Transcript Stones
GALL BLADDER The gall bladder is: Pear shaped, 7.5 – 12 cm long 30 to 50 mL capacity Fundus, body, neck, and infandibulum The cystic duct: 3cm in length 1-3 mm in diameter Valves of Heister a RHD b LHD c CHD d PV e HAP f GDA h CBD l CD k Neck GB j Body i fundus m CA The common hepatic duct: 2.5 cm in length Union of R & L hepatic ducts The common bile duct: 7.5cm in length Union of cystic and CHD 4 parts; Blood supply of gall bladder: The cystic artery a branch of R hepatic artery Accessory CA from GD art. In 15% RHA anterior to CHD Toutuous RHA and short CA, Caterpillar turn or Moynihan’s hump. Lymphatics: Subserosal and submucus lymphatics to the cystic LN of coeliac LNhilum of liverLund Subserosal lymphatics to subcapsular lymphatics of liver SURGICAL PHYSIOLOGY Bile: 40ml hour 97% water Bile salts 1-2%, bile pigments 1%, cholestrol, and fatty acids Functions of gall bladder: Reservoir Concentration of bile, 5 - 10 times Secretion of mucus– 20ml/day Ultrasound; stones and size Plain radiograph; calcification MRCP; anatomy and stones CT scan; cancer and anatomy HIDA scan; function ERCP; stones, and strictures Ultrasonography: Non-invasive Standard initial imaging for patient suspected to have a gall stone and in jaundiced patients. Ultrasonography:can demonstrate Gall stones GB size, thickness of its wall, presence of inflammation around it, pericystic edema. Size of CBD, occasionally stones in it. Tumour of pancreas. Endoscopic ultrasound; Stone and obstruction of lower CBD Plain radiogaph: Radiopaque gall stones in 10% Porcelain GB.. calcified GB..25% CA. Limey bile Gas in the wall, emphysematous cholecystitis Gas in the biliary tree; Endoscopic sphincterotomy Surgical bilio-enteric anastomsis Internal biliary fistula Porcelain GB Gas in gall bladder Oral cholecystography Once was of first choice in the dx o gall stones Intravenous cholangiography f Radioisotope scanning: Tc 99m labelled with derivatives of iminodiactic acid (HIDA, PIPIDA), that are excreted in the bile. Dx of acute cholecystitis GB not visulized Bile Leakage, assessment Dimethyl iminodiacetic acid (HIDA) scan. INVESTIGATIONS OF THE BILIARY TRACT Computerized limited Tomography scan; usefulness in investigating the biliary tree Only when there is a possibility of cancer of gall bladder or bile ducts Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice CT SCAN Computed tomography scan demonstrating a gallstone within the gall bladder (arrowed). Magnetic Resonance Cholangiopancreatograph: (MRCP) Standard for biliary tree investigation Contrast is not needed MRCP Magnetic resonance cholangiopancreatography crosssectional image demonstrating a hilar mass (thick arrow) and gallstones (thin arrow) ENDOSCOPIC RETROGRADE CHOLANGIOPANREATOGRAPHY (ERCP) Side veiwing endoscopie Cannulation of ampulla of Vater Injection of contrast to visualize the bile ducts Also bile can be taken for cytological and microbiological tests Brushings from strictures ERCP PERCUTANEOUS TRANSHEPATIC CHOLANGOGRAPHY (PTC): Preparation; Normal PT Antibiotics DX and therapy; Visulization of biliary tree Placement of; catheter Stenting choledochoscope PTC Peroperative cholangiography Operative biliary endoscopy (choledochoscopy) DISEASES OF GALL BLADDER AND BILIARY PASSAGES Congenital Acquired CONGENITAL ABNORMALITIES OF THE GB AND BILIARY TREE Absence of GB The phrygian cap Floating GB Double GB Absence of CD Low insertion of CD An accessory cholecystohepatic duct ( small ducts of Luschka) EXTRAHEPATIC BILIARY ATRESIA Aetiology and 1 pathology: per 14000 live birth Equal and female If untreated the child dies before the age of 3 years 20% associated anomalies, cardiac, situs inversus, absent vena cava Classification: Type I: atresia restricted to the CBD Type II: atresia of the CHD Type III: atresia of the right and left HD Clinical features: 1/3 jaundiced at birth All jaundiced by the end of first week Meconium little bile stained Pale stool and dark urine Osteomalacia Pruritis Clubbing, skin xanthoma Diff. Dx.: Alpha 1 antitrypsin deficiency Choledochal cyst Inspissated bile syndrome Neonatal hepatitis Traetment: Roux-en Y anastomosis Kasai procedure CHOLEDOCHAL CYST Weaknes of part or whole of the wall of the CBD Anomalous junction of the biliary pancreatic junction; High amylase Repeated attacks of panreatitis Clinical features: premalignant At any age, Attacks of; juandice Cholangitis Swelling in the right hypochondrium US –abnormal cyst MRI– clear anatomy Treatment: Radical excision of the cyst and reconstruction of Roux en Y jejunal loop the biliary tract using TRAUMA Iatrogenic Accidental, is rare, penetrating or crushing Presentation of acute abdomen Treatment: GB—cholecystectomy Bile ducts: Drainage using T tube –Roux-en-Y GALL STONES (CHOLELITHIASIS) Most common pathology Affecting about 10–15% of the adult population. Mostly asymptomatic in >80% Cholecystectomy is one of the most common operations performed by general surgeons. AETIOLOGY OF GALLSTONES Metabolic Infective Stasis RISK FACTORS ASSOCIATED WITH FORMATION OF GALL STONES Age > 50 years Female sex (twice risk in men) Genetic or ethnic variation High fat, low fibre diet Obesity Pregnancy (risk increases with number of pregnancies) Hyperlipidaemia Bile salt loss (ileal disease or resection) Diabetes mellitus Cystic fibrosis Antihyperlipidaemic drugs (clofibrate) Gallbladder dysmotility Prolonged fasting Total parenteral nutrition TYPES OF GALL STONES: Cholesterol Pigment stones Mixed stones CHOLESTEROL STONES Contain mainly pure cholesterol •Mostly single ( cholesterol solitaire) •Obesity, •high-calorie diets •certain medications PIGMENT STONES: Black stones Contents: insoluble bilirubin pigment polymer mixed with calcium phosphate and calcium bicarbonate. < 30% cholesterol Hemolysis; Hereditary spherocytosis Sickle cell anaemia PIGMENT STONES: Brown stones: calcium bilirubinate, calcium palmitate and calcium stearate, as well as cholesterol form in the bile duct and are related to bile stasis and infected bile. MIXED STONES: Cholesterol major component Ca bilirubinate, Ca palmitate, Ca carbonate, Ca phosphate, and proteins Account for 90% Multiple Faceted INCIDENCE OF GALL STONES Female Fat Fertile Fifty Flatulent CAUSAL FACTORS IN GALL STONE FORMATION Metabolic Infective Stasis Metabolic: Cholesterol Bile salts Phospholipid High cholesterol “Supersaturated” or “lithogenic” bile Aging contraceptives Female Obesity Clofibrate Interruption of enterohepatic circulation of bile salts lead to low bile salts. Infection: Unclear centre of stone mucus plug as nidus for stone formation B glucuronidase unconjugated insoluble bilirubin. Radiolucent Bile stasis: Decrease contractility of gall bladder Estrogen in pregnancy Parenteral nutrition Truncal vagatomy EFFECTS AND COMPLICATIONS OF GALL STONES In the GB: Silent up to 80% Chronic cholecystitis Acute cholecystitis Gangrene Perforation Empyema Mucocele carcinoma In the bile ducts: Obstructive jaundice Cholangitis Acute In panreatitis the intestine: Acute intestinal obstruction ( gall stone ileus) Acute cholecystitis Biliary Colics Chronic cholecystitis ACUTE CHOLECYSTITIS Right hypochondrial pain Radiate to back, chest Referred right shoulder pain Occ. Start at epigastrium or left subcostal Start at night Other symptoms; Dyspeptic symptoms Vomiting fever ACUTE CHOLECYSTITIS Several hours to few days Fever leucocytosis BILIARY COLIC Few minutes to few hours No fever No Leucocytosis DIFFERENTIAL DX Common: Appendicitis Perforated peptic ulcer Acute pancreatitis Uncommon: Acute pyelonephritis MI Pneumonia, right lower lobe DIAGNOSIS Physical examination: Murphy’s sign Palpable tender gall bladder. DIAGNOSIS Ultrasound Liver function test Bilirubin WBC CXR pneumonia ,air under diaphragm ECG GUE and urine culture TREATMENT Conservative Urgent cholecystectomy Early cholecystectomy Elective cholecystectomy CONSERVATIVE TREATMENT with NPO IV fluids NG tube Analgesia Antibiotics Follow up CONSERVATIVE TREATMENT 90% respond to conservative treatment. Subsequent treatment: Early cholecystectomy next op. list 5-7 days Elective cholecystectomy 6 weeks URGENT CHOLECYSTECTOMY When to stop conservative treatment: •Increasing: •pain and tenderness •pulse and temperature •leucocytosis Conservative treatment is not advised the •Uncertinity about dx EMPYEMA OF THE GALL BLADDER Pus filled gall bladder A sequel to acute cholecystitis or Mucocele Treatment: Cholecystectomy Disturbed anatomy---- drainage (Cholecystostomy) later cholecystectomy Acalculous cholecystitis Acute or chronic Dx by: Radioisotope in acute cholecystitis Acute acalculous can occur in patients after major surgery, trauma, burn CHOLECYSTECTOMY Indications Preperation procedure CHOLECYSTECTOMY Indications Symptomatic cholelithiasis Trauma Part of other operation -----Whipple’s procedure Neoplasia of Gall Bladder Preparation for operation ■ Full blood count ■ Renal profile and liver function tests ■ Prothrombin time ■ Chest X-ray and electrocardiogram (if over 45 years or medically indicated) ■ Antibiotic prophylaxis ■ Deep vein thrombosis prophylaxis ■ Informed consent CHOLECYSTECTOMY Laparoscopic cholecystectomy Open colecystectomy •Gold standard COMPLICATIONS OF CHOLECYSTECTOMY Inraoperative: Biliary injuries Iatrogenic injuries to near by organs Bleeding. Early postoperative: CBD obstruction------------Jaundice CBD injury --------------Collection , Biliary peritonitis Bleeding ---------------Local hematoma, Shock Missed stone in CBD COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY access complications bile duct injuries Biliary injury: Bile leakage Local collection or excessive bile drainage if drain is present Biliary peritonitis PAIN AFTER CHOLECYSTECTOMY Causes: Incorrect preoperative diagnosis - for example, irritable bowel syndrome, peptic ulcer, gastro.oesophageal reflux Retained stone in the CBD or CD stump Iatrogenic biliary injury stricture of common bile duct Papillary stenosis or dysfunctional sphincter of Oddi ALTERNATIVE TREATMENT Criteria for non-surgical treatment of gall stones Cholesterol stones < 20 mm in diameter Fewer than 4 stones Functioning gall bladder Patent cystic duct Mild symptoms SUMMARY POINTS Gall stones are the commonest cause for emergency hospital admission with abdominal pain Laparoscopic cholecystectomy has become the treatment of choice for gallbladder stones Risk of bile duct injury with laparoscopic cholecystectomy is around 0.2% Asymptomatic gall stones do not require treatment Cholangitis requires urgent treatment with antibiotics and biliary decompression by endoscopic retrograde cholangiopancreatography OBSTRUCTIVE JAUNDICE Attributed to CBD obstruction Stone in CBD Carcinoma of CBD Tumor of head of pancreas FB inside the CBD Paracitic MANAGEMENT OF CBD OBSTRUCDTION Following Jaundice cholecystectomy ---- immediate action Ultrasound Dilatation Collection at porta hepatis Biochemical investigations Immediate MRCP: If stone detectedendoscopic extraction(ERCP) If CBD obstruction--- surgery If bile leakage : Percutaneous Stenting drainage STONES IN THE CBD Several years after cholecystectomy CBD infestation by Ascaris lumbricoides or clinorchis sinensis STONES IN THE CBD Clinical presentation: Asymptomatic Jaundice ( Charcoat triad ) Cholangitis Fever and rigor Jaundice Pain STONES IN THE CBD Signs: Tenderness upper abdomen and RUQ STONES IN THE CBD Management: Dx Ultrasound Liver function test Liver biopsy MRCP ERCP STONES IN THE CBD Resuscitaion Relief of obstruction STONES IN THE CBD Resuscitaion Rehydration Broad spectrum Antibiotics Attention to clottingVit K STONES IN THE CBD Relief of obstruction Endoscopic Extraction Some sphincterotomy of stone by Dormia basket or balloon catheter times stent placement STONES IN THE CBD Percutaneous transhepatic cholangiography: then drainage Percutaneous choledochoscopy STONES IN THE CBD Surgery: Choledochotomy CHOLEDOCHOTOMY Indications: Preoperative: Stone in CBD Dilatation of CBD History of jaundice Peroperative: Palpable stone Dilated CBD STRICTURE OF CBD Benign stricture: 80% postoperative 20% inflammatory Malignant stricture CAUSES OF BENIGN BILIARY STRICTURE Congenital ■ Biliary atresia Bile duct injury at surgery ■ Cholecystectomy ■ Choledochotomy ■ Gastrectomy ■ Hepatic resection ■ Transplantation Inflammatory ■ Stones ■ Cholangitis ■ Parasitic ■ Pancreatitis ■ Sclerosing cholangitis ■ Radiotherapy Trauma Idiopathic POSTOPERATIVE STRICTURE Technical error during cholecystectomy Blind control of bleeding in Calot triangle Failure to identify the anatomy at Calot triangle Acute inflammation Mirizzi syndrome Short or absent cystic duct Anatomical anomalies POSTOPERATIVE STRICTURE CBD obstruction Deeping jaundice Partial obstruction delayed jaundice POSTOPERATIVE STRICTURE Radiological investigations: Ultrasound MRCP Cholangiography Through PTC ERCP tube POSTOPERATIVE STRICTURE Treatment Supportive Relief of obstruction Temporary: stentingERCP Transhepatic external drainage and stenting For ERCP --- strictures of recent onsent: guide wire---- balloon dilatation---stent placement POSTOPERATIVE STRICTURE Definite relief of obstruction: Choledocho-jejunostomy Late complications: CBD stricture Stone in CBD Post cholecystectomy pain syndrome Wrong preoperative diagnosis Complication of cholecystectomy PARASITIC INFESTATION OF THE BILIARYBILIARY TRACT ascariasis The round worm, Ascaris lumbricoides, commonly infests the intestine Complications: strictures, suppurative cholangitis, liver abscesses and empyema of the gall bladder HYDATID DISEASE Jaundice: Cyst near porta hepatis Rupture of cyst into the biliary passages TUMOURS OF THE BILE DUCT Benign tumours of the bile duct: Rare Symptoms problems not distinguished from common biliary Malignant tumours of the bile duct Rare, but incidence increasing Presents with jaundice and weight loss Diagnosis by ultrasound and CT scanning Jaundice relieved by stenting Surgical excision possible in 5% Prognosis poor – 90% mortality in 1 year the tumour is usually an adenocarcinoma (cholangiocarcinoma). predominantly in the extrahepatic biliary RISK FACTORS ulcerative colitis, hepatolithiasis, choledochal cyst ,sclerosing cholangitis. liver fluke infestations in the Far East CLINICAL FEATURES Jaundice Abdominal pain, weight early satiety loss palpable gall bladder INVESTIGATIONS Biochemical investigations tumour marker CA19-9 ultrasound and CT scanning define: the level of biliary obstruction the locoregional extent of disease the presence of metastases percutaneous ERCP transhepatic cholangiography TREATMENT Most patients are inoperable, but 10–15% are suitable for surgical resection CARCINOMA OF GALL BLADDER Risk factors Comon in india Incidence 9% Gall stonesless than 1% 90% of Ca GB have gall stones CARCINOMA OF GALL BLADDER Pathology: Schirrous adenocarcinoma Squamous cell Mixed sq adenocarcinoma CARCINOMA OF GALL BLADDER Spread: Direct invading the liver Lymphatics Peritoneal seedlings Clinical features: Mostly elderly 70 years 5:1 ratio Females more than males Same as cholecystitis Suspected during cholecystectomy then preoved by histopathology CARCINOMA OF GALL BLADDER Jaundice: Mass in liver late sign INVESTIGATION non-specific findings such as anaemia, leucocytosis, mild elevation of transaminases and increased erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP). Elevated CA19-9 US and CT scan percutaneous biopsy Laparoscopy CARCINOMA OF GALL BLADDER Treatment: Usually discovered after cholecystectomy and so no further surgical treatment required If tumor good prognosisconfined to mucosa transmural disease, a radical en bloc resection of the gall bladder fossa and surrounding liver along with the regional lymph nodes. PATHOGENESIS OF STONE FORMATION For cholesterol stones: Supersturation of bile with cholesterol Low bile acid concentration For pigment stones: accompany haemolysis like in: Usually Spherocytosis Sickle cell disease Prosthetic heart valves For mixed(brown) stones: Stasis Infection—beta glucuronidase unconjugated bilirubin insoluble