• 2. Absence of gallstones or other
structural Pathology
Supportive Criteria
• 1. Low ejection fraction on gallbladder
scintigraphy
• 2. Normal liver enzymes, conjugated
bilirubin, and amylase/lipase

5. Classification of Functional Gallbladder
and Sphincter of Oddi Disorders
1. Localization
А. Functional gallbladder disorder
B. Functional sphincter of Oddi disorder
2. Etiology
А. primary
B. secondary
3. Functional status
А. Hypofunction or hyperfunction of gallbladder
B. Spasm or insufficiency of Oddi sphincter
Clinical forms of functional gallbladder and sphincter of
oddi disorders
• hyperkinetic-hypertonic
• hyperkinetic-hypotonic
• hypokinetic-hypotonic
• hypokinetic-hypertonic

6. Diagnostic Criteria for Functional GB
and SO Disorders
Must include episodes of pain located in the epigastrium and/or right
upperquadrant
and all of the following:
1. Episodes lasting 30 minutes or longer
2. Recurrent symptoms occurring at different intervals (not daily)
3. The pain builds up to a steady level
4. The pain is moderate to severe enough to interrupt the patient’s daily
activities or lead to an emergency department visit
5. The pain is not relieved by bowel movements
6. The pain is not relieved by postural change
7. The pain is not relieved by antacids
8. Exclusion of other structural disease that would explain the symptoms
Supportive criteria
The pain may present with 1 or more of the following:
1. Pain is associated with nausea and vomiting
2. Pain radiates to the back and/or right infrasubscapular
region
3. Pain awakens from sleep in the middle of the night

7. Functional GB Disorder
GB dysfunction is a motility disorder
of the GB that manifests symptomatically
with biliary pain as a consequence of
either an initial metabolic disorder or a
primary motility alteration of the GB in the
absence, at least initially, of any
abnormalities of bile composition.

8. Clinical syndromes
• Dyspeptic
• Painful
• Asthenic-vegetative
• Cholestasis

9. History
• disease duration longer than 3 months, a congenital susceptibility,
congenital abnormalities of the gallbladder and biliary tract
• hyperfunction
paroxysmal pain in the right upper quadrant, the umbilicus in
20-30 minutes after eating, physical or emotional stress
loss of appetite,
fatigue, emotional lability
• hypofunction :
dull, aching pain in the right upper quadrant in 60 - 90 minutes
after meals, exercise stress
nausea, vomiting,
bitter taste in the mouth,
fatigue, emotional lability,

10. ANOMALIES OF THE GALLBLADDER
FORM

11. Clinical Presentation:
• pain on palpation right upper quadrant,
the umbilicus,
• possible positive gallbladder symptoms,
• hypokinetic type– enlarged liver (soft, movable,
painless, declining rapidly after use holekinetics)
• possible - distal hyperhidrosis, pathological
dermographism, susceptibility to hypertension,
functional systolic murmur

12. Laboratory Investigations
• Normal tests of liver biochemistries and
pancreatic enzymes

13. Dynamic ultrasonic cholecystography using
holekinetic breakfast
• (egg yolks, sorbitol solution)
• Measuring the volume of the gallbladder (GB) is performed on an
empty stomach and after stimulation at 5, 15, 30, 40, 60 minutes.
• Registration the GB phase reduction:
Phase I (4-6 min): in the condition of the SO, the lengthening of
this phase to testify about spasm SO.
Phase II (15 min.): in the condition of the SO, the volume is
reduced by the GB 29 - 31%.
Phase III (30 min.): in the condition
of the sphincter Lyutkensa, GB volume
continues to decrease by 30-35%.
Phase IV - GB continued decline
of 33% - 65% compared to the initial
volume.

14. Dynamic ultrasonic
cholecystography using
holekinetic breakfast
• Hyperkinetic type of dysfunction GB
gallbladder volume reduced by more than
65% for 60-90 minutes after taking
holekinetic
• Hypokinetic type - less than 33%.

15. Series holetsistogramm after secretion stimulation with
multiple congenital constrictions of the gallbladder
(arrow): the GB shape during its reduction are
unchanged

16. Dynamics of changes in the GB size of the patient
with the GB hyperkinetic dyskinesia (30 min. after
choleretic breakfast GB emptied by 70%)

17. Diagnostic Criteria for Functional
GB Disorder
Must include all of the following:
1. Criteria for functional GB and SO
disorders
2. GB is present
3. Normal liver enzymes, conjugated
bilirubin, and amylase/lipase

18. Diagnostic Criteria for Functional
Biliary SO Disorder
Must include both of the following:
• 1. Criteria for functional GB and SO disorder
• 2. Normal amylase/lipase
Supportive criterion
• Elevated serum transaminases, alkaline
phosphatase, or conjugated bilirubin temporally
related to at least two pain episodes

19. Ultrasonographic assessment of
duct diameter
• A dilated common bile duct of 8 mm or
greater usually indicates the presence of
increased resistance to bile flow at the
level of the SO, especially after fatty
meals;
• The maximal diameter of common hepatic
bile duct is normally 6 mm or less
• Typically, the bile duct diameter is
monitored by transabdominal US.

20. Treatment
• diet.
• Power should be regular, no hearty, 4-5 times a day
• mechanical and chemical processing
• Recommended: vegetable and fruit salads, vinaigrettes,
boiled eggs, cheese, cottage cheese, meat, and fish
boiled or baked form, vegetarian soups, milk and milk
products and juices, the addition of vegetable oils in
salads
• Excludes food with a high content of extractives (strong
meat, fish, mushroom broth, spices, pickles, smoked)
are limited by refractory fats - lard, pork, soft drinks and
cold drinks and food (biliary tract spasm contribute).

21. Treatment
Hyperkinetic (hypertonic) type
• sedatives - sodium bromide, tranquilizers at age doses, (course
duration and the choice of drug depends on the severity of
neurological disorders neurologist determined);
• holespazmolitiki:
- drotaverine
- pinaverium bromide
- gimekromon
- prifinium bromide
• choleretic (drugs that stimulate the synthesis of bile, including
those that contain bile extract):
- True (stimulates the synthesis of bile acids) - ursodeoxycholic
acid
- Gidroholeretiki (stimulates the synthesis of the water component
of bile)
- Mineral water for 3 - 5 ml per kg of body
weight three times a day. Course duration 2 - 3 weeks.

22. Treatment
Hypokinetic (hypotonic) type
• choleretics
• cholekinetics (drugs that stimulate contraction GB):
- Powder turmeric root
- An extract of artichoke leaves
- Vegetable oils (sunflower, corn, olive)
- Flax seeds. Course duration - 2 - 3 weeks;
• if indicated
- prokinetics:
- domperidone
• tyubazh 2 times a week number 5 - 7 with mineral water “
(medium salinity), 100 - 200 ml per taking for hypotonic
form.

23. Regular medical check-up
• Examination by a GP, pediatrician - 2 times per
year;
• Pediatric Gastroenterology - 1 per year;
• otolaryngologist, dentist - if necessary
• coprogramma - 1 per year
• Ultrasonography of the abdomen - 1 per year
• duodenal intubation and biochemical study of
bile - 1 per year (if necessary)
• Anti-relapse treatment: 2 times a year (the first
year), then - 1 time a year.

24. Chronic cholecystitis (gall
stones without) ICD-10: K81
• chronic inflammatory disease of the
gallbladder, promotes the development
and combined with functional disorders of
the gallbladder motility (dysfunction) and
changes in physical and chemical
composition of bile (dyscholia)
• is uncommon in children

25. Etiology
Dominant: infection
- E. coli, Staphylococcus, Proteus, Clostridium,
viral hepatitis, enteroviruses, adenoviruses
Supplemental:
- disturbance of motor function of the gallbladder
- dyscholia of bile
- congenital anomalies of the biliary tract
- irregular meal
- pancreatobiliary reflux (aseptic inflamation of the
gallbladder wall)
- parasitic diseases (giardiasis, opisthorchiasis,
amoebiasis, ascariasis)
- endocrine disorders

26. Pathogenesis
In the case of the infectious nature of cholecystitis, the
following ways of infection in the gall bladder:
• Ascending from the intestine through the ductus
choledochus
• Lymphogenous through extensive contacts lymphatic
system of the liver and gallbladder to the abdominal
cavity
• Hematogenous (from the mouth, nose, throat, lungs,
kidneys and other organs).
• Aseptic cholecystitis:
- Chemical, physical factors
- Violation of the outflow of bile associated with
abnormalities of biliary system, sphincter system
dysfunction, impaired physical and chemical properties
of bile.

27. Clinical Presentation
• right upper quadrant or
epigastric pain
• bitterness in the mouth
• dyspepsia
• Compromised genealogical history of biliary system
• moderate, steady large liver mass, especially for
cholecystocholangitis
• positive symptoms of GB - Murphy, Ortner

28. Laboratory Investigations
• Complete blood count - a moderate leukocytosis, accelerated
erythrocyte sedimentation rate
• Total bilirubin and its fractions, a slight increase in total bilirubin,
more due to the direct-reacting bilirubin
• AP - within the normal range, or a slight increase
• proteinogram - increasing alpha-2 and gammaglobulins
• glucose level in the blood plasma, blood and urine amylase,
cholesterol, β-lipoprotein, - without pathology
• helminth eggs in faeces (opisthorchiasis, ascariasis) and protozoa
(Giardia) - can be detected Giardia cysts, eggs opisthorchis, Ascaris
• Bacteriological study of bile - elevated white blood cell count,
bilirubin salts in the gallbladder bile
• Biochemical bile - high cholesterol, reducing the concentration of
bile acids

29. International ultrasound criteria of
chronic cholecystitis
(by M.Yu.Denisov, 2001)
• Thickening and induration of the
gallbladder wall> 2 mm
• Increasing the size of the gallbladder more
than 5 mm from upper limit of the age
norm
• The presence of the shadow of the wall of
the gallbladder
• Sludge syndrome

30. Instrumental Investigations
• Dyskinetic changes at numerous moment
duodenal intubation in combination with
changes the biochemical properties of bile
(dyscholia)
• Dynamic ultrasonic cholecystography using
holekinetic breakfast with the definition of
contractile function GB
• X-ray examinations - cholecystography,
retrograde cholangiopancreatography (only
strict indications, if necessary confirm the
anatomical defect or stones).

31. Principles of treatment
• Regimen
• Diet
• Elimination of the etiological factor
• Normalization evacuation function of GB
• Improvement of the rheological properties of
bile

32. Regimen ang Diet
• bed rest only during exacerbation,
accompanied by abdominal pain and fever
• Fractional feeding
• Limit irritating products: meat broth, animal
fats, egg yolks, hot spices, pastry, chocolate

33. Principles of treatment
Elimination of the etiological factor
Antibiotics:
• Amoxicilline( 1st line) or
• CP 3d generation or
• Macrolides
• Drugs from the group of co-trimoxazole
• Duration of 7-10 days

34. Principles of treatment
Cholecystitis with hypokinetic dyskinesia of GB:
• prokinetics (domperidone)
• cholekinetics
• Tyubazh
Cholecystitis with hyperkinetic dyskinesia of GB:
• Selective myotropic spasmolytics (mebeverine)
• choleretics

35. Regular medical check-up and prophylaxis
• Clinical supervision for 3 years
• Chronic nidus of infection sanitation 2 times a year (3-
fold testing for helminths, an otolaryngologist and dentist
examination)
• Normalization of body weight
• Physical education and sport
• Regular meals
• Restriction of the use of animal fats and carbohydrates
• Usage plenty of fluids
• Early treatment of dysfunction of the GB and the SO

36. Chronic pancreatitis (CP),
ICD-10: K86
• inflammatory and degenerative disease of
the pancreas, lasting more than 6 months
and is characterized by fibrosis of the
parenchyma and functional insufficiency
• In children, chronic pancreatitis is mainly
a secondary disease,
• 14% of all cases are primary disease
(Rimarchuk GV et al., 2000).

37. Etiological factors
• Transferred acute pancreatitis
genetic predisposition
• Blunt abdominal trauma
• Cystic fibrosis
• Infections - mumps, Yersinia
infection, chicken pox, hepatitis,
Coxsackie virus, Mycoplasma
• Helminthiasis
• Obstructive disorders duct
pancreas: toxic and drug effects
• Other reasons (allergy,
connective tissue disease,
hyperlipidemia, hypercalcemia)

38. KEY COMPONENTS OF PATHOGENESIS
CP:
• Obstruction of the secretion tract
of the pancreas,
increase intraduodenum
pressure
• Activation of pancreatic enzymes
in the ducts and gland parenchyma
- swelling and secretory failure
• Violations of the microcirculation -
ischemia, edema, impaired
permeability of cell membranes,
destruction of acinar cells.
• Accumulation in the acinar cells
peroxidation
lipids, free radicals,
causing cell damage,
inflammation, acute-phase protein synthesis.
• Defect litostatina synthesis, leading to precipitation
of protein and calcium and obstruction of small ducts with
subsequent periductal inflammation and fibrosis

39. Working classification of chronic pancreatitis
in children (G.V. Rymarchuk)
1. Origin - primary and secondary;
2. The disease course - relapsing, monotonous;
3. Disease severity - mild, moderate, severe;
4. Functional condition of the pancreas:
a) exocrine function - hyposecretory, hypersecretory, obturative,
the normal type of pancreatic secretion;
b) endocrine function - hyperfunction, hypofunction of insular
cells, complications - pseudocyst, pankreolithiasis, diabetes,
pleurisy, etc.;
5. Concomitant diseases - peptic ulcer disease, gastroduodenitis,
cholecystocholangitis, hepatitis, enteritis, colitis, ulcerative colitis,
etc.

40. Diagnostic criteria of chronic
pancreatitis in children
The main
1. Recurring for at least 1 year episodes of abdominal
pain with localization:
• In the upper left quadrant
• deep epigastric
• band from subcostal to subcostal.
2. Previously diagnosed acute pancreatitis.
3. An impairment of exocrine pancreatic function,
according to the elastase-1 in the feces (less than 200
mg/g)
4. Changes in the structure of the
pancreas according to endosono-
graphy, computer or magnetic
resonance imaging.

41. Diagnostic criteria of chronic
pancreatitis in children(additional)
1. Changing the size and
structure of the pancreas
by ultrasound of the
abdomen.
Ultrasound scan of
the pancreas in chronic
pancreatitis: the arrows
indicate the dilated
pancreatic duct.

42. Diagnostic criteria of chronic
pancreatitis in children(additional)
2. Steatorrhea (neutral fat)
3. Increased lipase and (or) pancreatic amylase in the blood and
(or) urine.
4. Abdominal pain associated with the diet breach.
5. Abdominal pain associated with heaviness in the epigastrium
and nausea (vomiting).
6. Episodes of severe pain in the abdomen in history, became the
occasion for an emergency hospitalisation with suspected
surgical pathology.
7. Diabetes.
8. Cholelithiasis.
9. Anomalies of the common bile duct.
10. Hereditary hyperlipidemia and obesity.
11. Protein-energy malnutrition

44. Recurrent pancreatitis.
A.Recurrentpancreatitis in a 11-year-old girl
Endoscopic retrograde cholangiopancreatography
showed a dilated main pancreatic duct with
Multiple filling defects owing to proteinaceous
plugs. The common bile duct was also dilated.
B, Stones were extracted after pancreatic duct
sphincterotomy.
C, Postoperative opacification showed a Wirsung
duct clear of stone.

45. Coronal magnetic resonance cholangiopancreatography was
performed in this 5-year-old female with recurrent
pancreatitis. A dual drainage (arrows) system was seen in the
head of the pancreas consistent with pancreas divisum

46. Diagnostic criteria of chronic
pancreatitis in children
• To confirm the diagnosis of chronic
pancreatitis enough 4 criteria (including
the main one).

47. The projection of the sore points on the
anterior abdominal wall with pancreatic
diseases (scheme)
1 – Desjardin point
2 – Shofarr zone
3 - Mayo-Robson point
4 - Kutch point
5 - umbilicus

48. Retrograde
cholangiopancreatog
raphy in gallstone
disease in a frontal
view (a) and lateral
(b) projection: the
common bile duct (1)
dramatically
expanded, in the
lateral projection is
determined by the
defect contrast due
to stones (2); visible
contrast pancreatic
duct.
Endoscopic retrograde
cholangiopancreatography

49. TREATMENT CP DURING
EXACERBATIONS
Basic principles:
1. Individual treatment and flexibility
therapy based on clinical and
biochemical parameters.
2. Spare of pancreas by physiologically.

50. Diet
• Pancreatic diet
• In the first 1-3 days is enough to refrain from.
• Then allowed no strong unsweetened tea with
biscuits, stewed dried fruit, white bread, milk, dry
biscuit, rosehip tea.
• Diet gradually expand

51. TREATMENT OF CP DURING
EXACERBATIONS
• Relief of pain (spasmolytics, anticholinergic drugi)
• Suppression of gastric acid secretion (blockers H2 histamine
receptor, blockers, H +, K +, ATPase
• Reduction of enzymatic toxicity (inhibitors of proteolysis, infusion
therapy)
• Inhibitors of pancreatic secretion (analogues of endogenous
somatostatin
• Enzyme replacement therapy (mode for the functional rest of the
pancreas)
• Antibiotic therapy is conducted in order to prevent infection and
control (karbopenemy (imipenem), quinoline drugs (ciprofloxacin,
ofloxacin), cephalosporins (ceftriaxone, cefotaxime)
• Surgical treatment in the case of pseudocysts, narrowing or
occlusion of the common bile duct, scar contraction of major
duodenal papilla, duodenostasis.

52. Treatment in remission
• Diet for a year or more. Limit animal fat and
therefore increase the amount of carbohydrates
• Herbal medicine: birch leaves, marigold, mullein flowers,
meadowsweet, flax seed, Licorice root, field horsetail, violets trifoliate
• In order to improve metabolism prescribed multivitamins, methyluracil
• Physiotherapy: electrophoresis with lidaza, nicotinic acid, applications
ozokerite, mud
• Spa treatment. Mineral water of low salinity in the form of heat without
gas 50-100 ml 5-6 times a day between meals
• Treatment of accompanying diseases of the digestive system and the
foci of infection

53. Regular medical check-up and
prophylaxis
• anti-relapse quarterly replacement enzyme therapy.
• In the first year: examination monthly, quarterly investigation,
of amylase in the blood and urine, and alkaline phosphatase.
Further examination of the gastroenterologist and / or district
pediatrician carried out 2 times a year.
• Diet, limit physical activity, avoid jolting trips in transport and
vibration (!)
• Non-drug and drug therapy to normalize the activity of
gastropancreatoduodenectomy zone.
• Antirelapsing sanatorium-and-spa treatment is indicated for
clinical remission and normal values of exo- and endocrine
functions of the pancreas - Truskavets, Morshyn, Berezovsky
mineral water.