THE GALLBLADDER AND BILE DUCTS Functions of gallbladder : Reservoir of bile Concentration of bile ( active absorp of h20, nacl,co3)

o3) Secretion of mucocele ( if obstruct can cause mucocele)

+ murphys sign suggest acute inflammation + leucocytosis + moderately elevated LFT No resolution = empyema ( wall bcome necrotic + perforate = peritonitis ) Palpable, non tender gall bladder = courvoisiers sign 6. Treatment : biliary colic / cholecystitis = cholecystectomy Conservative tx followed by choles NPO + IV fluids Analgesics Antibiotics ( BSA effective against gram aerobes eg; cefuroxime, cefazolin, gentamicin ) Subsequent mx temp, pulse other p.e sign shows infalmmtion subside change iv fluid to regular diet) . Then, choles is performed

GALLSTONES ( CHOLELITHIASIS ) 1. Etiology : 3 main types , cholesterol, pigment ( brown/black) or mixed stones 5F ( fat , forty, fertile, female, fair ) 2. Clinical presentation : Ruq/epi pain may radiate to the back Colicky but more often as dull and constant Others : dyspepsia, flatulence, food intolerance( fat ), alteration bowel fre. Biliary colic severe ruq pain assoc with nausea n vomiting.Pain may radiate to chest. Severe pain wakes pt at night. 3. Complication of gallstone : Biliary colic Acute cholecystitis Chronic cholecystitis Empyema Mucocele Perforation Biliary duct obstruct Acute cholangitits Acute pancreatitis Intestinal obstruct ( gallstone ileus) 4. Differential diagnosis : Appendicitis Perforated peptic ulcer Acute pancreatitis Acute pyelonephritis MI Pneumonia right lower lobe U/S aids in diagnosis Do CT scan id uncertain 5. Diagnosis : Dx based on hx n pe with confrmatory radio studies ( ultrasound) Acute phase ruq tenderness exacerbate by inspiration by examners right subcostal palpation ( Murphys sign )

EMPYEMA OF GALLBLADDER filled with pus sequel of acute cholecystitis or infected mucocele tx drain n choles

CHOLEDOCOLITHIASIS 1. Sx : 2. Signs : Pain Jaundice Fever Acute cholangitis charcots triad

Tenderness RHypo + epi Jaundiced pt rmmbr courvoisiers law obstruction due to stone, gall bladder distention seldom occurs LFT , liver biopsy, ultrasound scan MRI and ERCP determine nature of obstruction Pus may b present in biliary tree = liver abcess Supp mx rehydration , correct clotting abnormalities , tx with BSA After pt been recussitated relief the obstruction Endoscopic papillotomy removed stone with dormia basket ,, put stent if not possible If fails, percutaneous transhepatic cholangiography = provide drainage

3. MX :

and subsequent percutaneous choledochoscopy CHOLEDOCOTOMY Do it when minimally invasive techniques for stone extraction is not available Aim to drain the common bile duct and remove stones by longitudinal incision of the duct. Then, t tube is inserted n duct closed around it Long limb of t tube brought out to the right side, and bile allow to drain externally Residual stone = place t tube for 6 weeks

CHOLANGIOCARCINOMA 1. 2. Adenoca, jaundice relieved by stenting

Clinical features : Jaundice , abdo pain, early satiety , weight loss PE jaundice, IX : LFT ele bilirubin, alkaline phosphatase Ultrasound and ct scan - level of obstruction Proximal tumours PTC Distal tumours ERCP 3. TX : Distal common duct tumors pancreaticoduodenectomy GALLBLADDER CA 1. Pathology Major are adenoca (90%) Grossly diff to diff from chronic chole Tumor commonly nodular + infiltrative + thicken gall bladder wall 2. Clinical feas: Aymptomatic Indistinguishable from biliary colic / choleycystitis Palpable mass = late sign 3. IX : Lab findings same as biliary obstruction Anemia, leucocytosis, mild inc ESR, CRP CA 19 -9 inc Dx by ultrasound n defined by multidetector row ct scan 4. TX : For transmural dz - radical en bloc resection of the gall bladder fossa n liver + regional lymph nodes