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BENIGN BILIARY TRACT DISEASES
DEVELOPMENT AND FUNCTION
• FROM FOREGUT ABOUT 3 /52 0F GESTATION
• BLOOD SUPPLY -- COELIAC AND SUPR. MESENTERIC VESSELS
• FUNCTION - TRANSPORTS, STORES AND RELEASES BILE
• COUINAUD’S SEGMENTAL ANATOMY
COMMON CONDITIONS
• BILIARY ATRESIA• CHOLEDOCHAL
CYST• GALL BLADDER
STONES • CBD STONES• RPC • BENIGN BILE DUCT
STRICTURES
• BILIRY HYDATID DISEASE
• BENIGN TUMOURS
INVESTIGATIONS PLAIN X’RAY • PNEUMOBILIA,• STONE,• GAS IN GALL BLADDER OR GALL
BLADDER WALL , • GALL STONE ILEUS
U/S
• SPECIFICITY 90%• ACOUSTC SHADOWING• PERICHOLECYSTIC FLUID • THICKENING OF GALL BLADDER
WALL • POLYPS AND STONES• CBD
RADIOLOGY Ix
• ORAL CHOLECYSTOGRAM • PTC- IN DIALATED DUCTS • ERCP• CT• HIDA • BILIARY MANOMETRY • EUS
CONG. ANOMALIES
• BILIARY ATRESIA--1/120000• KASAI PROCEDURE
• CHOLEDOCHAL CYST-- EXTRAHEPATIC OR INTRAHEPATIC
• TYPES 1-5
ACQUIRED- GALL BLADDER STONES • 11-36 % INCIDENCE • MIXED STONES 75-90%• CHOLESTEROL+ B.PIGMENTS+CA
SALTS IN A CORE -LAMINTED-MULTIPLE STONES-COLOUR WHITE TO GREEN TO BLACK 10% RADIO-OPAQUE
• CAUSE - BILE STASIS,INFECTION AND ABNORMALITIES OF BILE CONSTITUENTS
CHOLESTEROL STONES 1O %• LARGE SMOOTH EGG OR
BARREL SHAPED • CHOLESTEROL SOLITAIRE• RADIOLUCENT• CAUSE SAME AS ABOVE
PIGMENT STONES
• MULTIPLE , JET BLACK, SHINY , FRIABLE
• CA BILIRUBINATE • CAUSE -- EXCESS BILIRUBIN
SECRETION Ie.HAEMOLYTIC ANAEMIAS, INFECTIOS, MALARIA , LEUKEMIA etc
• COMMON IN ASIA .
CA. CARBONATE STONES RARE
• EXCESS SECRETION OF CA IN BILE
• GREYISH FACETED STONES • RADIO-OPAQUE
• ASYMTOMATIC
• BILIARY COLIC
• CHR. CHOLECYSTITIS
• ACUTE CHOLECYSTITIS
ACUTE CHOLECYSTITIS
• PAIN , FEVER,TACHYCARDIA• MILD JAUNDICE• GUARDING & REBOUND TENDERNESS• MURPHY’S SIGN• BOAS’ SIGN • RADIATION TO THE SHOULDER• ABSENCE OF SIGNS IN THE ELDERLY
BILIARY COLIC
• STONE IMPACTION AT THE NECK OF GB
• SEVERE PAIN• NO FEVER• ABSCENT MURPHY’S• RADIATES TO THE BACK - NOT TO
SHOULDER • MILDTENDERNESS IN THE EPIG.
CHR. CHOLECYSTITIS
• PAIN IN RUQ/ EPIG. • FATTY FOOD INTOLERANCE• RADIATION TO BACK AND SHOULDER • ABDOMINAL DISTENSION & FLATULENCE• DDx P. ULCER,H.HERNIA,DIVERTICULAR
DISEASE • SAINTS TRIAD: GS,D. DISEASE &H. HERNIA
COMPLICATIONS
• EMPYEMA OF GALL BLADDER • ACUTE EMPHYSEMATOUS CHOLECYSTITIS • XANTHOGRANULOMATOUS CHOLECYSTITIS • ACUTE ACALCULUS CHOLECYSTITIS • CHOLESTEROLOSIS-STRAWBERRY G.
BLADDER• ADENOMYOMATOSIS • MUCOCELE /INTERNAL BILIARY FISTULA
Mx OF GALL STONES
• GALL STONE DISSOLUTION THERAPY• MINIMALLY I. STONE
REMOVAL/DISSOLUTION• ESWL• CHOLECYSTECTOMY - OPEN AND
LAPAROSCOPIC• CHOLECYSTOSTOMY• PARTIAL CHOLECYSTECTOMY
COMPLICATIONS
• CBD INJURY-MIRRIZZI SYNDROME • VASCULAR INJURY• RETAINED CBD STONE • POSTCHOLECYSTECTOMY
SYNDROME
CBD STONES - PRESENTATION
• O. JAUNDICE• PANCRERATITIS • ASCENDING CHOLANGITIS • BILIARY COLIC • DYSPEPSIA• ELDERLY- OBSCURE SYMPTOMS• ASYMTOMAYIC
CBD STONES -CONT’D
• SUPRADUODENAL CBD EXPLORATION
• ERCP -LITHOTRIPSY• ESWL• TRANSDUODENAL EXPLORATION
& SPHINCTEROPLASTY• CHOLEDOCHODUODENOSTOMY
RECURRENT PYOGENIC CHOLANGITIS • ASIATIC/ ORIENTALS • CLONORCHIS SINENSIS • CHARCOT’S TRIAD• RAYNAUD’S PENTAD
RPC- Mx
• ERCP/ SPHINCTEROTOMY/LITHOTRIPSY• NASOBILIARY DRAINAGE -ACUTE
STAGE • CHOLEDOCHODUODENOSTOMY/
CHOLEDOCHOJEJUNOSTOMY• ACCESS LOOP• PTC- STONE REMOVAL• LIVER RESECTION