6 gall blader & biliary tree diseases
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- 1. GALL BLADER & BILIARY TREE DISEASES BY TEMESGEN
G/MARIAM(MD) FEB.04/2013
- 2. Lecture Out line Anatomy & Physiologic highlights
Clinical presentation of a patient with biliary ds Specific disease
entities : CHOLELITHIASIS Acute cholecystitis Obstructive jaundice
Gall bladder Ca
- 3. Anatomy OF THE Gallbladder The gallbladder is a pear- shaped
sac 7 to 10 cm long, with an average capacity of 30 to 50 Ml It has
four parts
- 4. Anatomy of The Bile Ducts Cystic duct Tortouse course,acute
angle of insertion 2-4cm long,3mm wide CHD CBD Variable length Upto
1cm in diameter
- 5. BLOOD SUPPLY
- 6. Anomalies The classic description of the extrahepatic
biliary tree and its arteries applies only in about one third of
patients The gallbladder may have abnormal positions, be
intrahepatic, be rudimentary, have anomalous forms, or be
duplicated
- 7. Physiologic highlights
- 8. Storage Concentration (reabsoption ) Secretion of mucus
coordinated motor response of gallbladder contraction and sphincter
of Oddi relaxation mediated by CCK
- 9. Clinical presentation of a patient with biliary ds Pain
typical (RUQ,epigastric) Biliary colic Jaundice Associated symptoms
Fever,chills & rigor Tightness/dullness Urine/stool
discoloration Radiation pruritus Nausea/vomiting Atypical
Indigestion,flatulence Dyspepsia,retrostern al pain Constitutional
symptoms Wt loss,anorexia,back pain
- 10. CHOLELITHIASIS/GALL STONE DS Epidemiology one of the most
common problems affecting the digestive tract Varies depending on
Age Sex Stone types Overall prevalence Western Asia Africa
- 11. Risk factors/etiology Major risk factors for pigmented
stones Infection Sickle cell anemia Hemolysis Stasis Parasitic
infestation 5f:Fat, fertile, flatulent, female of fourty
- 12. Pathogenesis/ pathophysiology Super saturation of bile Drop
in phospholipid Decrease in bile acid pool Increase cholesterol
secretion Biliary stasis(drainage) Biliary
dyskinesia/motility,TV,DM,pregnancy Infection Predisposing
factors
- 13. Composition of Bile
- 14. Impaired GB function Supersaturated bile Age Sex Absorption
Genetics Excretion Obesity Diet Emptying Absorption/EHC Nucleating
agents Mucus Glycoprotein Infection Deoxycholate SBS Fecal flora
Ileal resection
- 15. Clinical presentation of uncomplicated gallstone
Silent/incidental finding Typical /classical Biliay colic RUQ/
epigastic post prandial (50%) + nausea/vomiting Radiation to
Atypical Dyspepsia/indigestion Flatulence Belching Atypical
sites(retrosternal)
- 16. Physical Examination Ultrasound No remarkable Most
important modality May mild tenderness in First line of
investigation RUQ/epigastric area Laboratory CBC LFT
Sensitive/specific() Superior to CT scan Characteristic finding
Echogenic Acoustic shadow Move when pt change position May
Polp/stone in the cystic duct Stone 2.5cm) GB polp > 1cm Chronic
No immediate access to immunosuppresion Sickle cell anemia Bariatic
surgery Small multiple stone Child ?DM health care facility
Incidental(intra operative) Non functional GB
- 20. Category II Category III cholecystectomy Other causes IBS ,
PUD , Good outcome (all Diverticulosis , hiatal hernia,)should be
R/o Endoscopic evaluation What if the service is not there? Only
sub groug of patient relieved from their symptoms after
cholecystectomy relieved from their symptom)
- 21. Category IV Further work for underlying causes Missed stone
Sluge Biliary diskinesia choledocholelithiasis
- 22. Acute cholecystitis Secondary to gallstones in 90 to 95% of
cases Acute acalculous cholecystitis In 18x103 Ultrasound
Sensitivity/specificity(80) Evidences stone Empyema Thicken
(edematous)wall perforationm Perichlecystic fluid Mild elevation of
LFT bil , alk phospha Sonographic murphy sign HIDA (97 and 90%)
highly sensitive and specific for acute cholecystitis
- 27. Treament Conservative followed by interval /delayed
cholecystectomy Intravenous hydration and correction of any
associated electrolyte disorders NPO/NGT/ maintaince fluid
ANALGESIC Antibiotic Choice/duration/route of administration
Monitor response Early cholecystectomy
- 28. Obstructive jaundice Due to obstruction to the excretion of
bilirubin Confirmation that is obstructive is essential Most
frequent causes varies depending on age,geography,sex,..
Choledocholethiasis is most common(benign lesion) in many countries
Pancreatic head tumor commonest malignant
- 29. Classification of causes I. Excessive production (hemolytic
jaundice):- A. Inherited hemolytic anemia's B. Acquired hemolytic
anemia's II. Impaired transport to liver:- -Gilberts syndrome III.
Impaired hepatic conjugation:- A. Inborn errors B. Immaturity of
enzymes IV Impaired excretion(hepatocellular jaundice) A. Acquired
liver diseases B.Intrahepatic cholestasis
- 30. V. Bile duct obstruction(obstructive jaundi) A. Extra
hepatic:1.Stone 2.Neoplasms 3.Stricture 4.Atresia,ect B.
Intrahepatic
- 31. Pain similar to biliary colic Associated symptoms:
fever/chills , pruritus , darken urine , pale/ clay colored stool
Physical exam No remarkable finding Jaundice, Vital signs Scratch
marks Tenderness Corvesouires law Stigma for malignancy/liver
disease
- 32. Laboratory
- 33. Imaging Abdominal ultrasound Important first line
Sensitivity varies(55-91%) CBD Dilation > site> causes
Combination of clinical ,biochemical & U/S Jaundice + biliary +
gall stone + increased LFTS + Dilated CBD As the No of criteria
increases probability of stone in the CBD increases
- 34. Other imaging (not routinely used) MRCP ERCP Highly
sensitive & specific PTC EUS Helical CT scan HIDA
- 35. Management Endoscopic removal/drainage(ERCP Open/lap
Choledochotomy Spincterotomy/ plasty Drainage Choledochduedunostomy
choledochjejunostomy
- 36. Candidates for drainage Irremovable, impacted, distal CBD
stones Markedly dilated CBD, >1.5cm Distal duct obstruction from
tumor or stricture Recurrence after previous duct exploration
- 37. Gall bladder Ca Incidence Un common (2-3 % of GI
malignancies) Incidence varies Ethnicity , geographic High
incidence in Israel ,chili ,native Americans M:F 1:3 1% of
cholecystectomy for gall stone. >75% of cases> 60 years
- 38. Risk factors Cholithiasis is the most important risk factor
for gallbladder carcinoma, and up to 95% of patients with carcinoma
of the gallbladder have gallstones Porcelain gall bladder Primary
sclerosing cholangitis Chledochal cyst Association with gall
stone
- 39. Pathology > (90%) adenocarcinoma Scirrhous (60%)
Papillary(25%) Mucoid(15%) Spread Hemato Lymphatic direct
- 40. Table 54-2 -- TNM Staging for Gallbladder Cancer T T1
lamina propria (T1a) or muscular (T1b) layer T2 perimuscular
connective tissue, no extension beyond the serosa or into the liver
T3 perforates the serosa (visceral peritoneum) and/or directly
invades into liver and/or one other adjacent organ or structure
such as the stomach, duodenum, colon, pancreas, omentum, or
extrahepatic bile ducts T4 main portal vein or hepatic artery or
invades multiple extrahepatic organs and/or structures N N0 No
lymph node metastases N1 Regional lymph node metastases M M0 No
distant metastases M1 Distant metastases
- 41. Stage Grouping IA T1 N0 M0 IB T2 N0 M0 IIA T3 N0 M0 IIB T1
N1 M0 T2 N1 M0 T3 N1 M0 III T4 Any N M0 IV Any T Any N M1
- 42. clinical features
- 43. Diagnostic work up Management/progosis Diagnostic work up
Abdominal U/S CT SCAN MRI/MRC ERCP Surgery the only hope Incidental
cholecystectomy Early stage , better outcome The 5-year survival
rate of all patients with gallbladder cancer is