Download - 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