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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

  • 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

    2

  • 3

    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

  • 4

    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

  • 5

    -----------------

    Acalculous disease with gall bladder dysmotility

    Diagnosed by ROME II criteria

    -------------

    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

    Murphys 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

    Courvoisiers law

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

  • 6

    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 pass 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

  • 7

    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 c