Post on 17-Jan-2018
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Gall bladder and Biliary Gall bladder and Biliary diseasedisease
Dr.Umit AkyuzDr.Umit AkyuzGastroenterology DepartmentGastroenterology DepartmentYeditepe University,IstanbulYeditepe University,Istanbul
Biliary stone diseaseBiliary stone diseaseAcute cholecytitisAcute cholecytitisPrimer sclerosane cholangitisPrimer sclerosane cholangitisPrimer biliary cirrhosisPrimer biliary cirrhosisTumorsTumors
CHOLELITHIASISCHOLELITHIASIS
Chole – Chole – CYSTOCYSTO - GALLBLADDER- GALLBLADDER - - DOCHODOCHO – D. CHOLEDOCHUS – D. CHOLEDOCHUS
CHOLESTEROLCHOLESTEROL %75%75PIGMENT(blb, ca)PIGMENT(blb, ca) % 25% 25
CHOLESTROL STONESCHOLESTROL STONES
CHARACTERISTICS: CHARACTERISTICS: – PURE OR MIXEDPURE OR MIXED– SMALL OR LARGESMALL OR LARGE– SOLITARY OR MULTIPLESOLITARY OR MULTIPLE
PIGMENT STONESPIGMENT STONES• CHARACTERISTICS:
– ELDERLY– HEMOLYTIC STATES– CIRRHOSIS– MULTIPLE, IRREGULAR– CENTRAL CALCIFICATION
RISK FACTORSRISK FACTORS
4 4 FF : :– FFemaleemale– FFatat– FFertileertile– FFortyorty
3 D3 D– DDiabetesiabetes– DDrugsrugs– DDietiet
2 H2 H– HHLPLP– HHeredityeredity
Bile Salt MalabsorbtionBile Salt Malabsorbtion
COMPLICATIONSCOMPLICATIONS
STONE – PASSAGESTONE – PASSAGE– HYDROPS HYDROPS – CHOLECYSTITISCHOLECYSTITIS– ICTERUSICTERUS
Ac. CHOLECYTITISAc. CHOLECYTITISEMPYEMAEMPYEMAPERFORATIONPERFORATIONChr. CHOLECYTITISChr. CHOLECYTITIS
CLINICSCLINICS
COLIC:COLIC:– RUQ crampy PainRUQ crampy Pain
RADIATIONRADIATION BACKBACK
DYSPEPSIADYSPEPSIA
Ac. CHOLECYTITIS Ac. CHOLECYTITIS ++ COMPLICATIONS COMPLICATIONS
DIAGNOSISDIAGNOSIS
• USG• X-Ray Plain Film• ERC / P• PTC• CT
THERAPYTHERAPY
SpasmolyticaSpasmolyticaAntibioticsAntibioticsSURGERYSURGERY– Absolute ComplicationsAbsolute Complications– Relative ComplicationsRelative Complications
Medical:Medical:– Oral LytholysisOral Lytholysis– Ursodeoxy-cholic AcidUrsodeoxy-cholic Acid– ESLWESLW
therapytherapy
ACUTE CHOLECYSTITISACUTE CHOLECYSTITISAcute InflammationAcute Inflammation
PrimaryPrimary AbacterialAbacterialSecondarySecondary BacterialBacterial
• Enterococcus• E. Coli• Gr. (-) Bacilli• Anaerobs
– Bacteroides– Clostridia– Fusobacterium
SymptomsSymptoms
Biliary colicBiliary colicFever, chills, anorexia, nausea, vomitingFever, chills, anorexia, nausea, vomitingEnlarged GallbladderEnlarged GallbladderMurphy’s sign :Murphy’s sign :
RUQ-PalpationRUQ-Palpationincreased Pain inincreased Pain inInspirationInspiration
Diagnosis: Clinics, US, biochemistryDiagnosis: Clinics, US, biochemistry
ComplicationsComplications
EmpyemaEmpyema
GangreneGangrene
PerforationPerforation
IleusIleus
TherapyTherapy
PE - NutritionPE - Nutrition AntibioticsAntibiotics Cholecystectomie ?Cholecystectomie ?
for Complications !for Complications !
CHOLANGITISCHOLANGITIS
Charcot’s Charcot’s Biliary Biliary painpain
TriadTriad JaundiceJaundiceFeverFever
BacteriaBacteria
E. coliE. coliKlebsiellaKlebsiellaProteusProteusE. bacterE. bacterPseudomonasPseudomonasClostridiumClostridium
ComplicationsComplications
SepsisSepsisHepatic AbcessHepatic AbcessBil. StricturesBil. StricturesGallstonesGallstonesSec. Bil. CirrhosisSec. Bil. CirrhosisPHTPHT
TreatmentTreatment
ERCPERCP
AntibioticsAntibiotics
Primary Sclerosing CholangitisPrimary Sclerosing Cholangitis
İdiopathicİdiopathicintra+extrahepaticintra+extrahepaticChronicChronicFibrosing,Fibrosing,Diffuse Diffuse of bile Ductsof bile DuctsClinics:Clinics:
CholestasisCholestasisBile D. ObliterationBile D. ObliterationCirrhosisCirrhosis
ClinicsClinics
JaundiceJaundicePruritusPruritusFatiqueFatiqueWeight lossWeight loss
UCUC 75 %, 75 %, CD CD, , RRA, Sarcoidosis,A, Sarcoidosis, Sjögren SyndromeSjögren Syndrome
M/F 1/3M/F 1/3
ANCA + ; ANCA + ; IgM IgM
Complications Complications 5 – C5 – C
CholestasisCholestasisCirrhosisCirrhosisCholangitisCholangitisCholelithiasisCholelithiasisCholangiocarcinomaCholangiocarcinoma
TherapyTherapy
ABABCholestyramineCholestyramineUrsodeoxycholicacidUrsodeoxycholicacidSurgical : Liver Transplantation !Surgical : Liver Transplantation !
Primary Biliary CirrhosisPrimary Biliary Cirrhosis
İnterlobuler and septal bile ductsİnterlobuler and septal bile ductsMiddle aged populationMiddle aged population100-150/1 million100-150/1 million
ClinicsClinics
FatigueFatiguePiruritisPiruritisAsymtomaticAsymtomaticJaundinceJaundinceVariciel bleedingVariciel bleedingascitesascites
Assosiated DiseaseAssosiated Disease
keratoconjuctivites sikka (50%)keratoconjuctivites sikka (50%)Thyroid disease (15%)Thyroid disease (15%)Artrithes (10%)Artrithes (10%)Reynaud (9%)Reynaud (9%)SclerodermaSclerodermaRenal stonesRenal stonesBreast cancerBreast cancer
DiagnosisDiagnosis
AMA >1/40 (M2 band) 95%AMA >1/40 (M2 band) 95%AST, ALT highAST, ALT highIgM highIgM highBiluribune highBiluribune highHypercholesterolemia 80%Hypercholesterolemia 80%Pathology: florid duct lesionsPathology: florid duct lesions
ComplicationsComplications
OsteopeniaOsteopeniaFat soluble vit. DeficiencyFat soluble vit. Deficiencyhypercholesterolemiahypercholesterolemia
TreatmentTreatment
Ursodeoxycholic acidUrsodeoxycholic acidCorticosteroidsCorticosteroidsAzothioprineAzothioprineCyclosporineCyclosporineMethotraxateMethotraxatePenicilamine,colhicine no benefitPenicilamine,colhicine no benefitTransplantationTransplantation
TUMORSTUMORS
BENIGNBENIGN– PolipsPolips– AdenomyomatosisAdenomyomatosis– CholesterosisCholesterosis
MALIGNMALIGN– CarcinomaCarcinoma– AdenoAdeno– SquamousSquamous
Ductus CarcinomaDuctus Carcinoma– Pat Pat 60 Years60 Years