L10: Biliary Disorders

Question 1

Anatomy of Gall Bladder

Answer 1

Question 2

Capacity of Gall Bladder

Answer 2

30-50 ml

Question 3

Types of Gall Bladder Stones

Answer 3

• Cholesterol stones
• Pigment stones (20%)

Question 4

Cholesterol Stones

Answer 4

Question 5

Pigment Gall Bladder Stones

Answer 5

Question 6

Characters of Biliary Pain in Gall Bladder Stones

Answer 6

Question 7

Gall Bladder Stones

Physical Examination

Answer 7

• Tenderness to deep palpation (No rebound).
• Murphy sign (inspiratory arrest during deep palpation of the RUQ).

Question 8

Investigations for Gall Bladder Stones

Answer 8

Question 9

ECG in Gall Bladder Stones

Answer 9

to exclude myocardial ischemia (Pain may be due to myocardial ischemia).

Question 10

Lab tests in Gall Bladder Stones

Answer 10

Question 11

US in Gall Bladder Stones

Answer 11

Question 12

Radionuclide scanning (HIDA) in Gall Bladder Stones

Answer 12

Question 13

CT Scan in Gall Bladder Stones

Answer 13

• Less sensitive than US to detect gallstones.
• Only 20% radiopaque.
• Most useful to exclude other causes of upper abdominal pain such as aortic aneurysm, perihepatic abscess, or pancreatic pseudocyst.
• Detects rare complications such as air in GB wall in emphysematous cholecystitis or air-filled GB in biliary-enteric fistula.

Question 14

Plain Radiograph in Gall Bladder Stones

Answer 14

Most useful for diagnosis of intestinal obstruction.

Question 15

DDx of Gall Bladder Stones

Answer 15

Causes of upper abdominal pain
- e.g. MI, Acute cholecystitis, cholangitis, Acute pancreatitis, Intestinal obstruction,
PUD, RLL pneumonia,

Question 16

Managment of Gall Bladder Stones

Answer 16

Question 17

Admission Criteria of Gall Bladder Stones

Answer 17

Question 18

Discharge Crireria of Gall Bladder Stones

Answer 18

Question 19

Complications of Gall Bladder Stones

Answer 19

Question 20

Etiology of Cholecystitis

Answer 20

• Acute calculous cholecystitis
• Acalculous cholecystitis (10%)

Question 21

Managment of Cholecystitis

Answer 21

Admission Criteria

• All cases of cholecystitis should be admitted for
  parenteral antibiotics, analgesia, fluid replacement,
  and cholecystectomy in 24 - 72 hr.
• Unstable patients (gallbladder perforation or
  sepsis) require immediate surgery

Question 22

Def of Cholangitis

Answer 22

Partial or complete CBD obstruction:
- Gallstones, tumor, cyst, or Stricture.

Question 23

Symptoms of Cholangitis

Answer 23

Question 24

Managment of Cholangitis

Answer 24

Admission Criteria

• All patients should be admitted for IV antibiotic and possible biliary drainage
• Admit patients with signs of septic shock
  to the ICU.

Question 25

Epidemology of **GB Cancer**

Answer 25

- Rare malignancy - Usually affecting elderly patients. - Associated with gall-stones (in 70–90% of cases), calcified (“porcelain”) gallbladder and gallbladder polyps > 1 cm in diameter

Question 26

Prophylactic cholecystectomy should particularly be considered for .....

Answer 26

calcified (“porcelain”) gallbladder and gallbladder polyps > 1 cm in diameter

Question 27

Clinical Features of **GB Cancer**

Answer 27

 RUQ discomfort, weight loss, and jaundice.  A hard, tender mass is sometimes felt in GB region.  Occasionally condition is asymptomatic.

Question 28

Investigations for **GB Cancer**

Answer 28

Question 29

Managment of **GB Cancer**

Answer 29

 Surgical resection rarely curative as cancer spreads early to surrounding structures, including liver.  No clear role for systemic chemotherapy or radiotherapy.  Palliative approaches include biliary stenting to relieve jaundice,

Question 30

Mean survival Rate of **GB Cancer**

Answer 30

Mean survival rate is six months, and the five-year survival rate < 5%.

Question 31

def of **Gallstone Ileus**

Answer 31

Mechanical intestinal obstruction due to gallstone impaction within bowel lumen.

Question 32

Size of Stone in **Gallstone Ileus**

Answer 32

Stone is usually >2.5 cm.

Question 33

Epidemeology of **Gallstone Ileus**

Answer 33

 Most cases occur in patients >65 years.  Female > Male 5:1

Question 34

Pathogenesis of **Gallstone Ileus**

Answer 34

 Cholecystenteric fistula develops, permitting stone passage into intestine.  Duodenum is most common site of fistula formation.  Terminal ileum is most common site of impaction.

Question 35

Rigler Triad **Gallstone Ileus**

Answer 35

Question 36

Etiology of **GB Empyema**

Answer 36

- The presence of pus within the gallbladder. - It usually develops following acute cholecystitis, or cystic duct obstruction due to tumor e.g., cholangiocarcinoma.

Question 37

Symptoms of **GB Empyema**

Answer 37

Usually presents with RUQ pain and sepsis.

Question 38

Complications of **GB Empyema**

Answer 38

GB perforation with subsequent peritonitis is an important complication if left untreated.

Question 39

Dx of **GB Empyema**

Answer 39

CT or U/S may show a distended, fluid-filled GB, with pericholecystic fluid.

Question 40

TTT of **GB Empyema**

Answer 40

- IV antibiotics (e.g., 3rd generation cephalosporin & metronidazole). - Percutaneous GB drain insertion. - Cholecystectomy is usually delayed because of high rate of post-operative septic complications

Question 41

Done