Dr Devendra Sancheti gallstone disease


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powerpoint presentation of gall bladder disease

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Dr Devendra Sancheti gallstone disease

  1. 1. Presented by Vd. Devendra Sancheti Guide Dr.R.R.Patil HOD ROGNIDAN DEPARTMENT
  2. 2.  Types of gallstone  Cholesterol stones (20%)  Pigment stones (5%)  Mixed (75%)  Epidemiology  Fat, Fair, Female, Fertile, Fourty inaccurate, but reminder of the typical patient  F:M = 2:1  10% of Indian women in their 40s have gallstones
  3. 3.  Composition of bile:  Bilirubin (by-product of haem degradation)  Cholesterol (kept soluble by bile salts and lecithin)  Bile salts/acids (cholic acid/chenodeoxycholic acid): mostly reabsorbed in terminal ileum(entero-hepatic circulation).  Lecithin (increases solubility of cholesterol)  Inorganic salts (sodium bicarbonate to keep bile alkaline to neutralise gastric acid in duodenum)  Water (makes up 97% of bile)
  4. 4.  Cholesterol  Imbalance between bile salts/lecithin and cholesterol allows cholesterol to precipitate out of solution and form stones  Pigment  Occur due to excess of circulating bile pigment (e.g. Heamolytic anaemia)  Mixed  Same pathophysiology as cholesterol stones  Other Factors  Stasis (e.g. Pregnancy)  Ileal dysfunction (prevents re-absorption of bile salts)  Obesity and hypercholesterolaemia
  5. 5. 80% Asymptomatic  20% develop complications and do so on recurrent basis 
  6. 6.  Gallstone disease (and its related complications) Gastritis/duodenitis Peptic ulcer disease/perforated peptic ulcer Acute pancreatitis Right lower lobe pneumonia Miyocardial Infarction  If presenting with RUQ pain all patients should get       Blood tests  Abdominal xray / CXR (to exclude perforation/pneumonia)  ECG
  7. 7.  Can differentiate between gallstone complications based on:  History  Examination  Blood tests  CBC  LFT  CRP  Clotting  Amylase
  8. 8. Complication History Examination Blood tests Biliary Colic - Intermittent RUQ/epigastric pain (minutes/hours) into back or right shoulder -Tender RUQ -Murphy’s – -HR and BP (N) -Wbc (N) CRP (N) - LFT (N) Acute Cholecystitis -Constant RUQ pain into back or right shoulder -Feverish -Tender RUQ -Murphy’s + -Pyrexia, HR (↑) -Wbc and CRP (↑) -LFT (N or mildly (↑) Empyema -Constant RUQ pain into back or right shoulder -Feverish -Tender RUQ -Murphy’s + -Pyrexia, HR (↑), BP (↔ or ↓) -More septic than acute cholecystitis -Wbc and CRP (↑) -LFT (N or mildly (↑) Obstructive Jaundice -Yellow discolouration -Pale stool, dark urine -painless or associated with mild RUQ pain -Wbc and CRP (N) -LFT: obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔) -INR (↔ or ↑) Ascending Cholangitis Becks triad -RUQ pain (constant) -Jaundice -Rigors Gallstone Ileus - 4 cardinal features of Small Bowel Obstruction -Jaundiced -Non-tender or minimally tender RUQ -No peritonism -Murphy’s – -Apyrexial, HR and BP (N) -Jaundiced -Tender RUQ -Peritonism RUQ -high pyrexia (38-39) -HR (↑), BP (↔ or ↓) -Can develop septic shock -distended tympanic abdomen -hyperactive/tinkling bowel sounds -Wbc and CRP (↑) -LFT : obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔) -INR (↔ or ↑)
  9. 9.         Blood Tests Abdominal Xray (10% gallstones are radio-opaque) Chest Xray (to exclude perforation – MUST!) ECG (to exclude MI) Ultrasound Sonography: first line investigation in gallstone disease  Confirms presence of gallstones  Gall bladder wall thickness (if thickened suggests cholecystitis)  Biliary tree calibre (CBD/extrahepatic/intrahepatic) – if dilated suggests stone in CBD (normal CBD <8mm).  Sometimes CBD stone can be seen. MRCP: To visualise biliary tree accurately (much more accurate than ultrasound)  Diagnostic only but non-invasive  Look for biliary dilatation and any stones in biliary tree ERCP: Diagnostic and therapeutic in biliary obstruction  Diagnostic and therapeutic but invasive  Look for biliary tree dilatation and stones in biliary tree  Stones can be extracted to unobstruct the biliary tree and perform sphincterotomy  Risk of pancreatitis, duodenal perforation CT Abdomen: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene, or perforation and in acute pancreatitis (ultrasound not good for looking at pancreas)
  10. 10. Pathogenesis  Stone intermittently obstructing cystic duct (causing pain) and then dropping back into gallbladder (pain subsides) Ultrasound confirms presence of gallstones
  11. 11. Pathogenesis:  Due to obstruction of cystic duct by gallstone:  Cystic duct blockage by gallstone  Obstruction to secretion of bile from gallbladder  Bile becomes concentrated  Chemical inflammation initially  Secondarily infected by organisms released by liver into bile stream Ultrasound confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid) Complications of acute cholecystitis  Empyema of gallbaldder  Gangrene of gallbladder (rare)  Perforation of gallbaldder (rare)
  12. 12. Pathogenesis:  Stone obstructing CBD with infection/pus proximal to the blockage
  13. 13. Pathogenesis:  Gallstone causing small bowel obstruction (usually obstructs in terminal ileum)  Gallstone enters small bowel via cholecysto-duodenal fistula (not via CBD) Abdominal Xray – dilated small bowel loops  May see stone if radio-opaque Diagnosis of gallstone ileus usually made at the time of surgery.
  14. 14. Questions?
  15. 15. THANK YOU