BENIGN CONDITIONSAMARAN.M

FINAL YEAR MBBS , S2PROF.P.RAGUMANI UNIT

JAUNDICE JANEU ( FRENCH ) ; ICTERUS ( LATIN ) DEFINITION “REGAL” DISEASE

BENIGN CONDITIONS

CONGENITAL : BILIARY ATRESIA ; CHOLEDOCHAL CYST.INFLAMMATORY : SCLEROSING CHOLANGITIS.OBSTRUCTIVE : GALLSTONES ; BILIARY STRICTURES.

BILIARY ATRESIA

BILIARY ATRESIA

DEFINITION INCIDENCE 1 :

10,000 ASSOCIATED WITH

CONGENITAL ANAMOLIES

TYPES

TYPES OF BILIARY ATRESIA

PATHOGENESIS

CAUSES INFECTIONS : CMV, HPV,

REOVIRUS,

ROTAVIRUS.

AUTOIMMUNE

ABNORMAL DEVELOPMENT

TOXINS

VASCULAR DEFECTS

TREATMENT

HEPATICO-PORTO-

JEJUNOSTOMY PRESENTLY KASAI

PORTO-ENTEROSTOMY

8 WEEKS OF AGE

CHOLEDOCHAL CYST

CHOLEDOCHAL CYST

CYSTIC DIALTATIONS OF BILE DUCT

MORE COMMON IN ASIA

1 :1000 TYPES CAROLI’S DISEASE

( TYPE 5 ) CAUSE IS EXPLAINED

BY BABBIT THEORY

COMPLICATIONS OF CYSTS

PANCREATITIS MAINLY IN TYPE 3 GALLSTONE AND CBD STONE FORMATION BILIARY CIRRHOSIS MALIGNANCY ( CHOLANGIOCARCINOMA ; COMMON

IN POST.

WALL )

TREATMENT OF CYSTS

TYPE 1 COMPLETE EXCISION

OF CYST RECONSTRUCTION

BY HEAPTICO-JEJUNOSTOMY

TREATMENT OF CYSTS

TYPE 2 EXCISION OF

DIVERTICULUM SUTURING THE CBD

WALL

TREATMENT OF INTRADUODENAL PART

TYPE 3 ENDOSCOPIC

SPHINCTEROTOMY ( FOR

LESIONS < 3cm ) TRANSDUODENAL

APPROACH ( FOR

LESIONS > 3cm )

TREATMENT OF CYSTS

TYPE 4 EXTRAHEAPTIC PART

IS EXCISED AND RECONSTRUCTION PROCEDURE

INTRAHEPATIC PART ARE RESECTED ONLY WHEN THERE IS STRICTURES OR LIVER ABSCESS

LILY’S OPERATION

TREATMENT OF CAROLI’S DISEASE

TYPE 5 LEFT LOBAR DUCTS

ARE USUALLY AFFECTED

LOBAR RESECTION IS DONE.

BILOBAR INVOLVEMENT : TRANSPLANTATION

SCLEROSING CHOLANGITIS

SCLEROSING CHOLANGITIS INFLAMMATION AND SUBSEQUENT OBSTRUCTION OF BILE

DUCTS AT BOTH INTRAHEPATIC & EXTRAHEPATIC LEVELS

+ DILATATION OF PRESERVED SEGMENTS

HIGH RISK FOR CHOLANGIOCARCINOMA TYPES

1. PRIMARY ( NO CAUSE IS FOUND )

2. SECONDARY TO OTHER DISEASES

(CHEMOTHERAPY 5-FU)

PATHOGENESIS OF PSCAUTOIMMUNE ; HLA-B8/DR3

T CELL MEDIATED INFLAMMATION ; FIBROSIS & STRICTURES

PROGRESSIVE DESTRUCTION OF SMALL & MEDIUM SIZED DUCTS WITHIN LIVER & LARGE DUCTS OUTSIDE LIVER

OBSTRUCTION TO BILE FLOW (CHOLESTASIS)

CHRONIC INFLAMMATION

CHRONIC INFLAMMATION MAY PROGRESS TO :

CHOLANGIOCARCINOMA

CIRRHOSIS OF LIVER

MANAGEMENT

IMMUNOSUPPRESSION

•METHOTREXATE•AZATHIOPRINE•CYCLOSPORINE•TACROLIOMUS

GALLSTONE SOLUBILIZER

•URSODIOL ( suppresses hepatic synthesis of cholesterol )

LIPID LOWERING AGENT

•CHOLESTYRAMINE ( forms a non absorbable complex with bile acids and inhibits the reuptake )

STEROIDS IN LARGE DOSES VITAMIN SUPPLEMENTS

STENTING LIVER TRANSPLANTATION is the

only proven long term treatment

GENERAL

GALLSTONE

GALLSTONE CHOLELITHIASIS INVOLVES THE PRESENCE OF GALLSTONES IN

THE GALLBLADDER ;

CHOLEDOCHOLITHIASIS IS THE PRESENCE OD GALLSTONES IN COMMON

BILIARY DUCT

FAT, FERTILE , FORTY, FLATULENT, FEMALE

TYPES CHOLESTEROL STONES

PIGMENT STONES

MIXED ( COMMONEST 90 % )

CHOLESTEROL STONE PATHOGENESIS OBESITY PREGNANCY DRUGS HEREDITARY

PIGMENT STONES

INSOLUBLE Ca SALTS OF UNCONJ. BILIRUBIN

INORGANIC Ca SALTS

PIGMENT STONES

PIGMENT STONES PATHOGENESIS

PREDISPOSING FACTORS

CHRONIC HEMOLYTIC SYNDROMES

BILIARY INFECTION GI DISORDERS

PREDISPOSING FACTORS

ELEVATED LEVELS OF UNCONJUGATED BILIRUBIN

PIGMENT STONES

MANAGEMENT • CHENODEOXYCHOLIC ACID &

URSODEOXYCHOLIC ACID ( INHIBITS ABSORPTION OF CHOLESTEROL FROM

GUT)

DISSOLUTION

THERAPY

• OPEN CHOLECYSTECTOMY• CHOLEDOCHOTOMY• OPEN

CHOLEDOCHODUODENOSTOMY• OPEN CHOLEDOCHOJEJUNOSTOMY

OPEN PROCEDU

RES

• LAPROSCOPIC CHOLECYSTECTOMY

LAPROSCOPIC

PROCEDURES

OPEN CHOLECYSTECTOMY

PREOPERATIVE PREPARATION :

DEHYDARTION CORRECTION (IV DEXTROSE 5%)

IV ANTIBIOTICS

PNEUMOPERITONEUM WITH CO2 GAS AT SUBUMBILICAL PORT

GRASPING THE GALL BLADDER & CALOT’S TRAINGLE VISUALISATION

PLACING CLIPS AROUND CYSTIC DUCT & ATRERY TO CUT

GALL BLADDER IS DISSECTED OFF THE LIVER

BLEEDING CHECK & WASH & REMOVE THE GAS

BILIARY STRICTURE

BILIARY STRICTURE CAUSES

POST OP. ( MOST COMMON )

INFLAMMATORY CBD STONES

PARASITES

PSC

MALIGNANT TRAUMATIC

BISMUTH CLASSIFICATION

MANAGEMENT ERCP CHOLEDOCHOJEJUNOSTOMY CHOLEDOCHODUODENOSTOMY ROUX EN Y HEPATICOJEJUNOSTOMY ( IDEAL )

TAKE HOME MESSAGES

CONGENITAL MALFORMATION OF BILIARY TREE MAY BE EITHER ILEANA OR NAMITHA

SCLEROSING CHOLANGITIS IS AUTOIMMUNE INFLAMMATION + DESTRUCTION = OBSTRUCTION

MIXED TYPE IS THE COMMONEST STONE LAPROSCOPIC > OPEN PROCEDURE T TUBE PALCEMENT (CHOLANGIOGRAM

DONE TWICE )

DON’T AFRAID OF BEING DIFFERENT! HUMAN BEING IS ALWAYS AFRAID OF “BEING DIFFERENT” ; NOT BECAUSE THEY ARE DIFFERENT, ITS BECAUSE HUMANS ARE “WEAKER THAN” DIFFERENT !

THANK YOU