gall bladder and biliary disease

Gall bladder and Biliary Gall bladder and Biliary diseasedisease

Dr.Umit AkyuzDr.Umit Akyuz

Gastroenterology DepartmentGastroenterology Department

Yeditepe University,IstanbulYeditepe University,Istanbul

Biliary stone diseaseBiliary stone disease

Acute cholecytitisAcute cholecytitis

Primer sclerosane cholangitisPrimer sclerosane cholangitis

Primer biliary cirrhosisPrimer biliary cirrhosis

TumorsTumors

CHOLELITHIASISCHOLELITHIASIS

Chole – Chole – CYSTOCYSTO - GALLBLADDER- GALLBLADDER

- - DOCHODOCHO – D. CHOLEDOCHUS – D. CHOLEDOCHUS

CHOLESTEROLCHOLESTEROL %75%75

PIGMENT(blb, ca)PIGMENT(blb, ca) % 25% 25

CHOLESTROL STONESCHOLESTROL STONES

CHARACTERISTICS: CHARACTERISTICS: – PURE OR MIXEDPURE OR MIXED

– SMALL OR LARGESMALL OR LARGE

– SOLITARY OR MULTIPLESOLITARY OR MULTIPLE

PIGMENT STONESPIGMENT STONES• CHARACTERISTICS:

– ELDERLY

– HEMOLYTIC STATES

– CIRRHOSIS

– MULTIPLE, IRREGULAR

– CENTRAL CALCIFICATION

RISK FACTORSRISK FACTORS

4 4 FF : :– FFemaleemale– FFatat– FFertileertile– FFortyorty

3 D3 D– DDiabetesiabetes– DDrugsrugs– DDietiet

2 H2 H– HHLPLP– HHeredityeredity

Bile Salt MalabsorbtionBile Salt Malabsorbtion

COMPLICATIONSCOMPLICATIONS

STONE – PASSAGESTONE – PASSAGE– HYDROPS HYDROPS

– CHOLECYSTITISCHOLECYSTITIS

– ICTERUSICTERUS

Ac. CHOLECYTITISAc. CHOLECYTITIS

EMPYEMAEMPYEMA

PERFORATIONPERFORATION

Chr. CHOLECYTITISChr. CHOLECYTITIS

CLINICSCLINICS

COLIC:COLIC:– RUQ crampy PainRUQ crampy Pain

RADIATIONRADIATION BACKBACK

DYSPEPSIADYSPEPSIA

Ac. CHOLECYTITIS Ac. CHOLECYTITIS ++ COMPLICATIONS COMPLICATIONS

DIAGNOSISDIAGNOSIS

• USG• X-Ray Plain Film• ERC / P• PTC• CT

THERAPYTHERAPY

SpasmolyticaSpasmolytica

AntibioticsAntibiotics

SURGERYSURGERY– Absolute ComplicationsAbsolute Complications

– Relative ComplicationsRelative Complications

Medical:Medical:– Oral LytholysisOral Lytholysis

– Ursodeoxy-cholic AcidUrsodeoxy-cholic Acid

– ESLWESLW

therapytherapy

ACUTE CHOLECYSTITISACUTE CHOLECYSTITISAcute InflammationAcute Inflammation

PrimaryPrimary AbacterialAbacterial

SecondarySecondary BacterialBacterial

• Enterococcus• E. Coli• Gr. (-) Bacilli• Anaerobs

– Bacteroides– Clostridia– Fusobacterium

SymptomsSymptoms

Biliary colicBiliary colic

Fever, chills, anorexia, nausea, vomitingFever, chills, anorexia, nausea, vomiting

Enlarged GallbladderEnlarged Gallbladder

Murphy’s sign :Murphy’s sign :

RUQ-PalpationRUQ-Palpation

increased Pain inincreased Pain in

InspirationInspiration

Diagnosis: Clinics, US, biochemistryDiagnosis: Clinics, US, biochemistry

ComplicationsComplications

EmpyemaEmpyema

GangreneGangrene

PerforationPerforation

IleusIleus

TherapyTherapy

PE - NutritionPE - Nutrition

AntibioticsAntibiotics

Cholecystectomie ?Cholecystectomie ?

for Complications !for Complications !

CHOLANGITISCHOLANGITIS

Charcot’s Charcot’s Biliary Biliary painpain

TriadTriad JaundiceJaundice

FeverFever

BacteriaBacteria

E. coliE. coli

KlebsiellaKlebsiella

ProteusProteus

E. bacterE. bacter

PseudomonasPseudomonas

ClostridiumClostridium

ComplicationsComplications

SepsisSepsis

Hepatic AbcessHepatic Abcess

Bil. StricturesBil. Strictures

GallstonesGallstones

Sec. Bil. CirrhosisSec. Bil. Cirrhosis

PHTPHT

TreatmentTreatment

ERCPERCP

AntibioticsAntibiotics

Primary Sclerosing CholangitisPrimary Sclerosing Cholangitis

İdiopathicİdiopathicintra+extrahepaticintra+extrahepaticChronicChronicFibrosing,Fibrosing,Diffuse Diffuse of bile Ductsof bile DuctsClinics:Clinics:

CholestasisCholestasisBile D. ObliterationBile D. ObliterationCirrhosisCirrhosis

ClinicsClinics

JaundiceJaundicePruritusPruritusFatiqueFatiqueWeight lossWeight loss

UCUC 75 %, 75 %, CD CD, , RRA, Sarcoidosis,A, Sarcoidosis, Sjögren SyndromeSjögren Syndrome

M/F 1/3M/F 1/3

ANCA + ; ANCA + ; IgM IgM

Complications Complications 5 – C5 – C

CholestasisCholestasis

CirrhosisCirrhosis

CholangitisCholangitis

CholelithiasisCholelithiasis

CholangiocarcinomaCholangiocarcinoma

TherapyTherapy

ABAB

CholestyramineCholestyramine

UrsodeoxycholicacidUrsodeoxycholicacid

Surgical : Liver Transplantation !Surgical : Liver Transplantation !

Primary Biliary CirrhosisPrimary Biliary Cirrhosis

İnterlobuler and septal bile ductsİnterlobuler and septal bile ducts

Middle aged populationMiddle aged population

100-150/1 million100-150/1 million

ClinicsClinics

FatigueFatigue

PiruritisPiruritis

AsymtomaticAsymtomatic

JaundinceJaundince

Variciel bleedingVariciel bleeding

ascitesascites

Assosiated DiseaseAssosiated Disease

keratoconjuctivites sikka (50%)keratoconjuctivites sikka (50%)

Thyroid disease (15%)Thyroid disease (15%)

Artrithes (10%)Artrithes (10%)

Reynaud (9%)Reynaud (9%)

SclerodermaScleroderma

Renal stonesRenal stones

Breast cancerBreast cancer

DiagnosisDiagnosis

AMA >1/40 (M2 band) 95%AMA >1/40 (M2 band) 95%

AST, ALT highAST, ALT high

IgM highIgM high

Biluribune highBiluribune high

Hypercholesterolemia 80%Hypercholesterolemia 80%

Pathology: florid duct lesionsPathology: florid duct lesions

ComplicationsComplications

OsteopeniaOsteopenia

Fat soluble vit. DeficiencyFat soluble vit. Deficiency

hypercholesterolemiahypercholesterolemia

TreatmentTreatment

Ursodeoxycholic acidUrsodeoxycholic acid

CorticosteroidsCorticosteroids

AzothioprineAzothioprine

CyclosporineCyclosporine

MethotraxateMethotraxate

Penicilamine,colhicine no benefitPenicilamine,colhicine no benefit

TransplantationTransplantation

TUMORSTUMORS

BENIGNBENIGN– PolipsPolips– AdenomyomatosisAdenomyomatosis– CholesterosisCholesterosis

MALIGNMALIGN– CarcinomaCarcinoma– AdenoAdeno– SquamousSquamous

Ductus CarcinomaDuctus Carcinoma– Pat Pat 60 Years60 Years