DISORDERS OF THE BILE DUCTS (CHOLEDUCHUS)

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Transcript of DISORDERS OF THE BILE DUCTS (CHOLEDUCHUS)

  • DISORDERS OF THE BILE DUCTS (CHOLEDOCHUS)

    CHOLEDOCHOLITHIASISCHOLANGITISTREATMENT OF COMMON DUCT STONES

    STRICTURES AND BENING OBSTRUCTIVE DISORDERS OF THE BILE DUCTSTUMORS OF THE BILIARY TRACTUNCOMMON CAUSES OF BILE DUCT OBSTRUCTION

    Congenital Choledochal Cysts, Carolis Disease,Hemobilia, Pancreatitis, Ampullary Stenosis, Recurrent Pyogenic Cholangitis (Oriental Cholangiohepatitis),Sclerosing Cholangitis

  • CHOLEDOCHOLITHIASIS 1Biliary painJaundiceEpisodic cholangitisGallstones in gallbladder or previous cholecystectomy

    General Considerations15 % of patients with stone in the gallbladder

    are found to harbor calculi within the bile ducts5 % gallbladder is empty. (Otoctone stones)50 % patients with CBD stones remain asymptomatic

    Dilatation of CBD less marked

  • CHOLEDOCHOLITHIASIS 2

    Clinical FindingsA) Symptoms

    AsymtomaticBiliary colicCholangitisPruritus

    B) SignsIcter, tenderness, fever, chills, toxic

  • CHOLANGITIS (Bacterial Cholangitis)Acute cholangitis is an entity characterized by fever, chills, upper abdominal pain and jaundiceSome degree of biliary ductal obstruction andincreased intraductal pressuresThe important principle is that any case of cholangitis can progress to shock and can be fatal ifneglected

    Charcot triad= Acute cholangitisAbdominal pain, jaundice, fever

    Reynolds pentad= Toxic cholangitis+ Confusion and hypotension

  • CAUSES OF ACUTE CHOLANGITIS 1

    GallstonesBile duct stricture

    Benign causes (bile duct injury, anastomotic stenosis)Oriental cholangiopathyCongenital anomalies (Choledochal cysts Carolis diseaseBile duct atresia)Malignant causes

    CholangiocarcinomaPancreatic causesPeriampullary and duodenal carcinomaExtrinsic compression of the bile duct

    Parasitic infectionsClonorchis sinensisAscaris lumbricoides

  • CAUSES OF ACUTE CHOLANGITIS 2

    HemobiliaIatrogenic

    PTC or retrograde cholangiography (ERC)Indwelling biliary catheter or endoprosthesisBile duct ischemia

  • ORGANIMS ISOLATED FROM THE BILE IN CHOLANGITIS

    Gram-negative bacteriaKlebsiella species 54 %Esherichia coli 39 %Enterobacter species 34 Psedomonas species 24 Citrobacter species 21

    Gram-positive bacteriaEnterococcus 34Streptococcal species 38

    AnaerobesBacteriodes species 15

  • CHOLEDOCHOLITHIASIS 3

    Labaratory Findings:Leukocytosis 15.000/ LBilirubin (2-4) < 10 mg/dLAlkaline phosphatase SGOT (AST) and SGPT (ALT)

    DiagnosisUS (Dilatation of the CBD-MR Cholangiogram)ERCP

  • CHOLEDOCHOLITHIASIS 4

    Complications:Multipl intrahepatic abscesses

    TreatmentCholangitis should be treated with systemic antibiotics

    SeftazidimTazlocilline

    ERCP (sphincterotomy and stone extraction or temporarystenting or NBD and reintervention)Laparotomy

    Cholecystectomy + CholedochotomyT tube or choledochoducdenostomy or transduodenalsphincteroplasty

  • BENING BILIARY STRICTURES

  • BILE DUCT CANCER 1

    1 per 100.000 Frequency95 % are epithelial adenocarcinomas(chalangiocarcinomas) predominating in theextrahepatic biliary tree.Slow-growing tumorsSpread locally and by way of lymphaticsKlatskins tumor (hilar cholangiocarcinoma)

  • BILE DUCT CANCER 2

    DiagnosisPainless jaundiceCourvoisiers sign (distal tumor)Bilurubin > 10 mg/dLAlkaline phosphatase , K glutamyltranferaseCA 19-9 US, spiral CT, MR CholangiograpyPTCERC end stenting

  • DISORDERS OF THE BILE DUCTS (CHOLEDOCHUS)CHOLEDOCHOLITHIASIS 1CHOLEDOCHOLITHIASIS 2CHOLANGITIS (Bacterial Cholangitis)CAUSES OF ACUTE CHOLANGITIS 1CAUSES OF ACUTE CHOLANGITIS 2ORGANIMS ISOLATED FROM THE BILE IN CHOLANGITISCHOLEDOCHOLITHIASIS 3CHOLEDOCHOLITHIASIS 4BENING BILIARY STRICTURESBILE DUCT CANCER 1BILE DUCT CANCER 2