1. GALL BLADER & BILIARY TREE DISEASES BY TEMESGEN G/MARIAM(MD) FEB.04/2013

2. Lecture Out line Anatomy & Physiologic highlights Clinical presentation of a patient with biliary ds Specific disease entities : CHOLELITHIASIS Acute cholecystitis Obstructive jaundice Gall bladder Ca

3. Anatomy OF THE Gallbladder The gallbladder is a pear- shaped sac 7 to 10 cm long, with an average capacity of 30 to 50 Ml It has four parts

4. Anatomy of The Bile Ducts Cystic duct Tortouse course,acute angle of insertion 2-4cm long,3mm wide CHD CBD Variable length Upto 1cm in diameter

5. BLOOD SUPPLY

6. Anomalies The classic description of the extrahepatic biliary tree and its arteries applies only in about one third of patients The gallbladder may have abnormal positions, be intrahepatic, be rudimentary, have anomalous forms, or be duplicated

7. Physiologic highlights

8. Storage Concentration (reabsoption ) Secretion of mucus coordinated motor response of gallbladder contraction and sphincter of Oddi relaxation mediated by CCK

9. Clinical presentation of a patient with biliary ds Pain typical (RUQ,epigastric) Biliary colic Jaundice Associated symptoms Fever,chills & rigor Tightness/dullness Urine/stool discoloration Radiation pruritus Nausea/vomiting Atypical Indigestion,flatulence Dyspepsia,retrostern al pain Constitutional symptoms Wt loss,anorexia,back pain

10. CHOLELITHIASIS/GALL STONE DS Epidemiology one of the most common problems affecting the digestive tract Varies depending on Age Sex Stone types Overall prevalence Western Asia Africa

11. Risk factors/etiology Major risk factors for pigmented stones Infection Sickle cell anemia Hemolysis Stasis Parasitic infestation 5f:Fat, fertile, flatulent, female of fourty

12. Pathogenesis/ pathophysiology Super saturation of bile Drop in phospholipid Decrease in bile acid pool Increase cholesterol secretion Biliary stasis(drainage) Biliary dyskinesia/motility,TV,DM,pregnancy Infection Predisposing factors

13. Composition of Bile

14. Impaired GB function Supersaturated bile Age Sex Absorption Genetics Excretion Obesity Diet Emptying Absorption/EHC Nucleating agents Mucus Glycoprotein Infection Deoxycholate SBS Fecal flora Ileal resection

15. Clinical presentation of uncomplicated gallstone Silent/incidental finding Typical /classical Biliay colic RUQ/ epigastic post prandial (50%) + nausea/vomiting Radiation to Atypical Dyspepsia/indigestion Flatulence Belching Atypical sites(retrosternal)

16. Physical Examination Ultrasound No remarkable Most important modality May mild tenderness in First line of investigation RUQ/epigastric area Laboratory CBC LFT Sensitive/specific() Superior to CT scan Characteristic finding Echogenic Acoustic shadow Move when pt change position May Polp/stone in the cystic duct Stone 2.5cm) GB polp > 1cm Chronic No immediate access to immunosuppresion Sickle cell anemia Bariatic surgery Small multiple stone Child ?DM health care facility Incidental(intra operative) Non functional GB

20. Category II Category III cholecystectomy Other causes IBS , PUD , Good outcome (all Diverticulosis , hiatal hernia,)should be R/o Endoscopic evaluation What if the service is not there? Only sub groug of patient relieved from their symptoms after cholecystectomy relieved from their symptom)

21. Category IV Further work for underlying causes Missed stone Sluge Biliary diskinesia choledocholelithiasis

22. Acute cholecystitis Secondary to gallstones in 90 to 95% of cases Acute acalculous cholecystitis In 18x103 Ultrasound Sensitivity/specificity(80) Evidences stone Empyema Thicken (edematous)wall perforationm Perichlecystic fluid Mild elevation of LFT bil , alk phospha Sonographic murphy sign HIDA (97 and 90%) highly sensitive and specific for acute cholecystitis

27. Treament Conservative followed by interval /delayed cholecystectomy Intravenous hydration and correction of any associated electrolyte disorders NPO/NGT/ maintaince fluid ANALGESIC Antibiotic Choice/duration/route of administration Monitor response Early cholecystectomy

28. Obstructive jaundice Due to obstruction to the excretion of bilirubin Confirmation that is obstructive is essential Most frequent causes varies depending on age,geography,sex,.. Choledocholethiasis is most common(benign lesion) in many countries Pancreatic head tumor commonest malignant

29. Classification of causes I. Excessive production (hemolytic jaundice):- A. Inherited hemolytic anemia's B. Acquired hemolytic anemia's II. Impaired transport to liver:- -Gilberts syndrome III. Impaired hepatic conjugation:- A. Inborn errors B. Immaturity of enzymes IV Impaired excretion(hepatocellular jaundice) A. Acquired liver diseases B.Intrahepatic cholestasis

30. V. Bile duct obstruction(obstructive jaundi) A. Extra hepatic:1.Stone 2.Neoplasms 3.Stricture 4.Atresia,ect B. Intrahepatic

31. Pain similar to biliary colic Associated symptoms: fever/chills , pruritus , darken urine , pale/ clay colored stool Physical exam No remarkable finding Jaundice, Vital signs Scratch marks Tenderness Corvesouires law Stigma for malignancy/liver disease

32. Laboratory

33. Imaging Abdominal ultrasound Important first line Sensitivity varies(55-91%) CBD Dilation > site> causes Combination of clinical ,biochemical & U/S Jaundice + biliary + gall stone + increased LFTS + Dilated CBD As the No of criteria increases probability of stone in the CBD increases

34. Other imaging (not routinely used) MRCP ERCP Highly sensitive & specific PTC EUS Helical CT scan HIDA

35. Management Endoscopic removal/drainage(ERCP Open/lap Choledochotomy Spincterotomy/ plasty Drainage Choledochduedunostomy choledochjejunostomy

36. Candidates for drainage Irremovable, impacted, distal CBD stones Markedly dilated CBD, >1.5cm Distal duct obstruction from tumor or stricture Recurrence after previous duct exploration

37. Gall bladder Ca Incidence Un common (2-3 % of GI malignancies) Incidence varies Ethnicity , geographic High incidence in Israel ,chili ,native Americans M:F 1:3 1% of cholecystectomy for gall stone. >75% of cases> 60 years

38. Risk factors Cholithiasis is the most important risk factor for gallbladder carcinoma, and up to 95% of patients with carcinoma of the gallbladder have gallstones Porcelain gall bladder Primary sclerosing cholangitis Chledochal cyst Association with gall stone

39. Pathology > (90%) adenocarcinoma Scirrhous (60%) Papillary(25%) Mucoid(15%) Spread Hemato Lymphatic direct

40. Table 54-2 -- TNM Staging for Gallbladder Cancer T T1 lamina propria (T1a) or muscular (T1b) layer T2 perimuscular connective tissue, no extension beyond the serosa or into the liver T3 perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts T4 main portal vein or hepatic artery or invades multiple extrahepatic organs and/or structures N N0 No lymph node metastases N1 Regional lymph node metastases M M0 No distant metastases M1 Distant metastases

41. Stage Grouping IA T1 N0 M0 IB T2 N0 M0 IIA T3 N0 M0 IIB T1 N1 M0 T2 N1 M0 T3 N1 M0 III T4 Any N M0 IV Any T Any N M1

42. clinical features

43. Diagnostic work up Management/progosis Diagnostic work up Abdominal U/S CT SCAN MRI/MRC ERCP Surgery the only hope Incidental cholecystectomy Early stage , better outcome The 5-year survival rate of all patients with gallbladder cancer is