DISEASE OF BILIARY PASSAGES ,GALL STONES -...

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1 DISEASE OF BILIARY PASSAGES wit emphasis on GALL STONES ( By Dr.S.Uma Devi) Diseases of biliary passage include Infection Inflammation Stones Obstruction of biliary passages Commonest : disease obstruction and resultant obstructive jaundice Causes of biliary obstruction: Stricture Stones Cholangitis Pyelophlebitis Pancreatitis Abcess in porta hepatis Learning points Intraductal adenocarcinoma common ,but may escape detection 2.Primary sclerosing cholangitis- -gives beaded appearance to the duct Association-retroperitoneal or mediastinal fibrosis Anatomy of gall bladder Pear shaped sac resting beneath rt side of liver Main function-collect and concentrate bile Bile –produced in liver Released after eating Helps in digestion Conditions slowing or obstructing bile flow cause gall bladder disease Bilirubin is waste product of breakdown of RBCs

Transcript of DISEASE OF BILIARY PASSAGES ,GALL STONES -...

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DISEASE OF BILIARY PASSAGES wit emphasis on

GALL STONES

( By Dr.S.Uma Devi)

Diseases of biliary passage include

• Infection

• Inflammation

• Stones

• Obstruction of biliary passages

Commonest : disease

obstruction and resultant obstructive jaundice

Causes of biliary obstruction:

Stricture

Stones

Cholangitis

Pyelophlebitis

Pancreatitis

Abcess in porta hepatis

Learning points

Intraductal adenocarcinoma common ,but may escape detection

2.Primary sclerosing cholangitis-

-gives beaded appearance to the duct

Association-retroperitoneal or mediastinal fibrosis

Anatomy of gall bladder

Pear shaped sac resting beneath rt side of liver

Main function-collect and concentrate bile

Bile –produced in liver

Released after eating

Helps in digestion

Conditions slowing or obstructing bile flow cause gall bladder disease

Bilirubin is waste product of breakdown of RBCs

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Common disorder of gall bladder

• Cholestasis,

• polyp.

• cancer

• gall stone (stones in gall bladder)i.e.cholelithiasis,

• cholecystitis,

• Choledocholithiasis, (stones in common bile duct)

• gall stone ileus,

• primary sclerosing cholangitis

INTRODUCTION

Very common disease

Site of formation of gall stones

1.Gall bladder

2.Cystic duct

3.,Common bile duct

4. Hepatic bile duct

Gall stones consists of

Pure cholesterol or

Bile pigments

Mixed(common)

Also contain

Calcium corbonate or phosphate

Number

Usually multiple and faceted

There may be single stones

Nucleus for the formation of gall stones

Excess carbohydrates as in sweets

Common disorder of gall bladder

gall stone (stones in gall bladder)i.e.cholelithiasis,

s in common bile duct)

primary sclerosing cholangitis

GALL STONES

Nucleus for the formation of gall stones

in sweets

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Infection like typhoid

In the presence of cholecystitis cholesterol may get precipitated.

Lithogenic bile precipitates cholesterol

Size of stone

Varaiable

Size of sand grain to size of golf ball

Depends on duration of formation

Biliary sludge

When stones are very small microscopic they form sludge

Common in pregnancy

Conditions predisposing to formation of gall stones

1. excess cholesterol in bile

2.pigment stones form when there is excess bilirubin-Liver disease,hemolytic anemias

3.Poor muscle tone of gall bladder preventing complete emptying

CAUSES

Definite cause unknown

Possible causes

• Changes in bile concentration

Increased cholesterol

Decreased phospholipids or bile acids

• Inadequate emptying of gall bladder

• Infections

• Hemolytic disorder

CLINICAL FEATURES

Incidence

Commoner in women

Age above 40

Gall stones are uncommon in children

Risk factors

Excess alcohol consumption

Obesity

Diabetes

Female gender

Ethnic factor(ispianics,native Americans,Caucasions

Note :.Level of blood cholesterol has no relation to level of

cholesterol in bile

But diet rich in cholesterol may increase the risk of gall stones

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Genetic factor

Cirrhosis

Drugs-contraceptive pills ,cholesterol lowering drugs

Others

Long term parenteral nutrition

Certain surgeries for peptic ulcer

Rapid lose of weight or skipping meals

Inflammatory bowel disease like Crohns

Symptoms

May be asymptamatic. (small stones)

2. Biliary Colic and pain-

occurswhen stones migrate and get impacted in cystic duct during gall bladder contraction thus

increasing gall bladder tension

Site :Pain felt in epigastrium,rt hypochondrium below rt shoulder

Posteriorly in the back below right scapula

Aggrevating factors-

Pain worsens on deep inspiration

Follows fatty meals

Often nocturnal-Why?

On recumbancy,gall bladder lies horizontal which promotes stone migration and impaction.

Episodes of pain are sporadic,unpredictable

Once in few days,months or years after.

Duration -30 min to 6 hrs

Persistence of pain more than 6hrs indicates other causes or complications

Associated symptoms

vomiting at termination of the attack,but not always

Sweating

No fever usually

Pain usually recurrent

.Jaundice sometimes

Other symptoms

Abdominal fullness and gas

Relieved by

Narcotic analgesics,NSAID,Nitrates

Nature of pain

Sever/dull/constant/intermittent

CHARCOATS triad comprises of

• Intermittent jaundice,

• Intermittent Pain and

• Intermittent Fever with rigors

Triad is sign of ascending cholangitis

Cholecystitis predisposes to gall stones and

Gall stones in turn precipitates cholecystitis

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Acalculous disease with gall bladder dysmotility

Diagnosed by ROME II criteria

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SIGNS ON PHYSICAL EXAMINATION

On general exam

Obesity ,common in female gender,middle age

Patient may be pale,rolling,sweating

Fever in conditions with infection of biliary passages.

Jaundice –in CBD obstruction

Stigmata of other associated diseases may be found Jaundice,stigmata of ciirhosis of liver

Examination of Abdomen

During colic –tenderness over gall bladder esp.in cholecystitis

Murphy’s sign

While the patient inhales and examiner maintains steady pressure below rt costal margin

Tenderness is elicitable.

Localised rebound tenderness ,guarding and rigidity in pericholecystic inflammation

In acute gall stone pancreatitis,epigastric tenderness Cullens sign:

In severe gall stone pancreatitis, retroperitoneal hemorrhage causes ecchymoses of flanks

Grey turners sign:

Peri umbilical ecchymoses

Pigment stones

when excess bilirubin is produced

in hepatic cirrhosis

biliary tract infections

Hemolytic diseases

Are dark ,/black

Cholesterol stones are yellow

Brown stones

Secondary to bile stasis and bacterial infections

Site of stones

Stones may block

Common bile duct or

cystic duct or

ampulla of Vates (common bile duct and pancreatic duct join

Site of obstruction and diagnosis

Courvoisier’s law

In common bile duct obstruction “with stones” gall bladder as a rule is not palpable

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Gall bladder in this is shriveled, fibrotic and non distensible.

When there is malignant obstruction (e.g.carcinoma of head of pancreas) gall bladder is

distensible and hence palpable.

COMPLICATION

• Acute cholecystitis

• Chronic cholecystitis

• Cholangitis

• Choledocolithiasis(stones in bile duct)

• Pancreatitis

• .Fistula from inflamed gall bladder to duodenum

Stone passes through rectum

Sometimes stone gets impacted at the ileocecal junction and cause paralytic ileus

• Chronic gall stone disease leads to fibrosis and loss of function of gall bladder

• . Gall stones may predispose to carcinoma of gall bladder

Genesis of complications

Gall stones within gall bladder cause no problem:

But If many or large cause pain after fatty meal

Problems arise when stones move out of gall bladder

In blockage of CBD,Cystic duct or pancreatic duct,;

Bile or digestive enzymes get trapped in the duct ,cause inflammation,severe infection

and damage

This can be life threatening

INVESTIGATION

IMAGING STUDIES ROUTINE AND NEW

1.Plain x ray abdomen

2. Gall stones may be Radio opaque or radiolucent

3.Abdominal ultra sonography - best method

Gall stones show as echogenic foci in gall bladder

But less effective in showing stones of CBD

CBD passé behind duodenum and is also hidden by intestinal gas

4.Abdominal CT Shows distal common bile duct stones

5.ERCP-Endoscopic retrogradecholangio pancreatography

6.Endoscopic Ultra sound (to detect stones in distal CBD )

6.Gall bladder radionuclide scan

7.Oral cholycystography

8..Abdominal MRI

9.Newly emerged imaging study:

MRCP- magnetic resonance cholangio pancreatography

Identifies gall stones any where in biliary tract including common bile duct

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Other investigations

Urine test for bilirubin

10.Fecal fat

11.CBC to detect infection

12.Serum amylase

13. Liver function tests

LFT normal in uncomplicated cases

Abnormal LFT indicates complications

14.lipases

DIFFERENTIAL DIAGNOSIS

All the diferential cause for angina pain has to be considered

DD. for bloating and gas:IBS,constipation

TREATMENT

• Asymptomatic gall stones(silent stones)s do not warrant removal

(Though Certain exception are there for this general rule)

• If pain persists for more than 3 hrs-medical help needed

Pain of more than 6 hrs requires hospitalization -

• Injections of antispasmodic

Usually pain is controlled in one or two days

MEDICAL TREATMENT

Does not give permanent cure

Dissolving the stones by drugs made from bile acids

May take months or years for the stone to dissolve

Cholesterol stones respond better

Stones may recur

Tried in inoperable cases

Chenodeoxy cholic acid

Dose0.75gms to 4.5 gms daily oral.

Ursodiol- Urso deoxy cholic acid

For acute pain

IV fluids

Antispasmodics

Antibiotics

Sips of water but no food during acute pain

Other times -low fat diet

NON SURGICAL REMOVAL

Extra corporeal shock wave lithotripsy ESWL

Shock waves break the stones into tiny pieces

Effectiveness of this treatment is not established

After shock waves patient may get pain in Rt.hypochondrium

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SURGICAL TREATMENT

Indications

Recurring bouts of pain in spite of dietary changes

Procedure-removal of gall bladder-cholecystectomy

(Body can function without gall bladder)

Modes of removal of gall bladder

1.Through laproscopic surgery preferred method

Advantages

Minimally invasive

Shortens post op stay and discomfort

Reduces time of work

2.Open surgery

Indicated If laproscopic removal not feasible

( as in infection of biliary tract,scars from previous surgeries)

3.ERCP when?

a. Just before or during surgery to locate stones any where else in biliary system

-these can be removed at same time

b. After surgery if gall stones found later in biliary tract

c. Patients unfit for surgery

Prior to surgery

if there is infection of gall bladder or pancreas it has to be treated with antibiotics

Complications of open gall bladder surgery

Injury to common bile duct

Excessive bleeding

Infection of surgical wound

Injuries to liver,intestine major abdominal vessels

DVT related to long recovery period

Risks of general anesthesia

Complications of laproscopic cholecystectomy Associated spillage of gall stones in 5-40% cases

More so in men,elderly,obese,in acutely inflamed gall bladder, in presence of adhesions

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FOLLOW UP DIET

Low fat,low cholesterol diet

(Prevent symptoms but not stone formation)

There is no sure way to prevent gall stones only risks can be reduced.

PATHOPHYSIOLOGY OF GALL STONE FORMATION

Contined

Note:There is no known means to

www.yasmingallbladderdisease.com

(Prevent symptoms but not stone formation)

There is no sure way to prevent gall stones only risks can be reduced.

PATHOPHYSIOLOGY OF GALL STONE FORMATION

bmj

There is no known means to prevent gall

stones

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NATURAL HISTORY OF GALL STONES

continued

Stones in cystic duct

Obstruction to cystic

duct type I

NATURAL HISTORY OF GALL STONES

Gall stones

Silent-

Silent till death in 85%

Stones and

obstruction in

common bile duct

Obstruction to cystic Acute

cholecystitis

Gangrenous

cholecystitis

PerforationLocal peritonitis

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Stones and

obstruction in

common bile duct

Gangrenous

cholecystitis

Perforation

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Continued

Summary points

1. Gall stones are the commonest GI cause of hospital admission in

Obstruction to cystic duct type II

causing Chronic cholecytitis

Can be silent or cause carcinoma or

cause internal biliaryfistula

Stones in common bile duct

Gall stones are the commonest GI cause of hospital admission in western countries

Obstruction to cystic duct type II

causing Chronic cholecytitis

Can be silent or cause carcinoma or

cause internal biliaryfistula

From fistula-Gall stones

passout in feces or

cause gall stone ileus

Can be silent or cause CBD obstruction

CBD obstruction can cause

Cholangitis (leading to liver abcess ) or obstructive jaundice

or stricture

Pancreatitis in case of stone impaction in

ampulla of vater

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western countries

CBD obstruction can cause

Cholangitis (leading to liver abcess ) or obstructive jaundice

or stricture

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2. Upper abdominal pain is the commonest presenting symptom and USG abdomen is the

most cost effective diagnostic tool

3. The principles of treatment and patient selection have not been changed by laproscopic

surgery

4. Asymptomatic gall stones usually do not warrant intervention

5. Symptomatic gall stones are best treated by removal of the stones and by elimination of

the risk of recurrence.

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