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GALL BLADDER

BYDR.

HAYDER M. ABDULNABIMD, CABS

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ANATOMY

PEAR-SHAPED, 7.5-12.5 CMNORMAL CAPACITY- 50 MLFUNDUS, BODY, NECK (TERMINATES IN A

NARROW INFUNBIBULUM)( HARTMANN’S POUCH- A DILATATION IN

THE NECK DUE TO AN IMACTED STONE)CRISS-CROSS MUSCLE COAT (WELL

DEVELOPED IN THE NECK)GLANDULAR MUCOUS MEMBRANE WITH

CRYPTS OF LUSCHA

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THE CYSTIC DUCT 2.5 CM (CONTAINS THE SPIRAL VALVE OF HEISTER)

THE COMMON HEPATIC DUCT 2.5CM (UNION OF RT AND LT HEPATIC DUCTS)

THE COMMON BILE DUCT 7.5CM (JUNCTION OF CHD AND THE CYSTIC DUCT), OF 4 PARTS

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1- SUPRADUODENAL 2.5CM (RUNS IN THE FREE EDGE OF LESSER OMENTUM

2- RETRODUODENAL3- INFRADUODENAL4- INTRADUODENAL (PASSES

OBLIQUELY THROUGH 2ND PART OF DUODENUM, SURROUNDED BY THE SPHINCTER OF ODDI, OPENS AT THE SUMMIT OF THE PAPILLA OF VATER

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THE ARTERIAL SUPPLY OF THE GALL BLADDER

THE CYSTIC ARTERY (BRANCH OF THE RT HEPATIC ARTERY), USUALLY BEHIND THE CBD

ACCESSORY CYSTIC ARTERY (OCCASIONAL)(BRANCH OF THE GASTRODUODENAL ARTERY)

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LYMPHATICS

SUBSEROSAL AND SUBMUCOSAL DRAIN INTO THE CYSTIC LYMPH NODE OF LUND (SENTINEL LN) THEN TO THE HILUM OF THE LIVER TO THE COELIAC LYMPH NODES

SUBSEROSAL LYMPHATICS CONNECT WITH THE SUBCAPSULAR LYMPHATICS OF THE LIVER (FREQUENT SPREAD OF GALL BLADDER CA TO THE LIVER)

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FUNCTIONS OF THE GALL BLADDER

BILE IS COMPOSED OF 97% WATER, 1-2% BILE SALTS, 1% PIGMENTS, CHOLESTEROL AND FATTY ACIDS

LIVER EXCRETION RATE IS 40 ML/HOUR1- RESERVOIR (FASTING CAUSE

RESISTANCE INCREASE IN SPHINCTER OF ODDI) (FEEDING DECREASE THE RESISTANCE AND THE GALL BLADDER CONTRACTS BY THE ACTION OF CHOLECYSTOKININ RELEASED BY UPPER INTESTINAL MUCOSA IN RESPONSE TO FOOD PARTICULARLY FAT)

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2- CONCENTRATION OF BILE 5-10 TIMES ( BY ACTIVE ABSORBTION OF WATER, SOD. CHLORIDE, AND BICARBONATE) WITH INCREASE IN THE PROPORTION OF BILE SALTS, PIGMENTS, CHOLESTEROL AND CALCIUM

3- MUCIN SECRETION, 20ML/HOUR

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INVESTIGATIONS OF THE BILIARY TRACT

1- PLAIN RADIOGRAPH-- (RADIO-OPAQUE STONE 10%, PORCLAIN GALL BLADDER, LIMEY BILE, AIR)

2- ORAL CHOLECYSTOGRAPHY-- (A CONTROL X-RAY IS TAKEN THE DAY BEFORE AND IOPANOIC ACID CONTRAST MEDIUM TABLETS IS TAKEN ORALLY AT NIGHT, THE NEXT DAY ERRECT AND SUPINE X-RAY IS TAKEN TO THE RT HYPOCHONDRIUM AND X-RAY REPEATED TO OBSERVE GALL BLADDER CONTRACTION(

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RADIO-OPAQUE STONESPLAIN X- RAY

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PORCLAIN GBPLAIN X-

RAY

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PLAIN X-RAY

AIR

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ORAL CHOLECYSTOGRAM

STONES

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NONVISUALIZATION (NONFUNCTIONING) GALL BLADDER IS DUE TO-- FAILURE OF THE PATIENT TO TAKE THE TABLETS, VOMITING, MALABSORBTION, IMPAIRED LIVER FUNCTION, BLOCKED CYSTIC DUCT,SEVERE GALL BLADDER DISEASE (FAILURE OF CONCENTRATION)

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3- INTRAVENOUS CHOLANGIOGRAM– USING INTRAVENOUS RADIO-OPAQUE MEDIUM TO SHOW THE BILE DUCTS, MAY BE USED WITH ORAL CHOLECYSTOGRAM OR TOMOGRAPHY (A METHOD TO PUT ONE GIVEN PLANE INTO SHARP FOCUS WHILE BLURRING OTHERS)

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4- ULTRASONOGRAPHY (NONINVASIVE)

AND SHOWS BILIARY CALCULI, DILATION OF BILIARY TREE,CA HEAD PANCREAS, WALL THICKNESS, GALL BLADDER SIZE, HALLO SIGN

5- RADIOISOTOP SCANNING– USING RADIOACTIVE IODINE(131) OR Tc(99)

6- COMPUTED TOMOGRAPHY– IN OBESE OR PATIENTS WITH GASEOUS DISTENTION THAT MAKE ULTRASONOGRAPHY DIFFICULT

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US

STONE

GB

ACOSTIC SHADOW

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ULTRASONOGRAPHY

ACOSTIC SHADOW

STONECBD

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7- ENDOSCOPIC RETROGRADE CHOLAGIOPANCREATOGRAPHY

(ERCP)– BY CANNULATION OF THE AMPULLA OF VATER USING FIBEROPTIC DUODENOSCOPE AND INJECTION OF CONTRAST MEDIUM ,TO TAKE SAMPLE FOR CULTURE AND BRUSHING FOR CYTOLOGY. ITS USE CAN BE EXTENDED TO DO PAPILLOTOMY TO EXTRACT STONES, PASSING CATHETER OR DORMIA BASKET, AND STENT PLACING THROUGH STRICTURES.

IT MAY CAUSE ASCENDING BILIARY INFECTION, SO SHOULD BE DONE UNDER ANTIBIOTICS COVER

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ERCPCATHETER IN THE

AMPULLA

DUCT OF WIRSUNG

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8- PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY- INJECTION OF CONTRAST MEDIUM THROUGH A CHIBA OR OKUDA NEEDLE (15CM LONG , 0.7MM IN DIAMETER) INTO THE LIVER THROUGH THE 8TH INTERCOSTAL SPACE IN THE MIDAXILLARY LINE.

IT CAN BE USED TO PUT A CATHETER FOR DRAINAGE OR STENT FOR ANTEGRADE DRAINAGE.

BLEEDING TENDENCY IS A CONTRA INDICATION AND THE PROCDURE SHOULD BE DONE UNDER ANTIBIOTICS COVER

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PER CUTANEOUS TRANSHEPATIC

CHOLANGIOGRAM

CHIBA NEEDLE

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9- PEROPERATIVE CHOLANGIOGRAPHY– BY TAKING X-RAY DURING OPERATION AFTER INJECTING THE CONTRAST BY A POLYTHENE CATHETER INTRODUCED INTO THE CBD THROUGH AN OPENING IN THE CYSTIC DUCT TO DETECT ANY STONE IN THE CBD BEFORE EXPLORATION.

FAILURE OF THE CONTRAST TO ENTER THE DUODENUM MAY BE ALSO DUE TO SPHINCTER SPASM AND HERE SUCCINYLCHOLINE IS GIVEN TO EXCLUDE THIS POSSIBILITY

20% OF CASES THE MEDIUM ENTER THE DUCT OF WIRSUNG AND IT IS NOT NECESSARILY PATHOLOGICAL

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PER- LAPAROSCOPIC CHOLANGIOGRAPHY

CATHETER

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PER-OPERATIVE CHOLANGIOG

RAM

CBD

DUODENUM

CATHETER

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10- OPERATIVE BILIARY ENDOSCOPY (CHOLEDOCHOSCOPY)

11- PEROPERATIVE POSTEXPLORATORY CHOLANGIOGRAPHY (THROUGH THE T- TUBE)

12- POSTOPERATIVE CHOLANGIOGRAPHY (T-TUBE), 10-14 DAYS AFTER CHOLEDOCHOTOMY

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PER-OPERATIVE CHOLANGIOGRAPH

STONE IN

CBD

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PER-OPERATIVE CHOLEDOCHOSCOPE

Rt HEPATIC DUCT

Lt HEPATIC DUCT

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T-TUBE CHOLANGIOGRAM

T-TUBE

STONE IN COMMON

HEPATIC DUCT

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CONGENITAL ANOMALIES OF THE GALL BLADDER AND

BILE DUCTS1. ANOMALIES OF THE GALL BLADDER-

ABSENCE PHRYGIAN CAP (HAT OF THE PEOPLE

OF PHRYGIA IN ANCIENT ASIA MINOR) (FRENCH REVOLUTION LIBERTE CAP) FLOATING GALL BLADDER—TORTION DOUBLE GALL BLADDER

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2. ANOMALIES OF THE DUCTS- ABSENCE ATRESIA CONGENITAL DILATATION OF

INTRAHEPATIC DUCTS CHOLEDOCHAL CYST LOW INSERTION OF CYSTIC DUCT ACCESSORY

CHOLECYSTOHEPATIC DUCT

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3. ANOMALIES OF THE ARTERIES- RT HEPATIC ARTERY AND OR

CYSTIC ARTERY CROSS IN FRONT OF THE CHD

HEPATIC ARTERY TAKE A TORTOUS COARSE IN FRONT OF THE ORIGIN OF THE CYSTIC DUCT

RT HEPATIC ARTERY IS TORTOUS AND THE CYSTIC ARTERY IS SHORT (CATERPILLAR TURN)

ACCESSORY CYSTIC ARTERY

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GALL STONES(CHOLELITHIASIS)

1. MIXED STONES- 90%, CHOLESTEROL IS THE MAJOR COMPONENT, Ca CARBONATE, Ca PHOSPHATE, Ca PALMITATE AND PROTEIN (USUALLY MULTIPLE AND FACETED)

2. CHOLESTEROL STONES- (CHOLESTEROL SOLITAIRE)

3. PIGMENT STONES- (SMALL, BLACK, MULTIPLE)

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MIXED STONES

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MIXED STONES

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CHOLESTEROL STONES

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PIGMENTSTONES

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LIMEY BILE- OCCUR WHEN THERE IS GRADUAL OBSTRUCTION TO THE CYSTIC DUCT OR THE CBD (CHRONIC PANCREATITIS, CA PANCREAS)

THE GALL BLADDER WILL BE OPAQUE IN A PLAIN X-RAY (FILLED BY Ca CARBONATE AND Ca PHOSPHATE) WHICH IS THE COMPONENTS OF TOOTH PASTE

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CHOLESTEROL IS HELD IN SOLUTION BY THE DETRERGENT EFFECT OF BILE SALTS AND PHOSPHOLIPID (LECITHINE)TO FORM MICELLES.

ANY CHANGE IN THE EQUILIBRIUM BETWEEN THESE THREE ELEMENTS WILL LEAD TO GALL STONE FORMATION

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HYDROPLYLIC END

HYDROPHOBIC END

(CHOLESTEROL)

BILE SALT MICELLE

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PATHOGENESIS OF GALL STONE FORMATION

1. METABOLIC- INCREASE CHOLESTEROL LEVEL IN BILE(SUPERSATURATED OR LITHOGENIC BILE), WITH AGE, FEMALE ( CONTRCEPTIVE PILLS), OBESITY, PATIENTS ON CLOFIBRATE

BILE SALTS DECREASE BY INTERRUPTION OF ENTERO-HEPATIC CIRCULATION( ILEAL DISEASSE, RESECTION, BYPASS SURGERY, CHOLESTYRAMINE)

ESTROGEN DECREASE CONCENTRATION OF BILE SALT IN THE BILE(CCP)

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CHOLESTEROL SOLUBILITY

STATUS

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2. INFECTION- NIDUS3. BILE STASIS- GALL BLADDER

CONTRACTILITY DECREASE IN PREGNANCY, BY ESTROGEN(CCP), AFTER TRUNCAL VAGOTOMY, PATIENTS ON TPN ( LACK OF GOOD ORAL INTAKE) CAUSE DECREASE IN CHOLYCYSTOKININ SECRETION

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4. PIGMENT STONES OCCUR WITH HEMOLYSIS( HEREDITARY SPHEROCYTOSIS, SICKLE CELL ANEMIA, THALASSEMIA, MALARIA)

WHERE BILIRUBIN PRODUCTION WILL INCREASE.

PIGMENT STONES ALSO INCEASE WITH BENIGN AND MALIGNANT STRICTURES AND WITH PARASITE INFESTATION OF THE BILIARY DUCTS( ASCARIS LUMBRICOIDES, CHLONORCHIS SINENSIS)

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INCIDENCE OF GALL STONES

FAT, FERTILE, FLATULENT, FEMALE, FIFTY- IS THE USUAL SUFFERER OF GALL STONES

IT CAN OCCUR AT ANY AGE AND IN BOTH SEXES

TOW THIRD ARE ASYMPTOMATICSAINT’S TRIAD- GALL STONES DIVERTICULOSIS HIATUS HERNIA

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COMPLICATIONS OF GALL STONES

1.IN THE GB- SILENT( NO INDICATION FOR OPERATION) CH CHOLECYSTITIS AC CHOLECYSTITIS GANGRENE PERFORATION EMPYEMA MUCOCELE CARCINOMA2. IN THE BILE DUCTS- OBSTRUCTIVE JAUNDICE CHOLANGITIS ACUTE PANCREATITIS3. IN THE INTESTINE- ACUTE INTESTINAL OBSTRUCTION (GALL STONE

ILEUS)

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CHRONIC CALCULOUS CHOLECYSTITIS

THICK, FIBROTIC WALL, BACTERIA ISOLATED IN LESS THAN 30% OF CASES FROM THE BILE AND SUGGESTS A CHEMICAL IRRITANTS IN THE BILE RATHER THAN BACTERIAL AS A CAUSE IN THE OTHER CASES

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CHRONIC CHOLECYSTITIS

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SIGNS AND SYMPTOMS

Rt HYPOCHONDRIAL PAIN- DISCOMFORT TO EXCRUTIATING

PAIN(BILIARY COLIC) RIADITES TO THE Rt SHOULDER PRESIPITATED BY FATTY MEAL ASSOCIATED BY NAUSEA AND VOMITING TENDERNESS IN THE Rt HYPOCHONDRIUM MURPHY’S SIGN MAY BE POSITIVE(IF PAIN LASTS MORE THAN 12 HOURS,

TEPERATURE INCREASE, AND WBC INCREASE, CONSIDER THE DIAGNOSIS OF AC CHOLECYSTITIS)

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DIAGNOSIS

ULTRASONOGRAPHY IS USUALLY THE ONLY INVESTIGATION REQUIRED

TREATMENTANALGESICS INCLUDING OPIATES

(SIMULTANEOUS INJECTION OF HYOSCINE BUTYLBROMIDE IS NEEDED TO ENCOUNTER THE EFFECT OF OPIATES ON THE SPHINCTER OF ODDI)

ANTIEMETICSLOW FAT DIET UNTIL------CHOLECYSTECTOMY(DISSOLUTION OF GALL STONES HAS NO LONGER

A ROLE IN THE TREATMENT OF GALL STONES)

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ACUTE CALCULOUS CHOLECYSTITIS

THE GALL BLADDER OFTEN ALREADY AFFECTED BY CHRONIC CHOLECYSTITIS

95% OF CASES THE STON IS IMPACTED IN THE HARTMANN’S POUCH OR OBSTRUCTING THE CYSTIC DUCT

MICRO-ORGANISMS CAN BE ISOLATED IN MOST OF THE CASES FROM THE BILE OR GB WALL

(E.COLI, STRTEP.FECALIS, BACTEROIDES, RARELY CLOSTRIDIA AND TYPHOID)

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ACUTE CHOLECYSTITIS

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SEQUELAE OF ACUTE CHOLECYSTITIS

1. RESOLUTION- BY BACK SLIPPING OF THE STONE(MUCOUS MEMBRANE LIFTING), AND RELEASE OF MUCOID OR MUCOPURULENT CONTENT

2. EMPYEMA(PYOCELE)- WHEN THE OBSTRUCTION PERSISTS

3. PERFORATION- LEADS TO LOCAL ABSCESS OR GENERALIZED PERITONITIS

(FUNDUS AND NECK)

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SIGNS AND SYMPTOMS

PAINNAUSEA AND VOMITINGPYREXIA(38C OR MORE)TENDERNESSMURPHY’S SIGNPALPABLE GBBOAS’S SIGN

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DIAGNOSIS

ULTRASONOGRAPHY

DIFFERENTIAL DIAGNOSISAPPENDICITISPERFORATED PEPTIC ULCERACUTE PANCREATITISACUTE PYELONEPHRITIS (Rt)MYOCARDIAL INFARCTIONBASAL PNEUMONIA (Rt)

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TREATMENT

1.CONSERVATIVE TREATMENT FOLLOWED BY CHOLYCYSTECTOMY

(90% OF CASES WILL SUBSIDE) BY – A. NASOGASTRIC ASPIRATION B. I V FLUID C. ANALGESIA D. ANTIBIOTICS (AGAINST GRAM -NEGATIVE

AEROBES) C. INTERVAL CHOLECYSTECTOMY (4-6

MONTHS) AFTER THE ACUTE EPISODE HAS

RESOLVED

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2. EARLY CHOLECYSTECTOMY – SHOULD BE DONE WITH IN 72 HOURS FROM THE ONSET OF ACUTE SYMPTOMS (GOLDEN PEROID)

3. EMERGENCY CHOLECYSTECTOMY- DONE AT ANY TIME NEEDED, WHEN DIAGNOSIS IS DOUBTFUL(ACUTE HIGH RETROCAECAL APPENDICITIS)

OR WHEN THERE IS PERFORATION

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MUCOCELE AND EMPYEMA

MUCOCELE- THE BILE IS ABSORBED AND REPLACED BY MUCIN SECRETION(STERILE BLADDER NECK OBSTRUCTION BY A STONE OR MALIGNANCY)

EMPYEMA- GALL BLADDER FILLED WITH PUS EITHER AS A SEQUELE OF AC CHOLECYSTITIS OR A MUCOCELE BECOME INFECTED

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MUCOCELE OF THE GB

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MUCOCELE OF THE GB WITH STONE IN THE HART. POUCH

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ACALCULOUS CHOLECYSTITISCHOLECYSTOSIS

NOT UNCOMMON GROUP OF CHRONIC INFLAMATION AND HYPERPLASIA OF ALL TISSUE ELEMENT-

1. CHOLESTEROSIS(STRAWBERRY GB)- WITH A STRAWBERRY INTERIOR AND YELLOW SPECKS (SEEDS OF CHOLESTEROL CRYSTALS)

2. CHOLESTEROL POLYPS- MUCH LESS NUMEROUS AND LARGER THAN THE YELLOW SEEDS

3. CHOLYCYSTITIS GLANDULARIS PROLIFERANS- (POLYPS, ADENOMYOMATOSIS,

INTRAMURAL DIVERTICULOSIS)

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NEW TECHNIQUES FOR GALL STONES

1. LITHOTRIPSY- EXTRACORPORIAL SHOCK WAVE

2. PERCUTANEOUS CHOLECYSTOLITHOTOMY- USING A NEPHROSCOPE UNDER US CONTROL

3. LAPAROSCOPIC CHOLECYSTECTOMY

4. MINICHOLECYSTECTOMY

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INDICATIONS FOR CHOLEDOCHOTOMY AT

CHOLECYSTECTOMY1. STONES FELT IN THE CBD2. THERE IS JAUNDICE OR HISTORY

OF JAUNDICE OR RIGOR(CHOLANGITIS)

3. DILATED CBD(10mm OR MORE)4. ABNORMAL LFT IN PARTICULAR A

RAISED ALKALINE PHOSPHATASE5. PRESENCE OF SINGLE FACTED

STONE IN THE GALL BLADDER

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POSTCHOLECYSTECTOMY SNDROME

PERSISTENCE OF SYMPTOMS AFTER GALL BLADDER REMOVAL DUE TO-

1. DISEASES OTHER THAN THE BILIARY TRACT(HIATUS HERNIA, PEPTIC ULCER, PANCREATITIS, DIVERTICULITIS OR IRRITABLE BOWWEL SYNDROME)

2. BILIARY CAUSES- A- RETAINED STONE IN THE CBD

B- LONG CYSTIC DUCT STUMP IS LEFT

C- CBD OPERATIVE DAMAGE (STRICTURE FORMATION)

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STONES IN THE COMMON BILE DUCT

EITHER SECONDARY DUE TO PASSAGE OF STONES FROM THE GALL BLADDER OR RARELY PRIMARY STONES OCCUR WITH IFESTATION OF THE BILIARY TREE BY ASCARIS LUMBRICOIDES AND CLONORCHIS SINUNSIS.

THESE STONES EITHER LEAD TO OBSTRUCTION OR INFECTION)CHOLANGITIS)

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SIGNS AND SYMPTOMS

ASYMPTYMATICPAINJAUNDICE (INTERMITTENT OR

PERSISTENT)(DARK URINE,PALE STOOL, PRURITIS)

FEVER AND RIGOR (CHOLANGITIS) (CHARCOT’S TRIAD)TENDERNESSIMPALPABLE GB (FIBROTIC AND

INCOMPLETE OBSTRUCTION) { COURVOISIER’S LAW }

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DIFFERENTIAL DIAGNOSIS

PANCREATIC CAVIRAL HEPATITISDRUG INDUCESPRIMARY BILIARY CIRRHOSIS

DIAGNOSISUS, ERCP, PTC

COMPLICTIONSBILIARY CIRRHOSISSUPPURATIVE CHOLANGITIS (LIVER

ABSCESSES, SEPTICAEMIA)

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PRE-OPERATIVE MANAGEMENT OF

OBSTRUCTIVE JAUNDICE1 .HIGH INTAKE OF GLUCOSE (BUILD

UP LIVER GLYCOGEN STORE)2 .VITAMIN K (FAT SOLUBLE), 10mg

IV OR IM3 .ANTIBIOTICS (BROAD

SPECTURUM)4 .HYDRATION (PEVENT RENAL

FAILURE) (5% DEXTROSE TO ENSURE 30 ml/HOUR URINE FLOW)

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SURGICAL PROCDURES1. ENDOSCOPIC PAPILLOTOMY (DORMIA

BASKET, BALLOON CATHETER)(STENT TO RELIEVE SYMPTOMS)

2. PERCUTANEOUS REMOVAL OF STONES BY BURHENNE METHOD (T- TUBE LEFT FOR SIX WEEKS AND THEN REMOVED, DILATION OF THE MATURE TRACT, STEERABLE CATHETER, AND THEN STONE BASKET)

3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN THE VERY ILL

4. SUPRADUODENAL CHOLEDOCHOTOMY WITH OR WITH OUT TRANSDUODENAL SPHINCTEROTOMY OR CHOLEDOCHODUODENOSTOMY

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EXPLORATION OF THE CBD

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DORMIA BASKET

ERCP

DILATED CBD

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STRICTURE OF THE CBD

BENIGN– POSTOPERATIVE 80% INFLAMMATORY MALIGNANT

POSTOPERATIVE STRICTUREDUE TO TEQUNICHAL ERROR DURING

CHOLECYSTECTOMY( 15% ONLY RECOGNIZED DURING SURGERY)

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CAUSES- 1. BLIND HAEMOSTAT APPLICATION IN AN EFFORT TO STOP UNEXPECTED BLEEDING ( PRINGLE’S MANOEUVRE )

2. TOO MUCH TRACTION ON THE GB 3. FAILURE TO IDENTIFY CALOT’S TRIANGLE(MUCH INFLAMMATION)

4. IGNORANCE OF THE ANATOMICAL ANOMALIES

5. LACERATION OF CBD (DURING EXPLORATION)

PRESENTED EITHER AS A- PROFUSE BILIARY FISTULA OR BILIARY PERITONITIS (DRIN OR NO DRAIN) B- DEEPENING JAUNDICE (BY SUSEQUENT FIBROSIS)

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INVESTIGATION

US, T-TUBE CHOLANGIOGRPHY, ERCP, PTC

TREATMENTIMMEDIATE ROUX EN Y

CHOLEDOCHOJEJUNOSTOMY IS THE BEST FOR BENIGN STRICTURES AND COMPLETE CBD TRANSECTION

IN DEBILITATING PATIENTS, AN EXTERNAL DRAINAGE CATHETER OR BALLOON DILATION AND A STENT

FOR MALIGNANT STRICTURES CHOLECYSTOJEJUNOSTOMY

CHOLEDOCHOJEJUNOSTOMY STENTING

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CARCINOMA OF THE BG

IT IS RARE AND FOUND IN LESS THAN 1% OF GB OPERATIONS, GALL STONES FOUND IN OVER 90% OF CASES, PATIENTS USUALLY IN THEIR 70S, FEMALE:MALE RATIO OF 5:1

THE USUAL TYPE IS SCIRRHOUS CA, BUT SEQUAMOUS OR MIXED SEQUAMOUS-ADENOCARCINOMA MAY BE FOUND

SPREAD BY DIRECT INVASION OF THE LIVER AND TO THE PORTA HEPATIS

DISTANT METASTASES ARE UNCOMMON

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SIGNS AND SYMOTOMS

IT MAY BE FOUND DURING CHOLECYSTECTOMY

MASS DUE TO THE TUMOUR OR OBSTRUCTION OF CYSTIC DUCT WHICH LEADS TO MUCOCELE

CHOLECYSTITIS(OBSTRUCTION OF THE CYSTIC DUCT)

JAUNDICE IN MORE THAN 50% OF CASES

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TREATMENT

RESECTION OF THE GB WITH THE ADGACENT PART OF THE LIVER

PALLATION TO RELIEVE JAUNDICE(STENT)

5 - YEAR SURVIVAL RATE IS 2-5%, BUT IF THE TUMOUR FOUND DURING CHOLECYSTECTOMY, IT WILL REACH MORE THAN 50%

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CHOLANGIOCARCINOMA(BILE DUCT CARCINOMA)

IT IS MORE COMMON THAN GB CARCINOMA

STONES PRESENT IN LESS THAN 30% OF CASES

MALE ARE SLIGHTLY MORE THAN FEMALE

USUALLY ADENOCARCINOMATHE PATIENTS ARE OLD AND

PRESENTS LATER

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TRATMENT

HILAR LESIONS RARELY RESECTABLE, AND MAY NEED EXTERNAL DRAINAGE

FOLLOWED BY RADIOTHERAPYTUMOURS OF THE LOWER END MAY BE

TREATED BY WHIPPLE’S OPERATION, OR STENTING

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BILIARY FISTULASEXTERNAL AND INTERNAL1 .EXTERNAL FISTULAS- NEARLY ALL FOLLOW BILIARY

OPERATION ON THE BILIARY TRACT OR DUODENUM, FROM INJURY OR LEAKINK ANASTOMOSIS

IT MAY PERSIST IF THERE IS DISTAL OBSTRUCTIONCAN BE ASSESSED BY SINOGRAM OR ERCP2. INTERNAL FISTULAS- WHEN A GALL STONE ULCERATE

THROUGH THE GB INTO THE STOMACH, DUODENUM, OR COLON

IT MAY CAUSE AIR TO BE SEEN IN PLAIN RADIOGRAPH IF LARGE ENOUGH, IT MAY LEAD TO SMALL BOWEL

OBSTRUCTIONOBSTRUCTION OF THE COLON GIVES THE SUSPITION OF

UNDERLYING CARCINOMA CAUSING NARROWING OF THE LUMEN

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LAPAROSCOPIC CHOLECYSTECTOMY

THE INDICTION ARE THE SAME AS FOR OPEN CHOLECYSTECTOMY

ADVANTAGES1. LESS POST-OPERATIVE PAIN2. SMALLER INCISIONS3. BETTER COSMESIS4. SHORTER HOSPITALIZATION5. EARLIER RETURN TO FULL ACTIVITY6. DECREASED TOTAL COSTS

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DISADVANTAGES

1. LACK OF DEPTH PERCEPTION2. VIEW IS CONTROLLED BY CAMERA3. MORE DIFFICULT TO CNTROL BLEEDING4. DECREASD TACTILE DISCRIMINATION5. POTENTIAL CO2 INSUFFLATION

COMPLICATIONS6. ADHESIONS AND INFLAMMATION LIMIT

ITS USE7. SLIGHT INCREASE IN BILE DUCT INJURY

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COMPLICATIONS OF LC

A. GENERAL- 1. HEMORRHAGE 2. BILE DUCT INJURY 3. BILE LEAK 4. RETAINED STONES 5. PANCREATITIS 6. WOUND INFECTION

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B. PNEUMOPERITONEUM RELATED 1. C02 EMBOLISM 2. VASO-VAGAL RFLEX 3. CARDIAC

ARRYTHMIAS 4. HYPERCARBIC

ACIDOSISC. TROCAR RELATED 1. ABDOMINAL WALL

BLEEDING, HEMATOMA 2. VISCERAL INJURY 3. VASCULAR INJURY

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LC THEATR

E

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VERES NEEDLE

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TELESCOPE

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DISSECTING CALOT’S

TRIANGLE

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GB DISSEC. BY DIATHERMY

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GB RETRIEVAL BAG