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GB & BILIARY TREE Begashaw M (MD). Gall bladder pear shaped organ of 7.5 – 12.5 cm length & capacity of 50cc Parts-Fundus,Body & Neck cystic duct - joins.

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Presentation on theme: "GB & BILIARY TREE Begashaw M (MD). Gall bladder pear shaped organ of 7.5 – 12.5 cm length & capacity of 50cc Parts-Fundus,Body & Neck cystic duct - joins."— Presentation transcript:

1 GB & BILIARY TREE Begashaw M (MD)

2 Gall bladder pear shaped organ of 7.5 – 12.5 cm length & capacity of 50cc Parts-Fundus,Body & Neck cystic duct - joins GB with common hepatic duct to form CBD

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4 Functions - Reservoir for bile - Organ for concentrating the bile - Secretion of the mucus

5 Cholelithiasis most common pathology of biliary tree

6 Classification 1- Cholesterol stone (6%)-usually solitary 2- Mixed stone (90%)-cholesterol is the major component with others like calcium bilirubinate -multiple, faceted & associated with infection 3- Pigment stone: composed of calcium bilirubinate -usually small, multiple & black -associated with hemolytic disease

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8 Risk factors Age > 40 yrs Female sex Obesity Rapid weight loss – Very low calorie diet – Surgical therapy of morbid obesity Pregnancy Fat Fat Fertile Fertile Flatulent Flatulent Female Female Fifty Fifty

9 Pathogenesis 1- Metabolic:bile formed is supersaturated or lithogenic 2- Infection: increased mucus plug formation & scarring /nidus 3- Stasis: Progesterone in multiparous women is believed to be contributory

10 Clinical Presentation  Most-90%  Asymptomatic  Hx - RUQ colicky pain - Dyspepsia, fatty food intolerance, flatulence, abnormal postprandial bloating  P/E -RUQ tenderness -Risk factors - identified

11 Complications  Gall bladder -chronic cholecystitis -acute cholecystitis -gangrene -perforation -empyema -mucocele -carcinoma  Bile duct -obstructive jaundice -cholangitis -acute pancreatitis  Intestine -Gall stone ileus

12 Diagnostic workup Ultrasound  detects stone in GB PAXR  Only 10% of stones are radio opaque  Differential diagnosis 1. PUD 2. Hiatal Hernia 3. Carcinoma of stomach 4. Diverticular disease 5. Angina pectoris

13 Treatment  Surgery: Open or Laparoscopic 1-cholecystectomy  main stay of treatment 2-cholecystostomy for bad risk patients with severe infection -Severe Acute cholecystitis -Gall bladder empyema

14 Acute Cholecystitis is an acute inflammation of gall bladder due to obstruction of neck of gall bladder or cystic duct stone In absence of stone  Acalculous cholecystitis

15 Pathogenesis Direct pressure of calculus  ischemia, necrosis, and ulceration with swelling edema & impairment of venous return  Favors bacterial multiplication End result - Pericholecystic abscess - Fistula formation between gall bladder & bowel - GB empyema/mucocele Commonly  E.coli, Klebsiella, Streptococci, Enterobacter & Clostridial

16 Clinical features Hx - chronic cholecystitis /Cholelithiasis - RUQ/epigastric pain radiate to back - Fever/vomiting P/E - RUQ tenderness with rebound tenderness - GB may be palpable - Murphy’s Sign +ve : sudden arrest of inspiration due to tenderness of inflamed gall bladder which is palpated during deep inspiration

17 DDX - Perforated PUD - Biliary colic - Pneumonia - Pancreatitis - Hepatitis

18 IXns  WBC: Leucocytosis  CXR or PAXR: pneumonia/radio opaque stone  Ultrasound: detects calculi, gall bladder wall thickening & pericholecystic fluid

19 Treatment 1- conservative - Admit - keep NPO - Start on IV fluid - Insert NGT - Analgesics - Antibiotics - ampicillin & gentamycin - Follow -fever, abd findings/WBC count reduction - cholecystectomy after 6 weeks 2. Surgical treatment: Cholecystectomy

20 OBSTRUCTIVE JAUNDICE  Jaundice is a yellowish discoloration of the sclera, mucous membrane & skin  becomes clinically evident when the level of serum billirubin reaches 2.0 to 3.0 mg/dl

21 Classification I Medical: Pre hepatic  hemolytic Hepatic  liver problems II Surgical: obstruction of biliary tree  obstructive jaundice

22 Biochemical features

23 Extra hepatic biliary obstruction  Lumen -Gall stone -Parasitic  Ascaris  Wall -Atresia -Stricture -Tumor  Extrinsic -pancreatic head ca -ampullary ca -Pancreatitis -Choledochal cyst

24 Clinical manifestation  Hx - Intermittent jaundice  stone - Progressive jaundice - +/- Pruritis - Urine/stool  clay color - RUQ pain - Loss of appetite/weight loss - History trauma/surgery

25  P/E - G/A  obesity/emaciation - Depth of jaundice/pallor - Hepatomegaly, splenomegaly - Ascites - Palpable GB - Liver mass - Skin scratch marks

26 Courvoisier’s Law  If in presence of jaundice, the gall bladder is palpable, then the jaundice is unlikely to be due to stone  True in 60%of cases

27 Investigations - Hemoglobin-Anemia  Malignancy - U/A  billirubin/urobilinogen - Serum billirubin  total & direct - Serum  alk pase - Ultrasound  gall stone, choledochal cyst, dilated bile duct, Neoplasm - LFT - PT

28 Treatment  Surgery  Perioperative -Antibiotic prophylaxis -Parenteral vit K +/- FFP -Fluid resuscitation -careful post operative fluid balance


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