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GB & BILIARY TREE

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

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GB & BILIARY TREE

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  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

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

  4. Cholelithiasis • most common pathology of biliary tree

  5. 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

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

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

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

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

  10. 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

  11. 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

  12. 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 Acalculouscholecystitis

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

  14. Clinical features Hx - chronic cholecystitis/Cholelithiasis - RUQ/epigastricpain 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

  15. DDX - Perforated PUD - Biliarycolic - Pneumonia -Pancreatitis - Hepatitis

  16. IXns • WBC: Leucocytosis • CXR or PAXR: pneumonia/radio opaque stone • Ultrasound: detects calculi, gall bladder wall thickening & pericholecysticfluid

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

  18. 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

  19. Classification I Medical: Pre hepatichemolytic Hepaticliver problems II Surgical: obstruction of biliarytreeobstructive jaundice

  20. Biochemical features

  21. Extra hepatic biliary obstruction • Lumen -Gall stone -ParasiticAscaris • Wall -Atresia -Stricture -Tumor • Extrinsic -pancreatic head ca -ampullary ca -Pancreatitis -Choledochalcyst

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

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

  24. 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

  25. Investigations - Hemoglobin-AnemiaMalignancy - U/Abillirubin/urobilinogen - Serum billirubintotal & direct - Serum  alkpase - Ultrasoundgallstone, choledochal cyst, dilated bile duct, Neoplasm - LFT - PT

  26. Treatment • Surgery • Perioperative -Antibiotic prophylaxis -ParenteralvitK +/- FFP -Fluid resuscitation -careful post operative fluid balance

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