Download to read offline
More Related Content
Similar to Gall bladder disease.pptx
Gall bladder disease.pptx
- 1. Gall bladder disease MahtemeBekele (MD) Assistant professor of surgery Emergency directorate director Postgraduate program director SPHMMC 2/1/2023 mahteme bekele
- 2. Objectives • To identify –Common diseases of the GB – Common presenting symptoms of GB disease – principles and options of management GB disease 2/1/2023 mahteme bekele
- 3. 2/1/2023 mahteme bekele RUQAnatomy: GB Location • GB lies inferior to liver • Between the right and quadrate hepatic lobes • Hollow viscus in the gallbladder fossa 7-10cm • Consists of fundus, body, and neck • Neck tapers to cystic duct
- 4.
- 5. 2/1/2023 mahteme bekele RUQAnatomy Gallbladder Left liver lobe Hepatic artery Portal vein IVC Cystic duct Right liver lobe Common Bile Duct Quadrate liver lobe
- 6. 2/1/2023 mahteme bekele TheBile Duct System • Liver makes bile 500-1000ml/day • Out to common hepatic duct • Goes to… – Common bile duct to duodenal ampulla – Cystic duct to gall bladder
- 7. 2/1/2023 mahteme bekele Gallbladderfunction • Reservoir for bile ( contains 40–70 ml bile) • Concentrates bile up to 5-10x – water is absorbed – bile salts and solutes become concentrated • Secretion of mucous up to 20 ml/d • Contract &release bile into duodenum
- 8. 2/1/2023 mahteme bekele GallbladderAnomalies • Agenesis • Hypoplasia • Hyperplasia • Total reduplication • Subtotal division of fundus • Phrygian cap • Septated gallbladder • Floating gallbladder
- 9. 2/1/2023 mahteme bekele PathologicConditions of the GB • Cholelithiasis • Cholecystitis • Sludge • Gall bladder Cancer • GB polyps – Benign polyps » Adenomyomatosis » Adenoma » Cholestrolistasis » Inflammatory polyps » Miscellaneous – Malignant polyps » Adenocarcinoma » Miscellaneous
- 10. 2/1/2023 mahteme bekele Cholelithiasis Incidences Mostcommon biliary pathology Prevalence: 6-10 % men, 12-20 % women Fat, fertile, flatulent, female of fifty. Majority of gallstones clinically silent 18-50% become symptomatic over 10-15yr
- 11. 2/1/2023 mahteme bekele Classification Basedon stone composition ,location& etiology. • Composition – Cholesterol stone – Pigment stone – Mixed stone • Location – GB – Extra hepatic BD – Intra hepatic BD – Major elements – cholesterol, bile pigments, calcium. – Others – Fe, P, CO3, mucus,debris
- 12. RISK FACTORS • Age>60yrs • Gender women b/n 20-60 2x risk •Estrogens •pregnancy, hormone replacement, pills •Obesity esp. in women •Rapid wt loss • Fasting Diabetes •SBS , TPN ---- increase PGS •cirrhosis & hereditary blood disorders •Vagotomy 2/1/2023 mahteme bekele
- 13. 2/1/2023 mahteme bekele pathogenesisof Gallstone Multifactorial • Metabolic(Abnormal bile production) • Bile stasis • infectious
- 14. 2/1/2023 mahteme bekele Nucleatingagents •Mucus •Glycoprotein •Infection Supersaturated bile •Age •Sex •Genetics •Obesity •Diet Absorption/EHC •Deoxycholate •SBS •Fecal flora •Ileal resection •Cholestiramine Impaired GB function •Emptying •Absorption •Excretion
- 15. 2/1/2023 mahteme bekele PathogenesisCholesterol & mixed stone occurs in three stages 1) Cholesterol saturation ♣mixed bile acids, lecithin &cholesterol…micelles ♣ any alteration …cholesterol precipitation ♣ due to ↑ed quantity or alteration of the vehicle …critical step ♣ supersaturation can occur due to secretion of hepatic bile with either high cholesterol or low bile acids or lecithin …litogenic bile
- 16. 2/1/2023 mahteme bekele 2)Nucleation cholesterol monohydrate crystals form & agglomerate …macroscopic stones promoters or retarding agents ● heat labile GP in the bile as potential pronucleating factors (e.g GB mucus) Stasis of bile in the GB ● ↓ GB motility & emptying ● ↑ed calcium ● ↑ PGS ● alteration in GB secretion &absorption 3) Stone Growth ● Due to cholesterol precipitation & agglomeration
- 17. 2/1/2023 mahteme bekele Pathogenesisof Pigmented Stones Due to altered solubilization of unconjugated bilirubin with precipitation of ca bilirubinate & insoluble salts 2 types 1.Brown pigment stones -common in Asia -secondary to infection -release of beta glucuronidase 2. Black pigment stones -pts with haemolytic dd. & cirrhosis
- 18. 2/1/2023 mahteme bekele ClinicalPresentation I. Asymptomatic Dx incidentally > 50% of pts with GS 25% of pts within 5 yr…symptomatic II. Symptomatic or cxn. of GS biliary Colic -sudden onset (30-60min) after meal -increased freq. & intensity with time -6-10% risk of recurrent each year -2% risk of comp. -large solitary stones…acute cholecystitis -multiple stones<4 cm…acute pancreatitis
- 19. 2/1/2023 mahteme bekele Complicationsof GS • IN THE GALLBLADDER due to mov’t of stones & infection cholecystitits →acute or chronic gangrene perforation -biliary peritonitis -biliary-enteric fistula empyema mucocele (hydrops) carcinoma
- 20. 2/1/2023 mahteme bekele Cxn…cont’d •IN THE BILE DUCTS obstructive jaundice cholangitis Acute pancreatitis • IN THE INTESTINE acute intestinal obstruction (GS ileus)
- 21. 2/1/2023 mahteme bekele Cholecystitis •Could be acute or chronic inflammation Calculous or acalculous • Risk factors: obstruction and bile stasis • Bacterial growth common but secondary
- 22. 2/1/2023 mahteme bekele CHRONICCHOLECYSTITIS incompletely resolved AC contracted fibrotic GB dyspepsia …belching ,flatus ,abdominal bloating ,fullness epigastric burning & Nausea & Vomiting
- 23. 2/1/2023 mahteme bekele ACUTECHOLECYSTITIS ►most common cxn. of GSD ► in 95%....GS impacted at Hartman’s pouch … acute inflammation of GB ► 50% bacteria cultured ► middle aged & elderly ►Hx of episodic biliary colic pain Unremitting for days
- 24. 2/1/2023 mahteme bekele Hxpersistence RUQ pain > 4 hrs + Nausea & Vomiting +/- Pyrexia +/- chills &Rigors P/E Direct & rebound tenderness & guarding In 50% mass in RUQ … 20% Leukocytosis Murphy’s sign +ve
- 25. 2/1/2023 mahteme bekele DDx perforated PUD appendicitis acute pancreatitis hepatitis lobar pneumonia pyelonephritis AMI
- 26. 2/1/2023 mahteme bekele ACALCULASCHOLECYSTITIS pts with major abdominal & thoracic surgery & TPN recovering from major trauma severe burns Acute emphysematous cholecycistitis serious form of Ac. xized by gas in the lumen or wall of the GB in the elderly pts 25% have DM CF as AC but pts are more toxic DX ….air in the gallblader or wall on plain abd. Film GS in 75% of pts
- 27. 2/1/2023 mahteme bekele INVESTIGATIONAND DIAGNOSIS 1. History & P/E Typical biliary colic may be associated with fatty meal intolerances Nausea and vomiting Any of the atypical symptoms Non-specific atypical symptoms like indigestion, abdominal bloating Belching although commonly reported by patients with gallstones, are less likely to be caused by cholelithiasis since they are least likely to disappear after cholecystectomy
- 28. 2. Standard baseline investigation - CBC -LFT -Serum Amylase ….. Acute pancreatitis - Blood culture 3. Plain radiography - 10% of GS are radio opaque -not routinely indicated -in acutely ill pts to R/O perforated viscus - Gas in the GB or BD 2/1/2023 mahteme bekele
- 29. 2/1/2023 mahteme bekele 4.ULTRASOUND primary screening procedure can show us…. Calculi with acoustic shadow thickened wall , distension of GB localized pericholecystic collection dilated CBD
- 30. 2/1/2023 mahteme bekele 5.Oral cholecystography (OCG) - replaced by U/S - used to assess GB function 6. IV cholangiography -to see extrahepatic biliary tree -effective in jaundiced pts. 7. CT & MRI - to R/O pancreatic head tumour 8. Scintography … to Dx acute cholecystitis
- 31. 2/1/2023 mahteme bekele 9.PTC & ERCP - in pts with comp. acute biliary dd. & jaundice - clotting studies before PTC - prophylactic antibiotics indicated in pts. - known GBS with increased bilirubin >10 mg/dl - Sx pts with previous cholecystectomy - pts with biliary Sx & inconclusive evidence
- 32. Management of GBstones • category 1-Gallstones on imaging studies but without symptoms • category 2- Typical biliary symptoms and gallstones on imaging studies • category 3-Atypical symptoms and gallstones on imaging studies • category 4 -Typical biliary symptoms but without gallstones on imaging studies 2/1/2023 mahteme bekele
- 33. Category 1 • Asymptomatic –SYMPTOMS DEVELOPMENT – ~3% /year ….2/3rd remain asymptomatic in 20years 2/1/2023 mahteme bekele
- 34. 2/1/2023 mahteme bekele Managementof acute cholecystitis A. Conservative Rx i. relief of pain NSIAD opiates & morphine i.v fluids if DHN ii. Control of nausea & vomiting keep NPO anti emetics NG tube iii. Control of fever broad spectrum Abs( blood culture) -cephalosporin's & aminoglycosides most pts respond within 48 hrs elective cholecystectomy after 6-8 wks
- 35. 2/1/2023 mahteme bekele Mxof…cont’d B. Definitive Rx I. Removal of GB & stones after 6-8wks ♣open cholecystectomy ♣ Laparoscopic cholecysectomy **Emergency cholecystectomy - pts not settling within 48 hrs - pts with DM to prevent gangrene II. Removal of GS alone ♣ medically dissolution agents (CDCA’& UDCA ) ♣ other procedures Lithotripsy (ESWL)
- 36. 2/1/2023 mahteme bekele Mxof stones in CBD • 1o stones originate in the CBD • 2o stones -- Most CBD stones originate in the GB • cxn of CBD stone Obst. Jaundice Cholangitis fever RUQ pain Charcot’s triad Jaundice Charcot’s triad + altered mental status Reynolds’s pentad + shock Suppurative cholangitis=>liver abscess Impaired LF =>Biliary cirrhosis
- 37. 2/1/2023 mahteme bekele •DDx of obstructive jaundice ►CBD stones ► Pancreatic head tumor ► Biliary stricture ► Periampulary tumors ► Drug induced jaundice, ► Hepatitis (viral) • Investigations LFT,U/S,ERCP,PTC ,MRI ,CT
- 38. 2/1/2023 mahteme bekele •choledochotomy Indications (1) palpable CBD stones (2) If there is jaundice or Hx of jaundice or cholangitis (3) dilated CBD (4) abnormal LFT, in particular, the alkaline phosphatase is raised