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DISEASES OF BILIARY PASSAGES with emphasis on GALL STONES
( By Dr.S.Uma Devi.M.D)
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,
(stone
s in common bile duct)
• gall stone ileus,
• primary sclerosing
cholangitis
gall stone (stones in gall
bladder)i.e.cholelithiasis,
primary sclerosing
cholangitis
Gall stones
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
in common bile duct)
Nucleus
for the formation of gall stones
Excess carbohydrates
as in sweets
Infection like typhoid
In the presence of
cholecystitis cholesterol may get precipitated.
Lithogenic bile precipitates cholesterol
Size of
stone
Variable
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
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
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
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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
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 differential 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
NATURAL HISTORY OF GALL STONES
es
Natural history of gall stones continued
Summary points
1.Gall stones are the
commonest GI cause of hospital admission in western countries
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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