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• Lymphatic supply-
Cystic lymph node
liver
FUNCTION OF G.B.
• ABSORBTION AND SECRATION
• MOTOR ACTIVITY.
• NEUROHORMONAL REGULATION
• CONTAIN OF BILE-
1 to 2% bile solt.
1%bile pigment
Cholesterol
Fatty acid
Water-97%.
precipitates.
Most of the time cholesterol secretion is
greatly increased without any reduction in
bile solt and phospolipids such as –polya
type partial gastrectomy, infection,
prolonged administration of progesterone.
Bile pigment stone results from
excessive
Haemolysis seen in haemolytic
anaemia septic
Haemolysis and malaria.There is
increased
Breakdown of haemoglobin and excess
of bile
Precipitates to form pigment stone.
output
Of bile salts & phospholipids reducing
the solubility
Of cholesterol.
4. INFECTIVE FACTOR: Its major cause of
gallstone
Infection includes organisms such as
E.coli,
Streptococcous etc.
reach
Gallbladder via bloodstream or from
bowel
through lymphatics.
TYPES OF STONES :
1 . PURE STONES. ( 10%)
CHOLESTEROL STONES.
PIGMENT STONES.
CALCIUM CARBONATE STONES.
2 . MIXED AND COMBINED STONES.
(90%)
•
1.PURE STONES :
A . Cholesterol stones
bilirubin >
>excreated in bile >>pigment stone in
gallbladder.)
• Calcium bilirubinate stones are earthly
brown to
C. CALCIUM CARBONATE STONES:
• Rare type.
• Greyishwhite with smooth surface.
• Alkalinity ofThe bile may favour
precipitation of calcium
• Carbonate with slow build up of stones
.size=2cm
• Sand grain to polyhedral in shape.
2 . MIXED AND COMBINED STONES :
• It has varying proportion of all three stones.
• Combined stones are those in which either
the central core or external
• Layer are pure and remainder of the stone is
a
mixture of constituents .
Cholesterol = yellow.
Bilirubinate = black.
meal.
(right upper qudrent,referred to
• ECG
• X-ray -straight abdomen.
• CT scan
• Ultrasonography
• PTC
• ERCP
• CHOLESCINTIGRAPHY
EFFECT AND
COMPLICATIONS.
1. IN THE GALLBLADDER :
1 .Asymptomatic gallstone
2.Hydrops of the gallbladder.
3.Flatulent dyspepsia.
4.Gallstone colic.
6.Chronic cholecystitis.
7.Carcinoma
2. IN COMMON BILE DUCT:
1.Obstructive jaundice.
2.Liver failure.
3. Cholangitis
3.IN PANCREAS :
1.Acute pancreatities.
3.Chronic pancreatitis.
•
4.IN THE INTESTINE:
Gallstone ileus.
SAINT`S TRIAD :
patient
present with flatulent dyspepsia.
CHOLECYSTIC HEART :
or heart
Block . This is known as Cholecystic heart.
ASYMPTOMATIC GALLSTONE:
After a long follow-up
serious
Complication have occurred in 20% of
cases;ie
Carcinoma of the gallbladder.
T/t –cholecystectomy.
FLATULENT DYSPEPSIA:
which
GALLSTONE COLIC:
Small calculi at neck/entry of
Abdomen.
ON EXAMINATION:
Enlarged gallblader on palpation.
SPECIAL INVESTIGATION:
10 mg/kg/day po dissolves
80% of tiny stones < 0.5
cm in diameter . For larger
stones (the majority), the
success rate is much
lower, even with higher
doses of ursodeoxycholic
CHOLECYSTECTOMY
• INDICATIONS-
1.Chronic cholesystities
2.Trauma to G.B.
3.Empyma
4.Gangrene of G.B.
5.Ca
1.
contraindication
• Acute cholecystitis.
• Blood coagulopathy
• Incision-
Right subcostal (kocher’s)
Lohey’s method
•
•
Ø •
•
•
Ø
PRE-OPERATIVE:
If pt.have some disturbance of liver
ACUTE CHOLECYSTITIS
Inflamation of gallbladder is associated
with calculi[90%].
PATHOGENESIS: FOUR FACTORS –
1.OBSTRUCTION OR STASIS.
2.CHEMICAL IRRITATION.
3.BACTERIAL INFECTION.
4.PANCREATIC REFLUX.
1.OBSTRUCTION OR STASIS: Stones obstruct
the
cystic duct .stone may pass into the common
bile
Duct & GIT.obstruction will cause stasis of bile
leading
to progessive concentration of bile & chemical
Irration of gallbladder.
stone .
Bile salts are very toxic to cells & this causes
may
also occur.
4. PANCREATIC REFLUX : Injection of
pancreatic
enzyme exercises a definite inflammatory
response.
Active lipases, amylases and proteases have
been
identified in the bile in patients of acute
cholecystitis
PATHOLOGY : Gallbladder enlarged two to
three times
- Bright red or violet to green black in colour
– serosa
conjested covered with fibrinous exudate –
areas of
Gangrene or necrosis – wall of Gallbladder
Mucosa is hyperaemic & show necrotic
surfaces =
Gangrenous Cholecystitis
give rise
to : a] Biliary peritonitis
cholecystitis
2. Heavy, fatty meal
back to
SIGNS: 1. Pyrexia is a regular feature
2. Jaundice is present in only 10% cases
{ rebound
tenderness}
inspiration
SPECIAL INVESTIGATION : 1. Blood
leucocytosis +
sr.bilirubin , sr.amylase +
2.ECG
4.Cholecystography
RADIOLOGICAL FINDING
D D : Perforated / penetrating peptic ulcer
.
Acute pancreatitis , gallbladder colic ,
hepatitis .
COMPLICTION : 1. Preforation
2. Pericholecystic
abscess
3. Internal fistula .
Treatment of Acute
Cholecystitis
• Conservative management:
٭NBM & NASOGASTRIC ASPIRATION for3-5
days. I.V. administration should be started
immediately in the beginning by 5% dextrose
saline & then changed according to the
electrolyte imbalance .Urine output should be
monitered.
*Anticholinergic drugs to reduce gastric
&pancreatic secretions.
*Analgesics except Morphine & Pethidine.
*Antibiotics- IInd generation
cephalosporin/chloramphenicol.
• Surgery:
Cholecystectomy: The operation for removal of
gallbladder.
Treatment of
Cholelithiasis
• Laparoscopic cholecystectomy for
symptomatic stones.
• For asymptomatic stones sometimes
stone dissolution.
• If gallstone has migrated into the
common bile duct-t/t is
cholecystectomy with
choledocholithotomy.
Chronic
Cholecystitis
PATHOLOGY:
The external surface becomes opaque
co n tra cte d d ila te d
ro n ic in fla m m a tio n o b stru ctio n
• CLINICAL FEATURES:
*Intolerance to fatty food
*belching
*postcibal epigastric distension
*nausea & vommiting
*pain-follows after meals,in the right
quadrant/epigastric region,radiates to the
back to the inferior angle of the right
scapula/inter-scapular region/right
shoulder.
• PHYSICAL SIGNS:
*Tenderness at right upper
quadrant/epigastric region
*Murphy’s sign may be positive
INVESTIGATION:
• Examination of blood does not reveal any
picture.
• Oral cholecystography shows non-
visualisation of gallbladder & is quite
diagnostic.
DIFFRENTIAL
• USG-accurate test DIAGNOSIS:
for diagnosis of
gallbladder.
Peptic ulcer,pancreatitis,oesophageal hiatus
hernia,appendicitis,right
pyelonephritis,myocardial
infarction,pleuritis,arthritic changes of thoracic spine,hepatitis.
TREATMENT:
Cholecystectomy
CHOLECYSTECTOMY
Methods:
•
•
•
ØDUCT-FIRST METHOD:
•
•
•
Ø
•
•
Ø
PRE-OPERATIVE:
If pt.have some disturbance of liver
10 mg/kg/day po dissolves
80% of tiny stones < 0.5
cm in diameter . For larger
stones (the majority), the
success rate is much
lower, even with higher
doses of ursodeoxycholic
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
(ERCP)
• The patient swallows an endoscope--a
long, flexible, lighted tube connected to
a computer and TV monitor. The doctor
guides the endoscope through the
stomach and into the small intestine.
The doctor then injects a special dye
that temporarily stains the ducts in the
biliary system. Then the affected bile
duct is located and an instrument on the
endoscope is used to cut the duct. The
stone is captured in a tiny basket and
removed with the endoscope.
ERCP