Cholelithiasis final year mbbs lecture
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Transcript of Cholelithiasis final year mbbs lecture
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GALLSTONES
by; Mr. ADEEL ABBAS
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• 20% are Cholesterol Stones.• 5% are Pigment Stones.• 75% are Mixed… … …
• In Asia 80% Pigment Stones.
• In Europe 80% Cholesterol Stones.
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Risk Factors
• BIG 4..?1. Female.2. Forty.3. Fertile.4. Fatty.
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Risk Factors
• Pregnancy.• OCP.• Hemolytic Anemia.• Cirrhosis.• Infection.• IBD/Terminal Ileal Resection.• TPN.• Hyperlipidemia.
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Pathogenesis
• Excess secretion of Cholesterol in Bile.• Excess Mucous Production.• Non-Functioning Gallbladder.• Stasis in Gallbladder.
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Pathological Effects
1. Silent Gallstones.2. Obstruction of the Cystic Duct.3. Movement of Stone into CBD.4. Ulceration of Stone through Gallbladder
Wall.
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Clinical Presentation
1. Biliary Colic.2. Acute Cholecystitis.3. Chronic Cholecystitis.4. Gallstone Pancreatitis.5. Obstructive Jaundice.6. Acute Cholangitis.7. Gallstone Ileus.8. Mucocele / Empyema of the Gallbladder.
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1. Biliary Colic
• Episodic Pain in RHC / Epigastrium.• Pain Radiates to Lower Pole of Right Scapula.• Sweaty, Nauseous, Vomiting Patient.• Intermittent Jaundice with Pale Stool & Dark Urine.
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• Differential Diagnosis:– Renal Colic.– Intestinal Obstruction.– Angina.
• Pain Episode may Resolve when Stone is Passed into CBD / Falls Back into the Gallbladder.
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2. Acute Cholecystitis
• Sever, Constant & Localized RHC Pain.• Fever / Toxaemia / Rigors / Leucocytosis.• Tenderness in RHC / Murphy’s Sign.• Palpable Gallbladder.• Complications;– Empyema.– Perforation.– Obstructive Jaundice.– Acalculous Cholecystitis.
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Murphy’s Sign
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Chronic Cholecystitis
• Repeated Inflammation resulting in Fibrosis & Thickening of Gallbladder.
• Longstanding Dyspepsia with Episodic Cholecystitis.
• Differential Diagnosis:– Peptic Ulcer.– Hiatus Hernia.– Angina.
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Gallstone Pancreatitis
• Due to Transient Blocking of Ampulla of Vater by Stone.
• Especially when Stones are Small & Numerous.
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Obstructive Jaundice
• Acute Onset.• History of Pain.• Non-Palpable Gallbladder.
• Courvoisier’s Law..?????
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Acute Cholangitis
CAUSE … ?
• Infection of Bile In the Biliary Tree…
• Charcot’s Triad … ?
1. Pain.2. Fever.3. Jaundice.
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• Predisposing Factors;– Stone in CBD.– Biliary Stricture.– Post – ERCP.– Post – Biliary Reconstructive Procedure.
• Antibiotics & Resuscitation followed by Decompression of Biliary Tree.
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Gallstone Ileus
• Gallstones may Erode into Duodenum / Colon.• Gallstone lodge at Level of Meckel’s Diverticulum /
Ileocaecal Valve.
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• Present as Acute Abdomen.
• Treat by;– Drip & Suck.– Urgent Laparatomy.
Cholecysto-Enteric Fistula LEFT UNTIL ACUTE EPISODE IS OVER.
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Investigations (for Gallstones)
• Ultrasound.• LFTs.• ERCP / MRCP.• AXR.• CT Scan
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Ultrasound Pictures
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Ultrasound
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ERCP
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MRCP
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CT SCAN
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Treatment
• Conservative Management for Acute Cholecystectomy.
• Laparoscopic Cholecystectomy.• Open Cholecystectomy.• Cholecystostomy.• Medical Treatment;– Chenodeoxycholic Acid.
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Acute Cholecystitis
• Principles of Management:– Admission to Hospital.– Pain Relief.– NPO.– IV Fluids.– Broad Spectrum Antibiotics.– Elective / Emergency Cholecystectomy.
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Laparoscopic Cholecystectomy
• Preoperatively;– U/S + LFT + Clotting Screen.– Exclude Peptic Ulcer & Hiatal Hernia.– Encourage Weight Loss & Smoking Cessation.– Consent.
• Ports;– 3 or 4 Ports.
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• Closure.• Postoperatively;– Orally Allowed when fully recovered.– Home in 24hrs when Pain-Free.
• Complications;
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THANK YOU . . . !