Behzad Nakhaei, M.D. , FICSFellowship in HepatoBiliary Surgery Mc Gill University

RUQ & Upper Abdomen Inflammation & Infection

GallBladder & Biliary System Disorders

( A Problem Solving Lecture )For Medical Students

Common Clinical PresentationsIn RUQ & Upper Abdomen

Due to Inflammation & Infection • Pain & Fever• Jaundice & Fever• Mass & Fever

• (One / Two Symptoms Dominate in each of these )

Signal the need for:

• Complete Blood Count

• Liver Function Test

• Serum Amylase

• PT , PTT

• Blood Culture

• Chest & Abdominal X ray

• Abdominal Ultrasonography

3 Most common Scenario :?

• Acute Cholecystitis?

• OR

• Acute Cholangitis?

• OR

• Acute Pancreatitis?

Pain & Fever?• Upper Abdomen Sepsis == RUQ Pain & Fever

• In 2/3 of Cases Biliary Origin • (Acute Cholecystitis, Biliary Colic, Acute Cholangitis)

• Acute Pancreatitis

• Pneumonia

• Hepatitis , Herpes Zoster

• Other gastrointestinal Disease• Sono is the most important Screening test for Acute

Biliary Infections.

Pain & Fever

– Diagnosis• Acute Cholecystitis • Biliary Colic• Acute Cholangitis• Acute Pancreatitis

– Sono Finding• Stone & Thickening of wall • Stone in Biliary Tree• Stone & Dilatation of CBD• Pancreas Enlargement

Cholecystitis ?

• Acute Calculous

• Acute Acalculous

• Emphysematous

• Hydrops

• Empyema

• Chronic

Risk Factors of Gangrene & Perforationin Acute Cholecystitis

• Systemic Toxicity

• Emphysematous Cholecystitis

• Acalculous Cholecystitis

Fever & Jaundice ?

• If the Patient Presents with :

• Fever > 38.5 & Jaundice

• Leukocytosis & Positive Blood Culture

• Stone & Biliary tree dilatation on Sono

• Reynolds, Pentad• ( Abdominal Pain, Fever&Chills,Jaundice,

Hypotension,Mental confusion )

• Dx is Acute Cholangitis

Cholangitis?

• Infection within Biliary tree Due to :• Choledocholithiasis

• Choledochal cysts

• Bile Duct CA

• Sphincteroplasty

• Instrumentation of Biliary tree

Cholangitis ?

• Acute Suppurative Cholangitis

• Cholangiohepatitis

• Sclerosing Cholangitis

Acute Suppurative Cholangitis?

• Pus within the Biliary tract

• Complicated by Obstructive Jaundice

• Charcot triad : Jaundice, Chill , Fever

• Age Over 70

• ERCP or PTC

• Surgical Intervention

Cholangiohepatitis

• Most common in China & Hong Kong

• Clonorchiasis

• Ascariasis

• Malaria Hemolysis

• E coli & Klebsiella

• Toxic Condition

• Emergency surgery

Sclerosing Cholangitis

• Involve Extra & Intrahepatic Biliary tree

• Association with Ulcerative colitis&Crohn

• HIV infection has been noted

• Most common in middle age men

• By Pass operation for Palliation

• Liver Transplantation for Cure

Fever & Abdominal Mass?

• The origin of Pathology is in the :

• GallBladder • Or

• Liver

Fever & Abdominal Mass?

– Possible Diagnosis Are :

• Empyema of GB

• Hydrops of GB

• Pyogenic Liver Abscess

• Liver infected Cysts

Biliary Enteric Fistula &

Gallstone Ileus

• Between GB & Duodenum 85%• Between GB & Colon 15 %• Can cause Mechanical Obstruction• Most often in Terminal Ilum• Past history of Cholelithiasis is present

Mirizzi,s Syndrome?

• A fistula between Hartmann's Pouch & CBD

• A Stone in the Ampulla of the GB can erode the CBD and can destroyed CBD Partially or

Completely

YOU!!!!!!!!

• Try to BEA Sophisticated Person