Gall bladder and Biliary disease Dr.Umit Akyuz Gastroenterology Department Yeditepe University,Istanbul.

Gall bladder and Biliary Gall bladder and Biliary diseasedisease

Dr.Umit AkyuzDr.Umit AkyuzGastroenterology DepartmentGastroenterology DepartmentYeditepe University,IstanbulYeditepe University,Istanbul

Biliary stone diseaseBiliary stone diseaseAcute cholecytitisAcute cholecytitisPrimer sclerosane cholangitisPrimer sclerosane cholangitisPrimer biliary cirrhosisPrimer biliary cirrhosisTumorsTumors

CHOLELITHIASISCHOLELITHIASIS

Chole – Chole – CYSTOCYSTO - GALLBLADDER- GALLBLADDER - - DOCHODOCHO – D. CHOLEDOCHUS – D. CHOLEDOCHUS

CHOLESTEROLCHOLESTEROL %75%75PIGMENT(blb, ca)PIGMENT(blb, ca) % 25% 25

CHOLESTROL STONESCHOLESTROL STONES

CHARACTERISTICS: CHARACTERISTICS: – PURE OR MIXEDPURE OR MIXED– SMALL OR LARGESMALL OR LARGE– SOLITARY OR MULTIPLESOLITARY OR MULTIPLE

PIGMENT STONESPIGMENT STONES• CHARACTERISTICS:

– ELDERLY– HEMOLYTIC STATES– CIRRHOSIS– MULTIPLE, IRREGULAR– CENTRAL CALCIFICATION

RISK FACTORSRISK FACTORS

4 4 FF : :– FFemaleemale– FFatat– FFertileertile– FFortyorty

3 D3 D– DDiabetesiabetes– DDrugsrugs– DDietiet

2 H2 H– HHLPLP– HHeredityeredity

Bile Salt MalabsorbtionBile Salt Malabsorbtion

COMPLICATIONSCOMPLICATIONS

STONE – PASSAGESTONE – PASSAGE– HYDROPS HYDROPS – CHOLECYSTITISCHOLECYSTITIS– ICTERUSICTERUS

Ac. CHOLECYTITISAc. CHOLECYTITISEMPYEMAEMPYEMAPERFORATIONPERFORATIONChr. CHOLECYTITISChr. CHOLECYTITIS

CLINICSCLINICS

COLIC:COLIC:– RUQ crampy PainRUQ crampy Pain

RADIATIONRADIATION BACKBACK

DYSPEPSIADYSPEPSIA

Ac. CHOLECYTITIS Ac. CHOLECYTITIS ++ COMPLICATIONS COMPLICATIONS

DIAGNOSISDIAGNOSIS

• USG• X-Ray Plain Film• ERC / P• PTC• CT

THERAPYTHERAPY

SpasmolyticaSpasmolyticaAntibioticsAntibioticsSURGERYSURGERY– Absolute ComplicationsAbsolute Complications– Relative ComplicationsRelative Complications

Medical:Medical:– Oral LytholysisOral Lytholysis– Ursodeoxy-cholic AcidUrsodeoxy-cholic Acid– ESLWESLW

therapytherapy

ACUTE CHOLECYSTITISACUTE CHOLECYSTITISAcute InflammationAcute Inflammation

PrimaryPrimary AbacterialAbacterialSecondarySecondary BacterialBacterial

• Enterococcus• E. Coli• Gr. (-) Bacilli• Anaerobs

– Bacteroides– Clostridia– Fusobacterium

SymptomsSymptoms

Biliary colicBiliary colicFever, chills, anorexia, nausea, vomitingFever, chills, anorexia, nausea, vomitingEnlarged GallbladderEnlarged GallbladderMurphy’s sign :Murphy’s sign :

RUQ-PalpationRUQ-Palpationincreased Pain inincreased Pain inInspirationInspiration

Diagnosis: Clinics, US, biochemistryDiagnosis: Clinics, US, biochemistry

ComplicationsComplications

EmpyemaEmpyema

GangreneGangrene

PerforationPerforation

IleusIleus

TherapyTherapy

PE - NutritionPE - Nutrition AntibioticsAntibiotics Cholecystectomie ?Cholecystectomie ?

for Complications !for Complications !

CHOLANGITISCHOLANGITIS

Charcot’s Charcot’s Biliary Biliary painpain

TriadTriad JaundiceJaundiceFeverFever

BacteriaBacteria

E. coliE. coliKlebsiellaKlebsiellaProteusProteusE. bacterE. bacterPseudomonasPseudomonasClostridiumClostridium

ComplicationsComplications

SepsisSepsisHepatic AbcessHepatic AbcessBil. StricturesBil. StricturesGallstonesGallstonesSec. Bil. CirrhosisSec. Bil. CirrhosisPHTPHT

TreatmentTreatment

ERCPERCP

AntibioticsAntibiotics

Primary Sclerosing CholangitisPrimary Sclerosing Cholangitis

İdiopathicİdiopathicintra+extrahepaticintra+extrahepaticChronicChronicFibrosing,Fibrosing,Diffuse Diffuse of bile Ductsof bile DuctsClinics:Clinics:

CholestasisCholestasisBile D. ObliterationBile D. ObliterationCirrhosisCirrhosis

ClinicsClinics

JaundiceJaundicePruritusPruritusFatiqueFatiqueWeight lossWeight loss

UCUC 75 %, 75 %, CD CD, , RRA, Sarcoidosis,A, Sarcoidosis, Sjögren SyndromeSjögren Syndrome

M/F 1/3M/F 1/3

ANCA + ; ANCA + ; IgM IgM

Complications Complications 5 – C5 – C

CholestasisCholestasisCirrhosisCirrhosisCholangitisCholangitisCholelithiasisCholelithiasisCholangiocarcinomaCholangiocarcinoma

TherapyTherapy

ABABCholestyramineCholestyramineUrsodeoxycholicacidUrsodeoxycholicacidSurgical : Liver Transplantation !Surgical : Liver Transplantation !

Primary Biliary CirrhosisPrimary Biliary Cirrhosis

İnterlobuler and septal bile ductsİnterlobuler and septal bile ductsMiddle aged populationMiddle aged population100-150/1 million100-150/1 million

ClinicsClinics

FatigueFatiguePiruritisPiruritisAsymtomaticAsymtomaticJaundinceJaundinceVariciel bleedingVariciel bleedingascitesascites

Assosiated DiseaseAssosiated Disease

keratoconjuctivites sikka (50%)keratoconjuctivites sikka (50%)Thyroid disease (15%)Thyroid disease (15%)Artrithes (10%)Artrithes (10%)Reynaud (9%)Reynaud (9%)SclerodermaSclerodermaRenal stonesRenal stonesBreast cancerBreast cancer

DiagnosisDiagnosis

AMA >1/40 (M2 band) 95%AMA >1/40 (M2 band) 95%AST, ALT highAST, ALT highIgM highIgM highBiluribune highBiluribune highHypercholesterolemia 80%Hypercholesterolemia 80%Pathology: florid duct lesionsPathology: florid duct lesions

ComplicationsComplications

OsteopeniaOsteopeniaFat soluble vit. DeficiencyFat soluble vit. Deficiencyhypercholesterolemiahypercholesterolemia

TreatmentTreatment

Ursodeoxycholic acidUrsodeoxycholic acidCorticosteroidsCorticosteroidsAzothioprineAzothioprineCyclosporineCyclosporineMethotraxateMethotraxatePenicilamine,colhicine no benefitPenicilamine,colhicine no benefitTransplantationTransplantation

TUMORSTUMORS

BENIGNBENIGN– PolipsPolips– AdenomyomatosisAdenomyomatosis– CholesterosisCholesterosis

MALIGNMALIGN– CarcinomaCarcinoma– AdenoAdeno– SquamousSquamous

Ductus CarcinomaDuctus Carcinoma– Pat Pat 60 Years60 Years