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