1. Behzad Nakhaei, M.D., FICS Fellowship in HepatoBiliary Surgery Mc Gill University RUQ & Upper Abdomen Inflammation & Infection GallBladder & Biliary System Disorders ( A Problem Solving Lecture ) For Medical Students

2. Common Clinical Presentations In RUQ & Upper Abdomen Due to Inflammation & Infection Pain & Fever Jaundice & Fever Mass & Fever (One / Two Symptoms Dominate in each of these )

3. Signal the need for: Complete Blood Count Liver Function Test Serum Amylase PT, PTT Blood Culture Chest & Abdominal X ray Abdominal Ultrasonography

4. 3 Most common Scenario :? Acute Cholecystitis? OR Acute Cholangitis? OR Acute Pancreatitis?

5. Pain & Fever? Upper Abdomen Sepsis == RUQ Pain & Fever In 2/3 of Cases Biliary Origin (Acute Cholecystitis, Biliary Colic, Acute Cholangitis) Acute Pancreatitis Pneumonia Hepatitis, Herpes Zoster Other gastrointestinal Disease Sono is the most important Screening test for Acute Biliary Infections.

6. Pain & Fever – Diagnosis Acute Cholecystitis Biliary Colic Acute Cholangitis Acute Pancreatitis – Sono Finding Stone & Thickening of wall Stone in Biliary Tree Stone & Dilatation of CBD Pancreas Enlargement

7. Cholecystitis ? Acute Calculous Acute Acalculous Emphysematous Hydrops Empyema Chronic

8. Risk Factors of Gangrene & Perforation in Acute Cholecystitis Systemic Toxicity Emphysematous Cholecystitis Acalculous Cholecystitis

9. Fever & Jaundice ? If the Patient Presents with : Fever > 38.5 & Jaundice Leukocytosis & Positive Blood Culture Stone & Biliary tree dilatation on Sono Reynolds, Pentad ( Abdominal Pain, Fever&Chills,Jaundice, Hypotension,Mental confusion ) Dx is Acute Cholangitis

10. Cholangitis? Infection within Biliary tree Due to : Choledocholithiasis Choledochal cysts Bile Duct CA Sphincteroplasty Instrumentation of Biliary tree

11. Cholangitis ? Acute Suppurative Cholangitis Cholangiohepatitis Sclerosing Cholangitis

12. Acute Suppurative Cholangitis? Pus within the Biliary tract Complicated by Obstructive Jaundice Charcot triad : Jaundice, Chill, Fever Age Over 70 ERCP or PTC Surgical Intervention

13. Cholangiohepatitis Most common in China & Hong Kong Clonorchiasis Ascariasis Malaria Hemolysis E coli & Klebsiella Toxic Condition Emergency surgery

14. Sclerosing Cholangitis Involve Extra & Intrahepatic Biliary tree Association with Ulcerative colitis&Crohn HIV infection has been noted Most common in middle age men By Pass operation for Palliation Liver Transplantation for Cure

15. Fever & Abdominal Mass? The origin of Pathology is in the : GallBladder Or Liver

16. Fever & Abdominal Mass? –Possible Diagnosis Are : Empyema of GB Hydrops of GB Pyogenic Liver Abscess Liver infected Cysts

17. Biliary Enteric Fistula & Gallstone Ileus Between GB & Duodenum 85% Between GB & Colon 15 % Can cause Mechanical Obstruction Most often in Terminal Ilum Past history of Cholelithiasis is present

18. Mirizzi,s Syndrome ? A fistula between Hartmann's Pouch & CBD A Stone in the Ampulla of the GB can erode the CBD and can destroyed CBD Partially or Completely

19. YOU!!!!!!!! Try to BE A Sophisticated Person