GB & BILIARY TREE

Begashaw M (MD)

Gall bladder

pear shaped organ of 7.5 – 12.5 cm length & capacity of 50cc

Parts-Fundus,Body & Neckcystic duct - joins GB with common

hepatic duct to form CBD

Functions

- Reservoir for bile

- Organ for concentrating the bile

- Secretion of the mucus

Cholelithiasis

• most common pathology of biliary tree

Classification

1- Cholesterol stone (6%)-usually solitary

2- Mixed stone (90%)-cholesterol is the major component with others like calcium bilirubinate

-multiple, faceted & associated with infection

3- Pigment stone: composed of calcium bilirubinate

-usually small, multiple & black

-associated with hemolytic disease

Risk factors

Age > 40 yrs Female sex Obesity Rapid weight loss

– Very low calorie diet – Surgical therapy of

morbid obesity Pregnancy

Fat Fertile Flatulent Female Fifty

Pathogenesis

1- Metabolic:bile formed is supersaturated or lithogenic

2- Infection: increased mucus plug formation & scarring /nidus

3- Stasis: Progesterone in multiparous women is believed to be contributory

Clinical Presentation

Most-90%Asymptomatic Hx

- RUQ colicky pain

- Dyspepsia, fatty food intolerance, flatulence, abnormal postprandial bloating

P/E

-RUQ tenderness

-Risk factors - identified

Complications

Gall bladder

-chronic cholecystitis

-acute cholecystitis

-gangrene

-perforation

-empyema

-mucocele

-carcinoma

Bile duct

-obstructive jaundice

-cholangitis

-acute pancreatitis Intestine

-Gall stone ileus

Diagnostic workup

Ultrasounddetects stone in GBPAXR Only 10% of stones are radio opaque Differential diagnosis

1. PUD

2. Hiatal Hernia

3. Carcinoma of stomach

4. Diverticular disease

5. Angina pectoris

Treatment

Surgery: Open or Laparoscopic

1-cholecystectomymain stay of treatment

2-cholecystostomy for bad risk patients with severe infection

-Severe Acute cholecystitis

-Gall bladder empyema

Acute Cholecystitis

is an acute inflammation of gall bladder due to obstruction of neck of gall bladder or cystic duct stone

In absence of stone Acalculous cholecystitis

Pathogenesis

Direct pressure of calculus ischemia, necrosis, and ulceration with swelling edema & impairment of venous returnFavors bacterial multiplication

End result

- Pericholecystic abscess

- Fistula formation between gall bladder & bowel

- GB empyema/mucocele CommonlyE.coli, Klebsiella , Streptococci,

Enterobacter & Clostridial

Clinical features

Hx

- chronic cholecystitis /Cholelithiasis

- RUQ/epigastric pain radiate to back

- Fever/vomiting P/E

- RUQ tenderness with rebound tenderness

- GB may be palpable

- Murphy’s Sign +ve : sudden arrest of inspiration due to tenderness of inflamed gall bladder which is palpated during deep inspiration

DDX

- Perforated PUD

- Biliary colic

- Pneumonia

- Pancreatitis

- Hepatitis

IXns

WBC: Leucocytosis CXR or PAXR: pneumonia/radio opaque

stone Ultrasound: detects calculi, gall bladder

wall thickening & pericholecystic fluid

Treatment

1- conservative

- Admit

- keep NPO

- Start on IV fluid

- Insert NGT

- Analgesics- Antibiotics - ampicillin & gentamycin - Follow -fever, abd findings/WBC count reduction

- cholecystectomy after 6 weeks

2. Surgical treatment: Cholecystectomy

OBSTRUCTIVE JAUNDICE

Jaundice is a yellowish discoloration of the sclera, mucous membrane & skin

becomes clinically evident when the level of serum billirubin reaches 2.0 to 3.0 mg/dl

Classification

I Medical:Pre hepatichemolyticHepaticliver problems

II Surgical: obstruction of biliary treeobstructive

jaundice

Biochemical features

Extra hepatic biliary obstruction

Lumen

-Gall stone

-ParasiticAscaris Wall

-Atresia

-Stricture

-Tumor

Extrinsic

-pancreatic head ca

-ampullary ca

-Pancreatitis

-Choledochal cyst

Clinical manifestation

Hx

- Intermittent jaundicestone

- Progressive jaundice- +/- Pruritis

- Urine/stoolclay color

- RUQ pain

- Loss of appetite/weight loss

- History trauma/surgery

P/E

- G/Aobesity/emaciation

- Depth of jaundice/pallor

- Hepatomegaly, splenomegaly

- Ascites

- Palpable GB

- Liver mass

- Skin scratch marks

Courvoisier’s Law

If in presence of jaundice, the gall bladder is palpable, then the jaundice is unlikely to be due to stone True in 60%of cases

Investigations

- Hemoglobin-AnemiaMalignancy

- U/Abillirubin/urobilinogen

- Serum billirubintotal & direct

- Serum alk pase

- Ultrasoundgall stone, choledochal cyst, dilated bile duct, Neoplasm

- LFT

- PT

Treatment Surgery Perioperative

-Antibiotic prophylaxis

-Parenteral vit K +/- FFP

-Fluid resuscitation

-careful post operative fluid balance