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

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

8. 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

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 manifestationHx
- 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