DISEASE OF BILIARY PASSAGES ,GALL STONES -...
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
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
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
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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