Guidelinesfor Third-year Students of the Medical Department

ubgect Propedeutics of the internal medicineModul № 2Enclosure module № 7Topic Diagnostics of the gall-bladder and biliary tract diseases. Clinical

presentation of the chronic cholecystitis, gallstones.Course 3Faculty Medical № 1

1. Importance of the topic Gall-bladder and biliary tract diseases are widely spread diseases of the gastrointestinal tract. They produce serious problems with health. Ability to recognizing gallstones, chronic cholecystitis and cholangitis is very important for every doctor or student, because sometimes these diseases appear with emergency life-threatened condition that should be resolved immediately, usually by sugary intervention.

2. Concrete aims: ─ Study main symptoms and signs of the biliary tract diseases─ Learn main instrumental methods that can help to establish chronic cholecystitis and cholangitis─ Learn laboratory features of the bile at patients with gallstones

3. Basic training level

Previous subject Obtained skillNormal anatomy Anatomy of the biliary tract, their blood supply and innervationNormal physiology Mechanics of bile formation and extractionHistology Ontogenesis of the biliary tract, histological structure of the

bale ducts and gall-bladderPropedeutics to internal medicine

Subjective, objective and instrumental examinations of the gastrointestinal patients

4. Task for self-depending preparation to practical training4.1. List of the main terms that should know student preparing practical training

Term TermHepatic or biliary colic 6-staging chromatic duodenal intubationGallstones Biliary tract dyskinesiaGall-bladder signs Bilious dyspepsia

4.2. Theoretical questions:1. Main syndromes at biliary tract affecting2. Data of the objective examination of the patients with biliary tract diseases3. Provocative symptoms of the gall-bladder affecting4. Main principles and purposes of the 6-staging chromatic duodenal intubation. It’s

diagnostic importance.5. Instrumental and laboratory methods of examination of patients with gall-bladder and

billiary tract diseases.6. Definition of chronic cholecystitis, its causes, main symptoms and signs.7. Definition of the cholelitiasis, its causes, main symptoms and signs.4.3. Practical task that should be performed during practical training

1. Revealing and assessment of symptoms and signs of chronic cholecystitis2. Revealing and assessment of symptoms and signs of Hepatic colic3. Revealing and assessment of instrumental and laboratory data at patients with

gallstonesTopic content

Main syndromes1. Pain syndrome (depends on the type of dyskinesia)

Localizes in the right subcostal region, in point of projection of the bottom of gall-bladder (the Makenzy point). It arises up after fat and fried food, in 3-5 hours later eating, irradiates into the right shoulder, under the right subscapularic region, in the region of heart (Botkyn’ symptom or cholecysto-cardial symptom)

It can be the severe, sharp brief or dull aching, required emergency care Mechanism of pain appearence: increase of internal pressure in the gall-bladder, spasm of the gall-bladder muscles, expansion walls of gall-bladder, increasing pressure in extra- and intrahepatic and biliary channels (compression

by the stones in the area of large duodenal papilla).2. Biliary dyspepsy - bitter taste in the mouth at mornings, vomiting with bile without relief, intolerance of fat and fried food, regurgitation (belching) by air, nausea, heartburn.3. Intestinal dyspepsy - related to the unstable selection of bile - alternation of diarrheas with constipations, flatulence, abdominal swelling.4. Syndrome of premenstrual tension at women – biliary diskinesia symptoms appear last

week before menses5. Astheno-neurotic (vegetative) syndrome – bad mood, irritation, nervousness,

weakness, fatigue

Data of physical examination Jaundice -yellowish skin and mucous, tracks from scratching due to skin itch (sign of

intrahepatic holestasis, calculesis) Pigmentation in right subcostal region (tracks from a hot-water bottle) At general examination a gall-bladder is not determinated and can be visible at

examination and palpation if patient has:1. gallstones2. gall-bladder cancer3. hydropsy of gall-bladder4. empiema (abscess) of gall-bladder5. cancer of pancreas head (the Kurvuasie’s symptom)

Provocative symptoms allow exposing pathology of gall-bladder the Kerr’s sign (pain at deep palpation of gall-bladder bottom) the Ortner’s sign (pain at percussion over the right costal arch the Lepene-Vasylenko’s sign (pain at percussion on the front wall of stomach on the right parallel to the right costal arch) the Mussy-Georgyevskiy’s sign (frenicus) - pain at deep palpation between the legs of right m.sternocleidomastoideus the Merphy’s sign (pain and breaking (stop) of inspiration during deep palpation of projection point of the gall-bladder bottom)

Investigations:Full blood analysis (leukocytosis, shift to the left at leukocytal formula, increasing ESR) Duodenal intubation with bile examination (6-staging chromatic duodenal intubation)

6-staging chromatic duodenal intubation 1 stage is the basal secretion of bile (duration 20-25 minutes, amount 20-25 ml)

2 stage is the stage of hold-up of biliary excretion due to closed Oddi’s sphincter (duration 2-7 minutes, amount – 0 ml)

3 stage is the stage of closed Lyutkens’s and opened Oddi’s sphincter, excretion bile from bile duct( duration – 3-6 minutes, amount 3-6 ml is portion A)

4 stage is a cystic bile, excretion bile from gal bladder (duration 20-30 minutes, amount 30-60 ml is portion B)

5 stage is a intrahepatic bile, excretion bile from common hepatic duct, secreting during examination in liver (duration 20-25 minutes, amount 20-25 ml is portion C)

6 stage is a remaining cystic bile, final contraction of gall bladder in 2-2,5 hours of examination (duration – 10-15 minutes, amount 10-15 ml).

Ultrasound examination of the lever, bile ducts and gall bladder in a rest and after bile-expelling breakfast.Radiologic investigation

oPlain abdominal X-ray examination(it is possible to see stone in a gall-bladder and bile ducts)

o Oral cholecystography - oral contrasting X-Ray examination (patient accepts the contrasting material in pills)

o IV cholecyatography - infusion intravenous contrasting X-Ray examination (the contrasting material is entered intravenously)

o Retrograde duodenocholecystocholangiopancreatography (a contrast is entered through a catheter entered by fybrogastroduodenoscope)

CHRONIC CHOLECYSTITIS is the chronic inflammatory disease of gall-bladder related with functional disorders (dyskynesia and dyscholia)

DIAGNOSTICS Clinical symptoms (see upper) positive provocative symptoms of palpation (6 symptoms mentioned above)

Duodenal intubation - the change of time and amount of 4 stages of cystic bile (portion B) – in a norm: amount 40-70 ml, time of selection 20-30 minutes.

1. decline of specific gravity of bile (norm value– 1016 ±1)2. change of pH of bile into sour reaction (norm value – 7,3 ± 0,1)3. decline of maintenance of bile acids in a cystic bile4. increase of concentration of cholesterol in a cystic bile (norm value 8,04 ± 0,72

mmol/l)5. decline of cholato-cholesterol coefficient (norm value - 29 ± 2)6. increase of concentration of bilirubin (norm value 3,8 ± 0,38 mmol/l)7. increase of concentration of sialic acids (norm value 130 ± 12 units)8. determination of the C-reactive protein (norm is negative)9. (+) bacteriological culture of cystic bile (in a norm a bile is sterile)

Results of ultrasound examination:1. increasing thickness of gall-bladder wall more than 4 mm (< 4 mm in a norm)2. (+) sonografic Merphy’s sign 3. increasing gall-bladder sizes more than 5 sm is higher than upper boder of norm for this age4. presence of shade from the gall-bladder wallspresence of paravisceral echo-negative shade (exudate)

Gall-Stone Disease or Cholelithiasis

Risk factors is “sign of 5 “F” – Female, Forty age, Fertile, Fat (obesity) Fair (complexion)

Reasons of development infection stagnation of bile in a gall-bladder congenital anomalies features of food heredity adynamy, decreased physical activity

A main pathological sign is forming of stones in the gall bladder (calcium, cholesterol, bilirubin, mixed)Stones can be silent (if they are located in a body and bottom of gall bladder) and active (if they are located in the bladder neck and ducts).The clinical signs appear only if stones become active. A main symptom (syndrome) is a hepatic (biliary) colic.

Symptoms and signs of biliary colic: intensive increased pain in right subcostal region, with a tendency to distribution a reason of appearing - use of fat, fried food, alcohol, after physical exercise, jolting

jorney the pain is appeared in 3-4 hours after eating (more frequent in a night-time) irradiation – upwards, in a right shoulder, in a right clavicula, in a right subscapular

region, sometimes – in the region of heart (the Botkin’s symptom) lake as angina pectoris

vomiting with bile does not relief patient’s condition fever, chill, trembling, anxiety, vegetative storm (diarrhea, constipation, swelling of stomach) Jaundice

Investigation of gallstones:1. Ultrasonography reflects stones in the gall bladder with 96% accuracy.2. Endoscopic retrograde cholangiopancreatography3. Plain abdominal X-ray identify calcified but not cholesterol stones with 15% accuracy.4. Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.

7. Reference source

o Handbook of diseases.-.2nd ed.- Springhouse Corporation, 2000 – P.197-200.

Test for self-control1. The pain due to gall-bladder and biliary ducts diseases appear after meal in:

a. ½ -1 hours;b. 1-2 hours;c. 7-8 hours;d. 3-4 hours;e. 2-6 hours.

2. What kinds of foods can cause the pain due to biliary disorders?a. Milk porridgeb. Fried potatoesc. Boiled vegetablesd. Boiled fishe. Apple pie

3. Where does the pain radiate due to biliary disorders?a. Umbilicus region b. Epigastric regionc. Left subcostal region d. Right subscapularic regione. Pubic region

4. If pain in the heart region appears at patient with biliary tract disorder it names …a. Angina pectorisb. Vegetative cardialgiac. Cholecystocardil symptomd. Stomach cardialgiae. Northing from above

5. What syndromes may be at patient with biliary tract disorders?a. Pain syndromeb. Asthenovegitative symdromesc. Biliary dyspepsiad. Syndrome of premenstrual tensione. All mentioned above

6. What syndromes cannot be at patient with biliary tract disorders?a. Pain syndromeb. Asthenovegitative symdromesc. Nephrotic syndromed. Syndrome of premenstrual tensione. Biliary dyspepsia

7. What symptoms characterize biliary dyspepsia?a. Dysphagia, odynophagia, heartburn, hematemesisb. Nausea, vomiting, hematemesis, early satietyc. Diarrhea, constipation, abdominal swellingd. Heaviness in the right subcostal region, nausea, bitter taste, vomitinge. Northing from mentioned above8. What symptoms characterize intestinal dyspepsia?

a. Dysphagia, odynophagia, heartburn, hematemesisb. Nausea, vomiting, hematemesis, early satietyc. Diarrhea, constipation, abdominal swellingd. Heaviness in the right subcostal region, nausea, bitter taste, vomitinge. E.Northing from mentioned above

9. If patient has biliary tract or gall-bladder disease during visual inspection you can find…

a. Weight loss, pale skin;b. Yellowish skin and mucous, tracks from scratching due to skin itch;c. Hyperemia of abdomen and chest, overweight;d. Diffuse cyanosis, visible peristaltic;e. Northing from mentioned above

10. If patient has biliary tract or gall-bladder disease during visual inspection you can find…

a. Anasarca, pale skin, swelled abdomen;b. Pigmentation in right subcostal region (tracks from a hot-water bottle);c. Hyperemia of abdomen and chest, overweight;d. Diffuse cyanosis, visible peristaltic;e. All mentioned above

11. When may gall-bladder be palpated?a. Gallstonesb. gall-bladder cancerc. hydropsy, empiema (abscess) of gall-bladderd. cancer of pancreas head (the Kurvuasie’s symptom)e. all mentioned above

12. When cannot gall-bladder be palpated?a. Gallstonesb. gall-bladder cancerc. in a normd. hydropsy, empiema (abscess) of gall-bladder

cancer of pancreas head (the Kurvuasie’s symptom)13. What provocative sign named Merphys?

a. pain at deep palpation of gall-bladder bottomb. pain at deep palpation between the legs of right m.sternocleidomastoideus c. pain and breaking inspiration during deep palpation of projection point of the gall-bladder bottom d. pain at percussion over the right costal arche. pain at percussion on the front wall of abdomen on the right parallel to the right costal arch

14. What provocative sign named Ortner’s?a. pain at deep palpation of gall-bladder bottomb. pain at deep palpation between the legs of right m.sternocleidomastoideus c. pain and breaking inspiration during deep palpation of projection point of the gall-bladder bottom d. pain at percussion over the right costal arche. pain at percussion on the front wall of abdomen on the right parallel to the right costal arch

15. Duodenal intubation is used for …a. assessment shape and size of the gall-bladderb. Function of the gall-bladder and biliary tractc. Disintoxication function of the liverd. Assessment shape and size of the biliary tracte. All mentioned above

16. The cystic bile during duodenal intubation is received at …

a. the 1 stageb. the 3 stagec. the 2 staged. the 5 stagee. the 4 stage

17. Ultrasound examination of the abdomen is used for …a. assessment shape and size of the gall-bladderb. Function of the gall-bladder and biliary tractc. Assessment structure, shape and size of the liverd. Assessment shape and size of the biliary tracte. All mentioned above

18. If patient has cholecystitis what changes if his bile may be found?a. specific gravity of bile is 1016b. pH of bile is 7,3c. C-reactive proteind. Bilirubin is 3,5 mmol/le. cholato-cholesterol coefficient 27

19. Ultrasound signs of chronic cholecystitis are…a. increasing thickness of gall-bladder wall more than 4 mmb. (+) sonografic Merphy’s sign c. increasing gall-bladder sizes more than 5 cm is higher than upper boder of norm d. presence of shade from the gall-bladder wallse. all mentioned above

20. What investigation is the most accurate for revealing gallstones?a. Ultrasonography of the gall bladder and the liverb. Endoscopic retrograde cholangiopancreatographyc. Plain abdominal X-rayd. Oral cholecystography shows stones in the gallbladder and biliary duct obstructione. All mentioned above

Control questions:1. Main syndromes at biliary tract affecting2. Data of the objective examination of the patients with biliary tract diseases3. Provocative symptoms of the gall-bladder affecting4. Main principles and purposes of the 6-staging chromatic duodenal intubation. It’s

diagnostic importance.5. Instrumental and laboratory methods of examination of patients with gall-bladder and

billiary tract diseases.6. Definition of chronic cholecystitis, its causes, main symptoms and signs.7. Definition of the cholelitiasis, its causes, main symptoms and signs.Practical task that should be performed during practical training

1. Revealing and assessment of symptoms and signs of chronic cholecystitis2. Revealing and assessment of symptoms and signs of Hepatic colic3. Revealing and assessment of instrumental and laboratory data at patients with

gallstones

Lecturer Demchuk A.V.