Curs 9 - Patologia chirurgical a cilor biliare

Dischinezii biliare

Litiaza biliar:

- litiaza vezicular
- litiaza cilor biliare

Colecistopatii alitiazice

Patologia tumoral a cilor biliare

Secreia de bil

500-1500ml, stim de secretin i VIP

=sol izoosm de -lii i compui organici:

- acizi biliari (chenodeoxi/lito/urso/colic)
- bilirubin
- colesterol
- lecitin
- proteine

La niv membr canaliculare hepatocit prin mec active i pasive, dependente sau nu de secr
acizilor biliari

Curgerea bilei

Reglat prin jocuri presionale (mmHg):

- CBP

8-12

- VB

6-16

- sf.Oddi 10-15 (150!)

VB (V=35-60cc) absoarbe 90% ap/4h

Relaxarea VB prin PP, YY

CCK evac VB (efect de vag, VIP, SS)

CCK, glucagon, distensia VB pres sf.Oddi

Morfina pres sf.Oddi

Tulburri de motilitate biliar

Fracia de ejecie VB sub CCK (N=75%) poate scdea

scdea sub 40%, CCK-HIDA

La cei cu colici fr calculi (5%) CCK poate reproduce colica biliar (benefic VBect)

Disfuncia sf.Oddi e respons de 10% din simpt persist postVBect ( colangiomanometria: evac ntrziat >45min, pres > pres dd + 40mmHg (benefic sf.ect ERCP)

Calculi veziculari
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=concreiuni solide de , formai din colesterol & sruri Ca ale pigmenilor biliari

Clasificare:

- colesterol pur (5-40mm, unic, oval, glb)

- colesterol mix (1-20mm, n., murif/faet)
- micti
micti (rari, colest 20-70%)
- pigmentari bruni (<
(<1cm, moi, n infecii)
- pigmentari puri (<
(<1cm, duri, n hemoliz)
Litiaza vezicular: Predispoziie

Calculi colesterol: 5F Fat Fasting Fertile Female Forty

Calculi pigmentari la pacieni cu:

- BR neconj (anemii hemolitice, ciroze hep)

- malabs (Crohn, rez ileale, vagotomii, NPT)
- staz (stenoze bil, chisturi congen CB, colangite,
pancreatite cr, diverticuli dd)

Calculi micti

Litiaza vezicular: Simptomatologie

Colica biliar:
biliar: durere colicativ intens n epig/hipoc dr, irad dorsal, dup ingestie CCK,
t=2-3h

Greuri/vrsturi ce calmeaz doar parial durerea

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Sindrom dispeptic biliar:

biliar:

- gust amar matinal

- flatulen postprandial precoce
- constipaie

Cefalee migrenoid

Litiaza vezicular:Examen obiectiv

Durere la palpare n hipoc dr/semn Murphy

Colecist palpabil

Semne de complicaie:

- febr
- icter
- iritaie peritoneal
- ocluzie intestinal

Litiaza vezicular:
vezicular: Ex. paraclinice

Bio: L, bilirub, amil, ALT/AST

Aspirat duodenal dup CCK (bila B): cristale colesterol, microcalculi

Rx - hipoc dr: 15% calculi sunt Rx-opaci

- colecistografie (contrast iodat oral)/95%

Eco: calculi hiperecogeni cu umbrire

umbrire post, sludge biliar, modificri parietale (gros 4mm,
dublu contur, polipi), CBP, CBIH, ficat, pancreas /98%

Litiaza vezicular: Diagnostic

+: colica biliar, VB palpabil, calculi eco/Rx, modif parietoVB

: - hepatomegalie dureroas
- ulcer,
ulcer, pancreatit, colit
- colic ureteral, apendicular
- nevralgie ic/sc

Evoluia litiazei veziculare

Asimptomatic (50% rmn mereu asimpt!)

Simptomatic (3-5%/an devin simpt/colici rep) ferm indicaie operatorie

Complicat (3-5%simpt/an devin complicate, 0,1%asimpt/an debuteaz prin compl)

Litiaza vezicular: Complicaii

Mecanice - hidrops VB
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- icter obstructiv
- ileus biliar

Inflamatorii - colecistit acut, piocolecistit,

perfor... abces, fistul biliar, peritonit
- colangit
- oddit, pancreatit

Degenerative - scleroatrofie VB
- fistule biliare
- cancer VB

Colecistita acut litiazic

Etiopat: persist obstr VB (hidrops) inflam infecie

infecie sec (E.coli, flor enteral, anaerobi)
ischemie empiem gangren
gangren (
(VBit enfizematoas) peritonit
peritonit

Clinic: durere (24h),

(24h), febr, Murphy, mas palp, irit perit

Bio:L(10-20000/mmc), f.alc, amil, BR, ALT/AST

P-clinic: eco (perete gros, cont neomogen, colecie lichid periVB), CT, RMN

Rp - AB, Aspast, AINS/analg, Aemetice, reechil/corecie tare

- colecistect (imediat, temporizat)
- colecistendez, drenaj
drenaj VB percutan transhep

Tratament

Diet cu evitare grs animale, cofein, condim, conserv, afumturi, oleaginoase,

leguminoase, etc

Cur balnear (ape sulfuroase: Olneti, Climneti, Tunad)

Medical: antispastice, antiemetice, analgetice, AB, AINS

Litoliz (acid urso/chenodeoxicolic, CH33butileter), litotriie US pt calculi unici, 2 cm,

colesterinici; cu 20-50% recuren la 2 ani

Chirugical: - colecistendez
- colecistectomie
colecistectomie (convent, mini, laparoscopic)
antero/retrograd sau bipolar

Indicaii ale colecistectomiei

Relativ: litaze asimptomatice, c. alitiazice

Profilactic:

- copii cu litiaz
- anemii hemolitice congenitale
- calculi 2,5cm
- chirurgie major sau bariatric
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- indisponibilit accesului la ngrijiri medicale

Absolut litiaze simpt, complicaii degener

Urgent n complicaii inflam & mec (

(ileus)
Colecistopatii alitiazice

Colecistita acut alitiazic de stres

Colecistoze (=afect degenerative neinflamatorii):

Colesteroloze (difuz, segmentar, polip colesterolotic, VB cu bil calcic)

Polipoze (papiloame, adenoame)
Diverticuloze (congen, adenomioze, adenomiom fundic)

Colecistite cronice alitiazice (parazitoze VB: lambliaza, hidatidoza; VB malform sau

disfuncional, cisticita, VB de porelan)

Colecistita acut alitiazic

=inflamaie acut a VB n absena litiazei; CAA pot fi:

primitive (excepionale,
(excepionale, prin mecc controversate)

septicemice (febr tifoid, paratifoide)

parazitare (lambliaz, ascaridioz)

ischemice (tromboze cistice n AS sau diabet)

posttraumatice/postoperatorii sec unor traumatisme cerebrale /politraumatisme/arsuri

severe sau chirurgiei de anvergur

Patogenie:
Patogenie: blocaj cistic cu distensie+ischemie perforaie

Clinic:
Clinic: debut mascat de simpt postagresional, febr/frison, durere hipoc dr, iritaie perit,
stare toxic

Diagn:
Diagn: semne perit, puncie perit bil, L, modif parietoVB + colecie eco/CT

Colecistita acut alitiazic - 2

Evol:
Evol: rapid (24-48h gangren, alter st gen), cu biliculturi+ (E.coli, clostridii,
pseudomonas, klebsiella)

Progn:
Progn: grav, 50% mortalitate

Tratament:
Tratament:

Colecistect clasic/laparoscopic

Colecistostomia clasic/laparoscopic/percutan

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AB-Rp (lactam/fluorchin + NH2

NH2glic + metro)

Colecistopatii cronice alitiazice

Etiopat: cauze directe (ered, malform, neurohorm, discolie, reflux dd+pc) sau indirecte
(gastrice, hepatice, uteroanexiale)

Clinic: durere, G, migrena, grea/vrs, icter, altern tranzit, febr, alergie, neuro, endocrino

Paraclinic: -L,-VSH,-BR,-amil; bila/tubaj dd; Rx (gol, VBgrafie), eco

Dg:
Dg: litiaza VB, ulcer, pancreatit, apendicit, HH...

Evol:Lg

Compl: icter, pancreatite, pioVB, cancer

Colecistopatii cronice alitiazice - Rp

Diet (nonCCK)

Cur balnear (Olneti, Climneti, Malna, Slnic MD, Tunad)

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Medical (Analg, Aspast, Metoclopr,sedative)

Chirurgical = VBectomie indicat n:

Complicaii acute (angiocolite, hidrops, pancreatit acut)

Suferin persistent sau recurent, fr rspuns /Rp.

Absena evacurii la VBRx cu cliee tardive (la 36-72 ore)

Persistena simptomelor dup eliminarea altor afeciuni

Suferine secundare (duodenite,

(duodenite, oddite, pancreatite cronice)

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