Grand Round Presentation – 21/11/06. Prologue: Journey Of The Stone Overview of the biliary...
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Transcript of Grand Round Presentation – 21/11/06. Prologue: Journey Of The Stone Overview of the biliary...
Grand Round Presentation – 21/11/06
Prologue: Journey Of The Stone
Overview of the biliary system & related organs
Presentation of 2 patients with gallstones
Pathology & aetiology of gallstones
Problems associated with gallstones
Investigation & management of gallstones
Fig 1: The Biliary System
Fig 2: ERCP - Contrast
Fig 3: ERCP - Sphincterotomy
Fig 4: ERCP - Endoscope
Fig 5: Double Pig-Tail Stent
Fig 5: MRCP
Fig 6: Gallstone Pancreatitis
Chapter 3: The Birth Of A Gallstone
Risks: 4 F’s: Fat, Fertile Females of Forty.
Also diet, rapid weight loss, drugs (OCP), diabetes
80% cholesterol-based, 20% pigment (Ca-bilirubinate):
Cholesterol & bile salts secreted from hepatocytes & stored in gallbladder
Stones form on a nidus (mucins) often when motility is ↡
3.1: Heart Of Stones
Cholesterol: super-saturation with relation to bile salts. Predisposes as cholesterol can precipitate on nidus
Pigment: black (Ca-salts & glycoproteins) which are associated with haemolysis
Pigment: brown (Ca-salts & fatty acids); occur during stasis. Can cause recurrent stones post-cholecystectomy
Cholesterol stones missed on radiographs as radiolucent
Chapter 4: Struggles With The Stones
Most are asymptomatic (80%), discovered incidentally
Biliary Colic +/- nausea, vomiting & jaundice
Aggravated by food (especially fatty), relieved by opiates
2ndry complications associated with pyrexia & ↟ pain
Cholecystitis (acute or chronic), empyema, mucocele, pancreatitis, cholangitis, perforation, fistulae & gallstone ileus
4.1: Judging The Jaundice
Unconjugated (haemolytic) or conjugated (congenital or cholestatic)
Biliary Obstruction: Intra-hepatic or Extra-hepatic: Extra-ductal or Intra-ductal
Intra-hepatic: Hepatitis, Cirrhosis, Drugs, Pregnancy. Associated with ↟ AST & ALT
Extra-hepatic: Carcinoma, strictures, inflammation, gallstones. Associated with ↟ ALP & GT
4.2: Problems With The Pancreas
GET SMASHED!• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps
• Autoimmune (PAN)
• Scorpion Sting
• Hyper -lipidaemia -Ca2+, Hypothermia
• ERCP, Emboli
• Drugs
4.2: Problems With The Pancreas
(…cont’)
Age > 55 years
pO2 < 8 mmHg
Glucose > 10 mmol/l
Blood Urea Nitrogen > 46 mg/dl
Calcium < 2 mmol/l
LDH > 600 u/l
WBC > 15 x109/l
Albumin < 32 g/l
Glasgow Modified Severity Scale (>3 = Severe)
Also APACHE-II, Ranson & Multi-Organ System Failure
Chapter 5: Chasing The Calculi
Clinical: History & Examination (jaundice, pain)
Bloods: ↟ ALP +/- amylase & bilirubin if obstructed
Radiograph / CT not useful without contrast
USS: imaging investigation of choice: non-invasive, accurate, cheap, sensitive (95%). Can be endoscopic
MRCP: T2, better for visualising ducts & level of calculi but not as sensitive in early dilatation
5.1: Removing The Rock
ERCP: Uses contrast to visualise biliary tree. Can be used to remove stones from CBD, insert stents and perform sphincterotomies. Can cause pancreatitis (5%)
Percutaneous transhepatic cholangiogram (PTC) sometimes used if close to the liver
If asymptomatic manage conservatively
Medical interventions include: shockwave lithotripsy, ursodeoxycholic acid (↡cholesterol secretion) & bile salts
5.1: Removing The Rock
Surgical includes laparoscopic & open cholescystectomy
Most laparoscopic. Incision in umbilicus, fill peritoneum with gas, insert light. 3 more incisions in RUQ for instruments. CD clipped & gallbladder removed in bag
5% need to convert to open: midline scar
Complications if wrong duct clipped, infection, perforation and if stones spilled into peritoneum or ducts
(…cont’)
Epilogue: Legacy Of The Stone
Gallstones are a common problem in the middle-aged and elderly population but are often asymptomatic
Diagnosis often made on history & examination +/- USS
Obstruction may present with jaundice & complications
MRCP & ERCP often used in cases of obstruction
Medical treatment may be used but most often laparoscopic cholecystectomy is performed
References: Writings On The Stone
Burroughs AK, Westaby D: Liver, biliary tract and pancreatic disease, In Kumar P, Clark M: Clinical Medicine (5th Edition). WB Saunders, 2002
Longmore M, Wilkinson I, Török E: Oxford Handbook Of Clinical Medicine. Oxford University Press, 2001
Adamek HE, Albert J, Weitz M: A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut, 1998; 43(5): 680-683
Ahmed A, Cheung RC, Keeffe EB: Management of gallstones and their complications. Am Fam Physician, 2000; 61(6): 1673-1688
Werner J, Feuerbach S, Uhl W, Buchler MW: Management of acute pancreatitis: from surgery to interventional intensive care. Gut, 2005; 54(3): 426-436