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 GB with common hepatic duct to form CBD

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

Cholelithiasis most common pathology of biliary tree

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Biochemical features

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

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

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

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

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

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