L10: Biliary Disorders Flashcards
Anatomy of Gall Bladder
Capacity of Gall Bladder
30-50 ml
Types of Gall Bladder Stones
- Cholesterol stones
- Pigment stones (20%)
Cholesterol Stones
Pigment Gall Bladder Stones
Characters of Biliary Pain in Gall Bladder Stones
Gall Bladder Stones
Physical Examination
- Tenderness to deep palpation (No rebound).
- Murphy sign (inspiratory arrest during deep palpation of the RUQ).
Investigations for Gall Bladder Stones
ECG in Gall Bladder Stones
to exclude myocardial ischemia (Pain may be due to myocardial ischemia).
Lab tests in Gall Bladder Stones
US in Gall Bladder Stones
Radionuclide scanning (HIDA) in Gall Bladder Stones
CT Scan in Gall Bladder Stones
- Less sensitive than US to detect gallstones.
- Only 20% radiopaque.
- Most useful to exclude other causes of upper abdominal pain such as aortic aneurysm, perihepatic abscess, or pancreatic pseudocyst.
- Detects rare complications such as air in GB wall in emphysematous cholecystitis or air-filled GB in biliary-enteric fistula.
Plain Radiograph in Gall Bladder Stones
Most useful for diagnosis of intestinal obstruction.
DDx of Gall Bladder Stones
Causes of upper abdominal pain
- e.g. MI, Acute cholecystitis, cholangitis, Acute pancreatitis, Intestinal obstruction,
PUD, RLL pneumonia,
Managment of Gall Bladder Stones
Admission Criteria of Gall Bladder Stones
Discharge Crireria of Gall Bladder Stones
Complications of Gall Bladder Stones
Etiology of Cholecystitis
- Acute calculous cholecystitis
- Acalculous cholecystitis (10%)
Managment of Cholecystitis
Admission Criteria
- All cases of cholecystitis should be admitted for
parenteral antibiotics, analgesia, fluid replacement,
and cholecystectomy in 24 - 72 hr. - Unstable patients (gallbladder perforation or
sepsis) require immediate surgery
Def of Cholangitis
Partial or complete CBD obstruction:
- Gallstones, tumor, cyst, or Stricture.
Symptoms of Cholangitis
Managment of Cholangitis
Admission Criteria
- All patients should be admitted for IV antibiotic and possible biliary drainage
- Admit patients with signs of septic shock
to the ICU.
Epidemology of GB Cancer
- Rare malignancy
- Usually affecting elderly patients.
- Associated with gall-stones (in 70–90% of cases), calcified (“porcelain”) gallbladder and gallbladder polyps > 1 cm in diameter
Prophylactic cholecystectomy should particularly be considered for …..
calcified (“porcelain”) gallbladder and gallbladder polyps > 1 cm in diameter
Clinical Features of GB Cancer
RUQ discomfort, weight loss, and jaundice.
A hard, tender mass is sometimes felt in GB region.
Occasionally condition is asymptomatic.
Investigations for GB Cancer
Managment of GB Cancer
Surgical resection rarely curative as cancer spreads early to surrounding structures, including liver.
No clear role for systemic chemotherapy or radiotherapy.
Palliative approaches include biliary stenting to relieve jaundice,
Mean survival Rate of GB Cancer
Mean survival rate is six months, and the five-year survival rate < 5%.
def of Gallstone Ileus
Mechanical intestinal obstruction due to gallstone impaction within bowel lumen.
Size of Stone in Gallstone Ileus
Stone is usually >2.5 cm.
Epidemeology of Gallstone Ileus
Most cases occur in patients >65 years.
Female > Male 5:1
Pathogenesis of Gallstone Ileus
Cholecystenteric fistula develops, permitting stone passage into intestine.
Duodenum is most common site of fistula formation.
Terminal ileum is most common site of impaction.
Rigler Triad
Gallstone Ileus
Etiology of GB Empyema
- The presence of pus within the gallbladder.
- It usually develops following acute cholecystitis,
or cystic duct obstruction due to tumor e.g.,
cholangiocarcinoma.
Symptoms of GB Empyema
Usually presents with RUQ pain and sepsis.
Complications of GB Empyema
GB perforation with subsequent peritonitis is an
important complication if left untreated.
Dx of GB Empyema
CT or U/S may show a distended, fluid-filled GB,
with pericholecystic fluid.
TTT of GB Empyema
- IV antibiotics (e.g., 3rd generation cephalosporin
& metronidazole). - Percutaneous GB drain insertion.
- Cholecystectomy is usually delayed because of high rate of post-operative septic complications
Done
