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Gall Bladder disorders and diseases.pptx
- 1. Dr Mohamed Shatat,MD Professor of Internal Medicine Minia University Gall bladder Disorders
- 2. Gallbladder Anatomy • Itis a pear-shaped sac…..length about 7.5 to 12.5 cm …..with an average capacity of 30 to 50 ml (the gallbladder can distend markedly and contain up to 300 ml) • located on the inferior surface of the liver attached to it by loose areolar tissue. Rich in blood vessels and lymphatic. • The Gallbladder covered by peritoneum reflected from Glisson Capsule • Less 10% complete covered by peritoneum (mesentery) • The gallbladder is divided into four anatomic areas: the fundus: the corpus (body), the infundibulum, and the neck. • Supplied by the cystic artery which arise from the right hepatic artery . • Venues drainage : drain into the right branch of portal vein. • Lymphatic drainage: drain into cystic lymph node.
- 3. a = righthepatic duct b = left hepatic duct c = common hepatic duct d = portal vein e = hepatic artery f = gastroduodenal artery g = left gastric artery h = common bile duct i = fundus of the gallbladder j = body of gallbladder k = infundibulum l = cystic duct m = cystic artery n = superior pancreaticoduodena l artery.
- 4. Gallbladder Physiology • Bileis mainly composed of water (97%), bile salts (1-2%), (1%) phospho-lipids, cholesterol, bile pigments, and electrolytes. • Bile is alkaline and PH 5.7 – 8.6. • The rate of bile secretion is 40 cc / hour. • The normal adult consuming an average diet produces within the liver 500 to 1000 ml of bile a day.
- 5. Gallbladder Function • Bilestorage. • Bile concentration 5-10 times by active absorption of water and sodium decreasing the bile volume 80-90%. • Secretion of mucin = 20 ml /day.
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- 7. Limited value inthe diagnoses GB disorder but helpful to rule out other differential diagnoses. Gallbladder stone can be seen by x-ray in 15- 20%. Abdominal X- ray:
- 9. Oral Cholecystography It involvesoral administration of a radiopaque compound that is absorbed, excreted by the liver, and passed into the gallbladder. largely been replaced by ultrasonography.
- 10. Ultrasonography An ultrasound isthe initial investigation of any patient suspected of disease of the biliary tree. It is noninvasive, painless, does not submit the patient to radiation, and can be performed on critically ill patients
- 11. Abdominal CT scansare inferior to ultrasonography in diagnosing gallstones. The major application of CT scans is to define the course and status of the extrahepatic biliary tree and adjacent structures. It is the test of choice in evaluating the patient with suspected malignancy of the gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of the pancreas. Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice. Computed Tomography
- 12. Biliary scintigraphy providesa noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information. The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis. The sensitivity and specificity for the diagnosis are about 95% each. Biliary leaks as a complication of surgery of the gallbladder or the biliary tree can be confirmed and frequently localized by biliary scintigraphy. Biliary Radionuclide Scanning (Hida Scan)
- 13. It has littlerole in the management of patients with uncomplicated gallstone disease. useful in patients with bile duct strictures and tumors, as it defines the anatomy of the biliary tree proximal to the affected segment. complications are bleeding, cholangitis, bile leak, and other catheter-related problems. Percutaneous Transhepatic Cholangiography N e e d l e
- 14. Magnetic Resonance Imaging Ithas a sensitivity and specificity of 95 and 89%, respectively, at detecting choledocholithiasis. MRI with magnetic resonance cholangiopancreatography (MRCP) offers a single noninvasive test for the diagnosis of biliary tract and pancreatic disease
- 15. Endoscopic Retrograde Cholangiographyand Endoscopic Ultrasound This test is rarely needed for uncomplicated gallstone disease, but for stones in the common bile duct, in particular, when associated with obstructive jaundice, cholangitis, or gallstone pancreatitis, ERC is the diagnostic and often therapeutic procedure of choice. Complications of diagnostic ERC include pancreatitis and cholangitis, and occur in up to 5% of patients.
- 20. Gallstone Disease Prevalence andIncidence : • Gallstone disease is one of the most common problems affecting the digestive tract (Autopsy reports have shown a prevalence of gallstones from 11 to 36%.). • The prevalence of gallstones is related to many factors: • age, gender, and ethnic background • Obesity, pregnancy, dietary factors, • Crohn's disease, terminal ileal resection, gastric surgery • hereditary spherocytosis, sickle cell disease, and thalassemia
- 21. Types of gallstone •Cholesterol stones () • Pigment stones () • Mixed () Epidemiology • Fat, Fair, Female, Fertile, Fourty inaccurate, but reminder of the typical patient • F:M = 2:1 • 10% of British women in their 40s have gallstones • Genetic predisposition – ask about family history Gallstones
- 22. 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) Pathogenesis
- 23. Cholesterol Imbalancebetween bile salts/lecithin and cholesterol allows cholesterol to precipitate out of solution and form stones OR stasis 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 Pathogenesis
- 24. Cholesterol Stones • Purecholesterol stones are uncommon and account for <10% of all stones. They usually occur as single large stones with smooth surfaces. • Most other cholesterol stones contain variable amounts of bile pigments and calcium, but are always >70% cholesterol by weight. usually multiple, of variable size. Colors range from whitish yellow and green to black. • Most cholesterol stones are radiolucent; <10% are radiopaque. • the primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol. • Supersaturation almost always is caused by cholesterol hypersecretion rather than by a reduced secretion of phospholipid or bile salts
- 25. Pigment Stones • Pigmentstones contain <20% cholesterol and are dark because of the presence of calcium bilirubinate • black and brown pigment stones have little in common and should be considered as separate entities • Black pigment stones are usually small, brittle, black, and sometimes speculated, formed by supersaturation of calcium bilirubinate, carbonate, and phosphate, most often secondary to hemolytic disorders, and in those with cirrhosis. Like cholesterol stones, they almost always form in the gallbladder. • Brown stones : They may form either in the gallbladder or in the bile ducts, usually secondary to bacterial infection (such as Escherichia coli)caused by bile stasis. calcium bilirubinate and bacterial cell bodies compose the major part of the stone.
- 26. 80% Asymptomatic 20% developsymptoms and complications (recurrent) Complications of Gallstones
- 37. • Biliary Colic •Acute Cholecystitis • Gallbladder Empyema • Gallbladder gangrene • Gallbladder perforation • Obstructive Jaundice • Ascending Cholangitis • Pancreatitis • Gallstone Ileus (rare) Complications of Gallstones
- 38. Gallstone disease(and its related complications) Gastritis/duodenitis Peptic ulcer disease/perforated peptic ulcer Acute pancreatitis Right lower lobe pneumonia MI When there is RUQ pain…… all patients should get Blood tests AXR/E-CXR (to exclude perforation/pneumonia) ECG Differential Diagnosis of RUQ pain
- 39. Can differentiate betweengallstone complications based on: • History • Examination • Blood tests • FBC • LFT • CRP • Clotting • Amylase Which Gallstone Complication?
- 40. Complication History ExaminationBlood tests Biliary Colic - Intermittent RUQ/epigastric pain (minutes/hours) into back or right shoulder - N&V -Tender RUQ -No peritonism -Murphy’s – -Apyrexial, HR and BP (N) -WCC (N) CRP (N) - LFT (N) Acute Cholecystitis -Constant RUQ pain into back or right shoulder -N&V -Feverish -Tender RUQ -Periotnism RUQ (guarding/rebound) -Murphy’s + -Pyrexia, HR (↑) -WCC and CRP (↑) -LFT (N or mildly (↑) Empyema -Constant RUQ pain into back or right shoulder -N&V -Feverish -Tender RUQ -Peritonism RUQ -Murphy’s + -Pyrexia, HR (↑), BP (↔ or ↓) -More septic than acute cholecystitis -WCC and CRP (↑) -LFT (N or mildly (↑) Obstructive Jaundice -Yellow discolouration -Pale stool, dark urine -painless or assocaited with mild RUQ pain -Jaundiced -Non-tender or minimally tender RUQ -No peritonism -Murphy’s – -Apyrexial, HR and BP (N) -WCC and CRP (N) -LFT: obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔) -INR (↔ or ↑) Ascending Cholangitis Becks triad -RUQ pain (constant) -Jaundice -Rigors -Jaundiced -Tender RUQ -Peritonism RUQ -Spiking high pyrexia (38-39) -HR (↑), BP (↔ or ↓) -Can develop septic shock -WCC and CRP (↑) -LFT : obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔) -INR (↔ or ↑) Acute Pancreatitis -Severe upper abdominal pain (constant) into back -Profuse vomiting -Tender upper abdomen -Upper abdominal or generalised peritonism -Usually apyrexial, HR (↑), BP (↔ or ↓) -WCC and CRP (↑) -LFT: (N) if passed stone or obstructive pattern ifstone still in CBD -Amylase (↑) -INR/APTT (N) or (↑) if DIC Gallstone Ileus - 4 cardinal features of SBO -distended tympanic abdomen -hyperactive/tinkling bowel sounds
- 41. Pathogenesis Stone intermittently obstructingcystic duct (causing pain) and then dropping back into gallbladder (pain subsides) USS confirms presence of gallstones Treatment Analgesia Fluid resuscitation if vomiting If pain and vomiting subside does not need admitting Biliary Colic
- 42. Pathogenesis: • Due toobstruction 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 USS confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid) Complications of acute cholecystitis • Empyema of gallbaldder • Gangrene of gallbladder (rare) • Perforation ofgallbaldder (rare) Acute Cholecystitis
- 43. Treatment • Admit formonitoring • Analgesia • Clear fluids initially, then build up oral intake as cholecystitis settles • IVF • Antibiotics • 95% settle with above management • If do not settle then for CT scan • Empyema percutaneous drainage • Gangrene/perforation with generalised peritonitis emergency surgery
- 44. Pathogenesis: Stone obstructing CBD(bear in mind there are other causes for obstructive jaundice) – danger is progression to ascending cholangitis. USS • Will confirm gallstones in the gallbladder • CBD dilatation i.e. >8mm (not always!) • May visualise stone in CBD (most often does not) MRCP • In cases where suspect stone in CBD but USS indeterminate • E.g.1 obstructive LFTs but USS shows no biliary dilatation and no stone in CBD • E.g. 2 normal LFTS but USS shows biliary dilatation Obstructive Jaundice
- 45. ERCP If confirmed stonein CBD on USS or MRCP proceed to ERCP which will confirm this (diagnostic) and allow extraction of stones and sphincterotomy (therepeutic) Treatment • Must unobstruct biliary tree with ERCP to prevent progression to ascending cholangitis • Whilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis
- 46. Pathogenesis: Stone obstructing CBDwith infection/pus proximal to the blockage Treatment • ABC • Fluid resuscitation (clear fuids and IVF, catheter) • Antibiotics • Pus must be drained* - this is done by decompressing the biliary tree • Urgent ERCP • Urgent PTC – if ERCP unavailable or unsuccesful Ascending Cholangitis
- 47. Acute Pancreatitis Pathogenesis • Obstructionof pancreatic outflow • Pancreatic enzymes activated within pancreas • Pancreatic auto-digestion USS: to confirm gallstones as cause of pancreatitis • USS not good for visualising pancreas CT: gold standard for assessing pancreas. • Performed if failing to settle with conservative management to look for complications such as pancreatic necrosis Treatment • Analgesia • Fluid resuscitation • Pancreatic rest – clear fluids initially • Identify underlying cause of pancreatitis • 95% settle with above conservative management • 5% who do no settle or deteriorate need CT scan to look for pancreatic necrosis
- 48. Gallstone ileus Pathogenesis: • Gallstonecausing small bowel obstruction (usually obstructs in terminal ileum) • Gallstone enters small bowel via cholecysto-duodenal fistula (not via CBD) AXR – dilated small bowel loops • May see stone if radio-opaque Treatment • NBM • Fluid resuscitation + catheter • NG tube • Analgesia • Surgery (will not settle with conservative management) – enterotomy + removal of stone Diagnosis of gallstone ileus usually made at the time of surgery.
- 49. Chronic Cholecystitis About twothirds of patients with gallstone disease present with chronic cholecystitis • characterized by recurrent attacks of pain( biliary colic). develops when a stone obstructs the cystic duct • vary from an apparently normal gallbladder with minor chronic inflammation in the mucosa, to a shrunken, nonfunctioning gallbladder with gross transmural fibrosis and adhesions to nearby structures. • The mucosa is initially normal or hypertrophied, but later becomes atrophied, with the epithelium protruding into the muscle coat, leading to the formation of the so-called Aschoff-Rokitansky sinuses
- 50. Clinical Presentation Typical presentation: •The chief symptom is pain (constant and increases in severity over the first half hour or so and typically lasts 1 to 5 hours ). located in the epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapulae…The pain is severe and comes on abruptly, typically during the night or after a fatty meal…The pain is episodic. The patient suffers discrete attacks of pain, between which they feel well. • Physical examination may reveal mild right upper quadrant tenderness during an episode of pain. If the patient is pain free, the physical examination is usually unremarkable • Laboratory values, such as WBC count and liver function tests, are usually normal in patients with uncomplicated gallstones. Atypical presentation ??
- 51. • Asymptomatic gallstonesdo not require operation • Indications • A single complication of gallstones is an indication for cholecystectomy (this includes biliary colic) • After a single complication risk of recurrent complications is high (and some of these can be life threatening e.g. cholangitis, pancreatitis) • Whilst awaiting laparoscopic cholecystectomy • Low fat diet • Dissolution therapy (ursodeoxycholic acid) generally useless Cholecystectomy
- 52. Cholecystectomy • All performedlaparoscopically • Advantages: • Less post-op pain • Shorter hospital stay • Quicker return to normal activities • Disadvantages: • Learning curve • Inexperience at performing open cholecystectomies
- 53. Tumors • Carcinoma ofthe Gallbladder : • Incidence : • the fifth most common GI malignancy in Western countries • accounts for only 2 to 4% of all malignant GI tumors, • two to three times more common in females than males • peak incidence is in the seventh decade of life • It is an aggressive tumor (The overall reported 5-year survival rate is about 5% ))
- 54. Etiology 1. Gallstone isthe most important risk factor for gallbladder carcinoma up to 95% of patients with carcinoma of the gallbladder have gallstones. • Larger stones (>3 cm) are associated with a 10-fold increased risk of cancer. 2. Polypoid lesions (( particularly in polyps >10 mm))) 3. calcified "porcelain" gallbladder is associated with >20% incidence of gallbladder carcinoma 4. choledochal cysts 5. exposure to carcinogens (azotoluene, nitrosamines)
- 55. Pathology • 80 and90% of the gallbladder tumors are adenocarcinomas while Squamous cell, adenosquamous, oat cell, and other anaplastic lesions occur rarely • spreads through the lymphatics, with venous drainage, and with direct invasion into the liver • Lymphatic flow from the gallbladder drains first to the cystic duct node (Calot's), then the pericholedochal and hilar nodes, and finally the peripancreatic, duodenal, periportal, celiac, and superior mesenteric artery nodes. • The gallbladder veins drain directly into the adjacent liver, usually segments IV and V, where tumor invasion is common • When diagnosed : • about 25% of gallbladder cancers are localized to the gallbladder wall • 35% have regional nodal involvement and/or extension into adjacent liver • approximately 40% have distant metastasis
- 56. • Clinical Manifestationsand Diagnosis • Signs and symptoms of carcinoma of the gallbladder are generally indistinguishable from those associated with cholecystitis and cholelithiasis. • More than one half of gallbladder cancers are not diagnosed before surgery • Laboratory findings are not diagnostic. • Ultrasonography often reveals a thickened, irregular gallbladder wall or a mass replacing the gallbladder. Ultrasonography may visualize tumor invasion of the liver, lymphadenopathy, and a dilated biliary tree . The sensitivity of ultrasonography in detecting gallbladder cancer ranges from 70 to 100% • A CT scan is an important tool for staging. identify a gallbladder mass or local invasion into adjacent organs. demonstrate vascular invasion. poor method for identifying nodal spread • MRCP has evolved into a single noninvasive imaging method that allows complete assessment of biliary, vascular, nodal, hepatic, and adjacent organ involvement • If diagnostic studies suggest that the tumor is unresectable, a CT scan or ultrasound-guided biopsy of the tumor can be obtained to provide a
- 57. TREATMENT 1. Surgery remainsthe only curative option for gallbladder cancer 2. no proven effective options for adjuvant radiation or chemotherapy for patients with gallbladder cancer. 3. Tumors limited to the muscular layer of the gallbladder (T1) simple cholecystectomy is an adequate treatment for T1 lesions and results in a near 100% overall 5-year survival rate 4. When the tumor invades the perimuscular connective tissue without extension beyond the serosa or into the liver (T2 tumors)… extended cholecystectomy should be performedincludes resection of liver segments IVB and V, and lymphadenectomy 5. For tumors that grow beyond the serosa or invade the liver or other organs (T3 and T4 tumors), there is a high likelihood of intraperitoneal and distant spread. If no peritoneal or nodal involvement is found, complete tumor excision with an extended right hepatectomy (segments IV, V, VI, VII, and VIII) must be performed for adequate 6. An aggressive approach in patients who will tolerate surgery has resulted in an increased survival for T3 and T4 lesions.
- 58. • Prognosis • The5-year survival rate of all patients with gallbladder cancer is <5%, with a median survival of 6 months. • Patients with T1 disease.excellent prognosis (85 to 100% 5- year survival rate). • T2 lesions treated with an extended cholecystectomy and lymphadenectomy compared with simple cholecystectomy is >70% vs. 25 to 40%, respectively • Patients with advanced but resectable gallbladder cancer are reported to have 5-year survival rates of 20 to 50%. • the median survival for patients with distant metastasis at the time of presentation is only 1 to 3 months. • The prognosis for recurrent disease is very poor • Death occurs most commonly secondary to biliary sepsis or liver failure.
- 59. When should symptomaticgallbladder stones be suspected? The characteristic symptoms of gallbladder stones, i.e. episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction to analgesics, should be identified by medical history and physical examination
- 60. Should patients withasymptomatic gallstones be treated? Routine treatment is not recommended for patients with asymptomatic gallbladder stones Is surgery indicated for gallbladder polyps? Cholecystectomy should be performed in patients with gallbladder polyps ≥1 cm without or with gallstones regardless of their
- 61. Is cholecystectomy indicatedin patients with porcelain gallbladder? Asymptomatic patients with porcelain gallbladder may undergo cholecystectomy Should prophylactic cholecystectomy be offered to patients with hereditary spherocytosis or sickle cell disease? Cholecystectomy should be considered in patients with hereditary spherocytosis and sickle cell disease and concomitant
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