GALL BLADDER, BILIARY GALL BLADDER, BILIARY SYSTEM, LIVER CIRRHOSISSYSTEM, LIVER CIRRHOSIS

الدكتورالدكتور

عبدالله عبدالله محمدصالح محمدصالح

العامة الجراحة العامة استشاري الجراحة استشاري

الجراحة فرع الجراحة رئيس فرع رئيس

نينوى طب نينوى كلية طب كلية

GALL BLADDER ANDGALL BLADDER AND BILIARY TRACTBILIARY TRACTThe gall bladder is pear shaped viscous organ located at visceral The gall bladder is pear shaped viscous organ located at visceral space of the liver at the plane dividing it to the two lobesspace of the liver at the plane dividing it to the two lobesThe gall bladder divided to theThe gall bladder divided to the;;1-fundus1-fundus2-body2-body3-infudibulum when it is dilated called Hartmann` pouch3-infudibulum when it is dilated called Hartmann` pouch4-neck4-neck

The neck is connected to the cystic duct which The neck is connected to the cystic duct which conectedconected to the to the common hepatic ductcommon hepatic ductExtra hepatic biliary ductExtra hepatic biliary ductThe right and left hepatid duct united to form hepatic duct at porta The right and left hepatid duct united to form hepatic duct at porta hepatis which join cystic duct to form common bile duct which join hepatis which join cystic duct to form common bile duct which join the pancreatic duct at the pancreatic duct at ampulla of Vatterampulla of Vatter at middle part of the at middle part of the second part of duodenum (second part of duodenum (duodenal papilladuodenal papilla) and they surrounded ) and they surrounded by by sphinctor of Oddisphinctor of Oddi

The common bile duct length is 5-10 cm. and The common bile duct length is 5-10 cm. and is diameter is 8mm.is diameter is 8mm.

1-superduodenl1-superduodenl

2-retroduodenal2-retroduodenal

3-intrapancreatic3-intrapancreatic

4-intraduodenal4-intraduodenal

Blood supplyBlood supply ; ;

1-Cystic artery is branch of right hepatic artery passes posterior to 1-Cystic artery is branch of right hepatic artery passes posterior to the hepatic duct the hepatic duct

2- direct branches from liver.2- direct branches from liver.

variation of cystic artery the most common arevariation of cystic artery the most common are

1-arises from gasteroduodenal artery1-arises from gasteroduodenal artery

2- passes anterior to the hepatic duct2- passes anterior to the hepatic duct

Vein;Vein;Directly to the liver and cystic vein to the right portal veinDirectly to the liver and cystic vein to the right portal vein

Lymphatic drainageLymphatic drainageTo the hilar lymph node then to the coelic lymph node.To the hilar lymph node then to the coelic lymph node.

Nerve supplyNerve supply parasympathetic from hepatic branch of vagus ,it cause contraction of parasympathetic from hepatic branch of vagus ,it cause contraction of

gall bladdergall bladder

Sympathetic from coelic plexus Sympathetic from coelic plexus

Gall bladder functionGall bladder function

1-bile reservoir1-bile reservoir 2- concentration of bile up to 10 fold due to absorption of NACL and 2- concentration of bile up to 10 fold due to absorption of NACL and

water.water.

3- mucous secretion3- mucous secretion

Content of bileContent of bile1-water and electrolyte1-water and electrolyte

2-bile salt cholic, deoxycholic chenodeoxycholic 2-bile salt cholic, deoxycholic chenodeoxycholic

3- cholesterol and phospholipid3- cholesterol and phospholipid

4-bile pigment bilirubin diglucuronide4-bile pigment bilirubin diglucuronide

Table 1 Composition of adult human hepatic bileTable 1 Composition of adult human hepatic bile    g/l%g/l%

Water  98.0Water  98.0

Bile salts 6.5–140.7Bile salts 6.5–140.7

Inorganic salts   0.7 Inorganic salts   0.7

Bile pigments 0.12–1.35  0.2Bile pigments 0.12–1.35  0.2

Fatty acids 1.6–4.1  0.15Fatty acids 1.6–4.1  0.15

Lecithin    0.1Lecithin    0.1

Cholesterol 0.8–1.8  0.06Cholesterol 0.8–1.8  0.06

Between 250–1000 ml of hepatic bile is secreted in 24 hBetween 250–1000 ml of hepatic bile is secreted in 24 h

Gall bladder and biliary tract investigationGall bladder and biliary tract investigation

1- 1- plain x-rayplain x-ray detect detect a-gall stone in 10%a-gall stone in 10% b-porcelain g.b.b-porcelain g.b. c- air in g. bc- air in g. b..

2-abdominal u.s2-abdominal u.s. is 1. is 1stst choice ,it detect choice ,it detect a- gall stone 98%a- gall stone 98% b- CBD stoneb- CBD stone c- g.b. size and wallc- g.b. size and wall d- dilatation of biliary tractd- dilatation of biliary tract e- masse- mass3- 3- oral cholecystographyoral cholecystography it was 1 it was 1stst choice choice

4-i.v. cholangiography4-i.v. cholangiography 5- ERCP 5- ERCP 6- MRCP6- MRCP

5-ERCP 5-ERCP

endoscopic reterogradecholangiopancreaticographyendoscopic reterogradecholangiopancreaticography 1-diagnostic for biliary tract disease (stone,tumour,dilatation,pancreatic 1-diagnostic for biliary tract disease (stone,tumour,dilatation,pancreatic

tumour,biobcy)tumour,biobcy)

2-therapeutic 2-therapeutic

a-sphinctrectomy. Removal of CBD stonea-sphinctrectomy. Removal of CBD stone

b-insertion of stentb-insertion of stent

complication of ERCPcomplication of ERCP

pancreatitispancreatitis

cholangitischolangitis

septicaemiasepticaemia

6-PTC percutaneus transhepatic cholangiography (chiba 6-PTC percutaneus transhepatic cholangiography (chiba needleneedle))

-diagnostic for biliary obstruction-diagnostic for biliary obstruction

-therapeutic for biliary drainage-therapeutic for biliary drainage

-prothrombin time +vit.K +antiboitic-prothrombin time +vit.K +antiboitic

7-C.T.scan7-C.T.scan

8- MRCP8- MRCP

magnetic resonance cholangiopancereatographymagnetic resonance cholangiopancereatography

it is standard technique for visualization of the it is standard technique for visualization of the biliary tractbiliary tract

9-radio-isotope scanning 9-radio-isotope scanning (HIDA(HIDA) 99TC) 99TC

for acute cholecystitisfor acute cholecystitis

congenital biliary atersiacongenital biliary atersia

biliary-enteric anastomosisbiliary-enteric anastomosis

10-per-operative cholangiography10-per-operative cholangiography

to detect missed bile duct stoneto detect missed bile duct stone

11-operative biliary endoscopy 11-operative biliary endoscopy (choledechoscopy(choledechoscopy))

Congenital abnormality of gall bladderCongenital abnormality of gall bladder

1-absence of gall bladder rare1-absence of gall bladder rare

2-phrygian g. b. Kinking of fundus 2-6%2-phrygian g. b. Kinking of fundus 2-6%

3-double g.b. 1;40003-double g.b. 1;4000

4-floating g.b. Has mesentery liable to 4-floating g.b. Has mesentery liable to torsiontorsion

5- absence of cystic duct5- absence of cystic duct

6- low insertion of cystic duct6- low insertion of cystic duct

7-accessory cholecystohepatic duct7-accessory cholecystohepatic duct

8- cystic duct might inter R. or L.hepatic duct8- cystic duct might inter R. or L.hepatic duct

Anomalies of cystic arteryAnomalies of cystic artery

1- accessory cystic artery1- accessory cystic artery

2-left hepatic artery arises from left gasteric 2-left hepatic artery arises from left gasteric arteryartery

3-right hepatic artery arises from superior 3-right hepatic artery arises from superior mesenteric arterymesenteric artery

4-right hepatic artery might be pass in front or 4-right hepatic artery might be pass in front or behind the C.B.D.behind the C.B.D.

5- cystic artery arises from gasteroduodenal 5- cystic artery arises from gasteroduodenal arteryartery

6-cystic artery passes anterior to the hepati duct6-cystic artery passes anterior to the hepati duct

Anomalies of bile duct Anomalies of bile duct Biliaey atersiaBiliaey atersia

inflammation of the extra hepatic biliary tract and it is cord inflammation of the extra hepatic biliary tract and it is cord likelike

Incidence; 1/10000 – 1/14000 birthIncidence; 1/10000 – 1/14000 birth

sex male=femalesex male=female

Clinical featureClinical feature;;

1- jaundice since birth pruritus1- jaundice since birth pruritus

2-pale stool ,dark urine2-pale stool ,dark urine

3-steatorea3-steatorea

4-20% associated with other disease4-20% associated with other disease

5-liver cirrhosis 5-liver cirrhosis

DDXDDX 1- 1- αα-anti-trpsin deficiency -anti-trpsin deficiency 2- choledochal cyst2- choledochal cyst 3- neonatal hepatitis3- neonatal hepatitis 4- phsiological jaundice4- phsiological jaundice INVESTIGATIONINVESTIGATION 1-s.bilirubin1-s.bilirubin 2-radio-isotope study2-radio-isotope study 3- laparotomy 3- laparotomy TREATMENTTREATMENT1-in 10% only distal part involved (roux-en-Y anastomosis)1-in 10% only distal part involved (roux-en-Y anastomosis)2-KASIA operation porto-enterostomy2-KASIA operation porto-enterostomy3-if 1 and 2 fail liver transplantation is indicated3-if 1 and 2 fail liver transplantation is indicated

Choledochale cystCholedochale cyst

Dilatation of the common bile duct either fusiform or Dilatation of the common bile duct either fusiform or diverticulum or interahepaticdiverticulum or interahepatic

the sex incidence is the samethe sex incidence is the sameClinical feature;Clinical feature; -age before 10 year-age before 10 year - jaundice- jaundice - fever- fever -right hypochondrial pain -right hypochondrial pain -cholangitis-cholangitisInvestigationInvestigation U.S. MRIU.S. MRITreatmentTreatment ; it is premalignamt ; it is premalignamt 1- Excision of the cyst and Roux-en-Y -anastomosis 1- Excision of the cyst and Roux-en-Y -anastomosis 2- Choledochjejunostomy other option2- Choledochjejunostomy other option

CAROLI`DISEASCAROLI`DISEASEE

Congenital dilatation of intera hepatic ductCongenital dilatation of intera hepatic duct

it lead to bile stasis, cholangitis, stone formationit lead to bile stasis, cholangitis, stone formation

Associated disease Associated disease

congenital hepatic fibrosiscongenital hepatic fibrosis

polycystic disease of liverpolycystic disease of liver

cholangio-carcinomacholangio-carcinoma

TrearmentTrearment;;

antibioticantibiotic

removal of stoneremoval of stone

lobectomylobectomy

Trauma;Trauma; gall bladder gall bladder penterating or crush injurypenterating or crush injury Clinical feature Clinical feature Acute abdomenAcute abdomenTreatment;Treatment; cholecystectomycholecystectomy If C.B.D. choledochojejunostomyIf C.B.D. choledochojejunostomy

Tortion of g.b.Tortion of g.b. long mesenterylong mesentery it cause mucocele,acute abdomenit cause mucocele,acute abdomenTreatment;Treatment; cholecystectomycholecystectomy

Gall stoneGall stoneIncidence Incidence

10-15% of adult population in the USA has gall 10-15% of adult population in the USA has gall stonestone

600000 cholecystectomy/year in USA600000 cholecystectomy/year in USA

85%of gall stone is asymptomatic85%of gall stone is asymptomatic

1-4% per year of asymptomatic become 1-4% per year of asymptomatic become symptomaticsymptomatic

Type of gall stoneType of gall stone 1-1-cholesterol cholesterol -pure cholesterol is not common it is 10%,-pure cholesterol is not common it is 10%, -it is large and single >2.5 cm.-it is large and single >2.5 cm. - radiolucent. - radiolucent. 2-2-mixedmixed - cholesterol is mixed with Ca bilirubinate, Ca phosphate - cholesterol is mixed with Ca bilirubinate, Ca phosphate -most common-most common -multiple-multiple -0.5-2.5cm. Diameter-0.5-2.5cm. Diameter -10% radiopaqe-10% radiopaqe 3- 3- pigmented stonepigmented stone it contain less than 30%cholesterol it contain less than 30%cholesterol a-blacka-black - insoluble bilirubine with Ca phosphate, Ca bicarbonate- insoluble bilirubine with Ca phosphate, Ca bicarbonate -20-30% -20-30% -accompany haemolysis-accompany haemolysis b-brown b-brown -it related to the bile stasis and infection-it related to the bile stasis and infection - is rare in g.b. it is formed in bile duct- is rare in g.b. it is formed in bile duct -Ca bilirubinate.Ca palmmitate and Ca stearate -Ca bilirubinate.Ca palmmitate and Ca stearate

Aetiology of gall stoneAetiology of gall stoneA-cholesterol and mixedA-cholesterol and mixed1-disterbed bile salt, cholesterol, phospholipid.1-disterbed bile salt, cholesterol, phospholipid.

normally bile salt/phospholipid is 25/1 .this in one hand and cholesterol normally bile salt/phospholipid is 25/1 .this in one hand and cholesterol concentration in other hand affect the cholesterol solubility. concentration in other hand affect the cholesterol solubility.

when bile supersaturated with cholesterol ,or bile salt decrease lead when bile supersaturated with cholesterol ,or bile salt decrease lead cholesterol crystal to nucleate and formation of stonecholesterol crystal to nucleate and formation of stone

this occur in malabsorption of bile salt ,liver disease, estrogen, this occur in malabsorption of bile salt ,liver disease, estrogen, obesity, high fatty dietobesity, high fatty diet

2-stasis of bile ,female hormone, vagatomy, D.M.2-stasis of bile ,female hormone, vagatomy, D.M.

B-pigmented stoneB-pigmented stone 1- black1- black -haemolytic anaemia -haemolytic anaemia

-liver cirrhosis-liver cirrhosis

2-brown2-brown infection E.C. produce B-glucuronidase enzyme which infection E.C. produce B-glucuronidase enzyme which change soluble bilirubine to insoluble bilirubin change soluble bilirubine to insoluble bilirubin

Clinical feature of gall stoneClinical feature of gall stone 85% is asymptomatic85% is asymptomatic

↓ ↓ 1-4%symptommatic every year1-4%symptommatic every year

Ch. Cholcystitis (biliary colic)Ch. Cholcystitis (biliary colic)

↓ ↓3-5% develop complication3-5% develop complication

1-acute cholecytitis→empyema→gangrene→perforation1-acute cholecytitis→empyema→gangrene→perforation

2-mucocele2-mucocele

3- Ca. of gall bladder3- Ca. of gall bladder

4-choledecholithiasis→cholangitis→liver abscess →liver 4-choledecholithiasis→cholangitis→liver abscess →liver cirrhosiscirrhosis

5-gall stone pancreatitis5-gall stone pancreatitis

6-cholcystodudenal fistula6-cholcystodudenal fistula

7-gall stone ileus (intestinal obstruction) stone 7-gall stone ileus (intestinal obstruction) stone

size >2.5cm.size >2.5cm.

Chronic cholcytitisChronic cholcytitis

--2/3 of gall bladder disease is presented as ch. Cholecytitis2/3 of gall bladder disease is presented as ch. Cholecytitis

-recrrent biliary cholic due to obstruction of cystic duct by -recrrent biliary cholic due to obstruction of cystic duct by gall stonegall stone

-pain radiate to back of chest and R. shoulder-pain radiate to back of chest and R. shoulder

-dyspepsia-dyspepsia

-murphy`sign +or –-murphy`sign +or –

-Pathology varies from minor inflamation in the mucosa to -Pathology varies from minor inflamation in the mucosa to the non- functioning gall bladder with fibrosis and the non- functioning gall bladder with fibrosis and adherent to surrounding organadherent to surrounding organ

InvestigationInvestigation;;

1-plain x-ray1-plain x-ray

2-u.s.2-u.s.

3- oral cholecystography3- oral cholecystography

Treatment;Treatment; cholecystectomycholecystectomy

Acute calculus cholecytitisAcute calculus cholecytitis-Cystic duct obstruction by stone with consequence infection usually by -Cystic duct obstruction by stone with consequence infection usually by

E.C. other bacteria.E.C. other bacteria.- distended g.b. - distended g.b. -inflammation in the wall – patchy necrosis- gangrene, perforation.-inflammation in the wall – patchy necrosis- gangrene, perforation.Clinical featureClinical feature;; 1- 80% history of biliary colic1- 80% history of biliary colic 2-Rt hypochondrial pain, tenderness , Boas`s sign2-Rt hypochondrial pain, tenderness , Boas`s sign 3-palpable g.b.3-palpable g.b. 4-pyrexia ,tachycardia.4-pyrexia ,tachycardia. 5-jaundice Mrrizi syndrome5-jaundice Mrrizi syndrome 6-W.B.C. incerease 6-W.B.C. incerease DDX- DDX- 1-perforated DU1-perforated DU 2- acute pancreatitis2- acute pancreatitis 3-acute appendicitis3-acute appendicitis 4-pyelonephritis4-pyelonephritis

DXDX; 1-CLINICAL FEATURE; 1-CLINICAL FEATURE

2- US2- US

3-leucosytosis3-leucosytosis

4-liver function test4-liver function test

Fate of acute cholecystitisFate of acute cholecystitis

1-resolution 1-resolution

2-complication2-complication

3-empyaema3-empyaema

4-chronic cholcystitis4-chronic cholcystitis

Treatment;Treatment; Two options Two options 11--Conservative treatmentConservative treatment;;

concervative treatment followed by cholecystectomy after 6-8 weeks concervative treatment followed by cholecystectomy after 6-8 weeks due to due to

- difficulty of surgery - difficulty of surgery - 90% respond to treatment- 90% respond to treatment 1- nil by mouth , i.v. fluid , N/G.?1- nil by mouth , i.v. fluid , N/G.? 2-antibiotic 32-antibiotic 3rdrd generation of cephalosporin, or 2 generation of cephalosporin, or 2ndnd with with

metronidazolemetronidazole 3-analgesic3-analgesic 4- follow up of patient if not respond surgery is indicated4- follow up of patient if not respond surgery is indicated a- cholecystectomya- cholecystectomy b- cholcystostomyb- cholcystostomy c- percutaneous cholecystomy c- percutaneous cholecystomy

2- Urgent cholecystectomy2- Urgent cholecystectomy with in 2-3 days up to one weak, idea is with in 2-3 days up to one weak, idea is toto

-ovoid complication of acute cholecystitis-ovoid complication of acute cholecystitis -one admission to hospital -one admission to hospital

Acute non calculus cholecytitisAcute non calculus cholecytitis..

acute inflammation of g.b. with out obstruction of cystic duct by stoneacute inflammation of g.b. with out obstruction of cystic duct by stone

It occur inIt occur in

1-burn,sever trauma1-burn,sever trauma

2-prolong PTN2-prolong PTN

3-complication of typhoid, brucellosis. 3-complication of typhoid, brucellosis.

Treatment ; urgent cholecystectomyTreatment ; urgent cholecystectomy

Mucocle;-Mucocle;-obstruction of cystic duct with out infectionobstruction of cystic duct with out infection

- absorption of bile.replaced by mucous- absorption of bile.replaced by mucous

- palpable g.b.- palpable g.b.

Treatment by cholecystectomyTreatment by cholecystectomy

EmpyemaEmpyema -complication of acute cholecystitis -complication of acute cholecystitis

-infection of mucocle-infection of mucocle

- tender ,painful gall bladder- tender ,painful gall bladder

Treatment; cholecystectomyTreatment; cholecystectomy

Cholecystectomy ; is removal of gall bladderCholecystectomy ; is removal of gall bladder

Indication;Indication; 1-ch. Cholecystitis1-ch. Cholecystitis

2-acute cholecystitis2-acute cholecystitis 3-acute non calcalus cholecystitis3-acute non calcalus cholecystitis 4-mucocele4-mucocele 5-empyaema5-empyaema 6-ca. of g.b.6-ca. of g.b. 7-stone in CBD7-stone in CBD 8-asymptomatic gall stone ? 8-asymptomatic gall stone ? -in DM,-in DM, - possibility of ca. in g. b.,- possibility of ca. in g. b.,

- in case of isolation from medical serves- in case of isolation from medical serves

Open cholecystectomyOpen cholecystectomy

LapratomyLapratomy

-Through Rt paramedian, midline, subcostal(Kocher) -Through Rt paramedian, midline, subcostal(Kocher) incisionincision

-Dissection of cystic artery , duct. CHD,CBD (Calot triangle)-Dissection of cystic artery , duct. CHD,CBD (Calot triangle)

-per operative cholangiography?-per operative cholangiography?

-ligation and incision of cystic artery and duct-ligation and incision of cystic artery and duct

-removal of g.b.-removal of g.b.

-drain?-drain?

Exploration of CBD 1-palpable stone in CBD 2-dilated CBD 3-jaundice,or history of jaundice 4-dilated cystic duct with small stone in g.b.

T-tube kept in side the CBD for 7-10 days then chlangigaphy and if no stone remove the tube

LAPRASCOPIC CHOLECYSTECTOMYLAPRASCOPIC CHOLECYSTECTOMY

-- Pneumoperitoneum by CO2 gas-- Pneumoperitoneum by CO2 gas

- 4-port at abdominal wall- 4-port at abdominal wall

- Telescope and instrument introduced through port- Telescope and instrument introduced through port

- g.b. is removed like open- g.b. is removed like open

advantageadvantage 1-less post operative pain 1-less post operative pain

2-early discharge from hospital2-early discharge from hospital

3-early return to work3-early return to work

4-bitter cosmetic4-bitter cosmetic

contraindicationcontraindication 1- ca. of g.b.1- ca. of g.b.

2- bleeding tendency2- bleeding tendency

3- C.V. and Respiratory failure3- C.V. and Respiratory failure

4- pregnancy?4- pregnancy?

Complication of cholecystectomyComplication of cholecystectomy A-general complicationA-general complication

B-specific complicationB-specific complication

1-haemorrage1-haemorrage

2-biliary leakage2-biliary leakage

3-sub-phrenic bile, or pus 3-sub-phrenic bile, or pus

4-jaundice - halothane4-jaundice - halothane

-missed stone in CBD-missed stone in CBD

-injury of CBD-injury of CBD

5-postcholecystectomy syndrome5-postcholecystectomy syndrome

Verses needle lap. cholcystectomyVerses needle lap. cholcystectomy

Lap. View Lap. View

choldochlithiasischoldochlithiasis -6-12% of patient with G.B. stone has stone in CBD, it is either -6-12% of patient with G.B. stone has stone in CBD, it is either

-secondary or primary -secondary or primary

-clinical feature-clinical feature;;

1- silent 1- silent

2- gall stone pancereatitis2- gall stone pancereatitis

3- Charcot triad ( pain+jaundice+fever,rigor)3- Charcot triad ( pain+jaundice+fever,rigor)

4- Reynold pentad (3+altered mental state+ shock)4- Reynold pentad (3+altered mental state+ shock)

5- sign of hepatocellular failure5- sign of hepatocellular failure

6- itching6- itching

7- Courvoisier`law ( dilatation of GB with jaundice is sign of 7- Courvoisier`law ( dilatation of GB with jaundice is sign of malignant obstruction)malignant obstruction)

00

InvestigationInvestigation1-liver function test1-liver function test 2-biood picture2-biood picture 3-us3-us 4-MRCP4-MRCP 5-ERCP5-ERCP

Treatment;Treatment; (remove the stone+ cholecysyectomy) (remove the stone+ cholecysyectomy) preparation of patient;preparation of patient; 1- i.v. fluid +mannitol1- i.v. fluid +mannitol 2- vit K2- vit K 3-antiboitic3-antiboiticRemoval of stone;Removal of stone; 1-ERCP papillotomy1-ERCP papillotomy +removal of stone by Dormia basket followed +removal of stone by Dormia basket followed

by cholecystectomyby cholecystectomy

2- if ERCP not available 2- if ERCP not available surgery surgery is indicatedis indicated -exploration of CBD removal of stone +T-tube-exploration of CBD removal of stone +T-tube -cholecystectomy-cholecystectomy - or choledochodudenostomy if CBD is more than 2cm.+stricture - or choledochodudenostomy if CBD is more than 2cm.+stricture

at lower end of CBD at lower end of CBD -after 10 days T-tube cholangiographys ,to detect missed stone -after 10 days T-tube cholangiographys ,to detect missed stone

then remove stonethen remove stone

Stone in CBDStone in CBD

T-tube cholangiography stone in CBDT-tube cholangiography stone in CBD

Stricture of bile ductStricture of bile duct;; 1-congenital1-congenital 2-bile injury2-bile injury 3-inflammtory3-inflammtory 4-idiopathic4-idiopathic 5-tumour5-tumour

TRAUMATIC strictureTRAUMATIC stricture 1-observed during surgery do R-x-en-Y-choledocho-jejunostomy1-observed during surgery do R-x-en-Y-choledocho-jejunostomy 2-not observed during surgery2-not observed during surgery patient develop jaundice or bile leakage or fistula or biliary peritoitispatient develop jaundice or bile leakage or fistula or biliary peritoitis Treatment;Treatment; ERCP, ERCP, stent ,stent , surgery Rx-en-y choledochojejunostomysurgery Rx-en-y choledochojejunostomy

Primary sclerosing cholangitis; jaundice, pain, pruritis,associated with inf.bowel disease.

Biliary ascariasis; - biliary colic - cholangitis and is complication

Treatment; antispasmin, antihelminthic drug, ERCP, surgery if there is complication

Ca. of g.b.Ca. of g.b. -rare, age >60 year-rare, age >60 year -associated with 1-gall stone 0.3-3% of gall stone has ca. with it.-associated with 1-gall stone 0.3-3% of gall stone has ca. with it. 2- porcelian g.b. 10- 25% of porcelian g.b. has ca.2- porcelian g.b. 10- 25% of porcelian g.b. has ca. Pathlogy; s.c.ca. or adenoca., or mixed.Pathlogy; s.c.ca. or adenoca., or mixed. metastasis ; direct to livermetastasis ; direct to liver -hilar l.node.-hilar l.node. -peritoneal cavity-peritoneal cavityClinical featureClinical feature;-1-like ch. cholecystitis;-1-like ch. cholecystitis 2-jaundice2-jaundice 3-palpable mass3-palpable massInvestigationInvestigation; us.ct-scan ,percutneous biobsy. serum CA19-9; us.ct-scan ,percutneous biobsy. serum CA19-9Treatment;Treatment; surgical resection surgical resection 1-g.b.1-g.b. 2-liver bed2-liver bed 3-hillar l.node3-hillar l.nodePrognosisPrognosis; is poor ,5% 5-year survival ; is poor ,5% 5-year survival

jaundicejaundiceIs yellow coloration of the body tissue and fluid which is due to high Is yellow coloration of the body tissue and fluid which is due to high

bilirubin in the blood,it occur when S. bilirubin exceeds 2.0-2.5mg/dlbilirubin in the blood,it occur when S. bilirubin exceeds 2.0-2.5mg/dl bilirubin metabolismbilirubin metabolism oldold RBC RBC in the RET spleen. Bone marrow in the RET spleen. Bone marrow

↓ ↓ globin + globin + hemeheme

↓ ↓ ↓ ↓ oxidation oxidation

amino acid amino acid biliverdinbiliverdin ↓ ↓ reducedreduced bilirubin bilirubin insoluble in water combined with albumin insoluble in water combined with albumin ↓ ↓ glucuronyl transferase in the liverglucuronyl transferase in the liver bilirubin diglucuronide water soluble, excreted via biliary bilirubin diglucuronide water soluble, excreted via biliary

tracttract ↓ ↓ by bacterial enzyme in the intestineby bacterial enzyme in the intestine stercobilinogen → stercolin (color of stool)stercobilinogen → stercolin (color of stool) ↓ ↓ 20% reabsorbed 20% reabsorbed ↓,↓, 90%of this is reexcreted. 90%of this is reexcreted. urobilinogen appear in urineurobilinogen appear in urine

aetiology;aetiology;

1-prehepatic haemolysis of RBC indirect bilirubin increase 1-prehepatic haemolysis of RBC indirect bilirubin increase

2- hepatic hepato cellalar disease both bilirubin increase2- hepatic hepato cellalar disease both bilirubin increase

3-post-hepatic- obstructive jaundice –surgical jaundice3-post-hepatic- obstructive jaundice –surgical jaundice

3-post-hepatic- obstructive jaundice –3-post-hepatic- obstructive jaundice –surgical jaundicesurgical jaundice

obstruction of biliary path way direct bilirubin increase later indirect obstruction of biliary path way direct bilirubin increase later indirect increase and it is due toincrease and it is due to

a- cause in the lumen eg stone, parasitea- cause in the lumen eg stone, parasite

b-in the wall of bile duct -congenital atersiab-in the wall of bile duct -congenital atersia

-inflammatory stricture-sclerosing cholangitis-inflammatory stricture-sclerosing cholangitis

-tramatic-tramatic

-malignant stricture-malignant stricture

-hydate cyst-hydate cyst

c-out side of bile duct -ca. of head of pancreasc-out side of bile duct -ca. of head of pancreas

-CBD tumor-CBD tumor

-metastasis lymph node in porta hepatis-metastasis lymph node in porta hepatis

the most common cause is 1- CBD stone 2- CA of head of pancreas 3- CBD stricture

cclinical features of obstructive jaundicelinical features of obstructive jaundice

1- jaundice1- jaundice

2- dark color urine2- dark color urine

3- clay ,pale color stool3- clay ,pale color stool

4-pruritis4-pruritis

5 -clinical feature of causative factor5 -clinical feature of causative factor

investigation;investigation; 1-1-blood examinationblood examination

2-liver function test -s . bilirubin2-liver function test -s . bilirubin -alkaline phosphatase-alkaline phosphatase -s.enzyme-s.enzyme - prothrombine time- prothrombine time - s. albumin- s. albumin - stercobilinogen- stercobilinogen 3- imaging –US, CT3- imaging –US, CT -MRCP-MRCP -ERCP-ERCP -PTC-PTC 4- Live biopsy4- Live biopsy

Treatment; is surgical Treatment; is surgical

pre operative preprationpre operative prepration

- good hydration normal saline- good hydration normal saline

- i.m. vitamine K- i.m. vitamine K

- anti biotic- anti biotic

surgical operation according to the causesurgical operation according to the cause