Gallbladder & Bile Ducts Anatomy Biliary Disease and - - PDF document
29/01/2013 Gallbladder & Bile Ducts Anatomy Biliary Disease and Pancreatitis Mr Panagiotis Georgiou MD, MRCS Academic Clinical Fellow in General Surgery Date: 29/01/2013 Physiology Congenital Abnormalities Bile Salts Liver
Date: 29/01/2013
Mr Panagiotis Georgiou MD, MRCS Academic Clinical Fellow in General Surgery
✤ Bile Salts ✤ Liver ✤ Gallbladder
✤
50 mls
✤
Concentrate 10-fold
✤ Miceles ✤ Enterohepatic circulation ✤ Reabsorbed 95%at distal ileum
✤ Biliary atresia ✤ Choledochal cysts
✤ Common ✤ Age ✤ F-emale, F-at, F-orty (40), F-ertile ✤ Cholesterol
✤ Bile is supersaturated with cholesterol
✤ Pigment
✤ Haemolytic blood disorders
✤ Biliary Colic ✤ Acute/Chronic Cholecystitis ✤ Pancreatitis ✤ Cholangitis ✤ Mucocoele ✤ Choledocholithiasis ✤ Gallstone ileus ✤ Cancer
✤ RUQ & Epigastric Pain ✤ Colicky ✤ Radiating at the back ✤ Worse with fatty meals ✤ No Signs of Sepsis
✤ Analgesia ✤ Light diet ✤ OP Surgery
✤ Obstruction and Infection ✤ Systemic illness ✤ Usually associated with GS ✤ RUQ pain and tenderness ✤ Murphy’s sign
✤ A, B, C ✤ Bloods & Blood Cultures ✤ IV Fluids, Analgesia and Abx ✤ eCXR ✤ USS ✤ MRCP/ERCP
✤ Empyema ✤ Gangrenous Gallbladder ✤ Perforation ✤ Pancreatitis
✤ Infection of the Bile Ducts ✤ Ascending Bacteria ✤ Associated with GS ✤ Charcot’s triad ✤ Pain, Jaundice, Temperature/Rigors
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✤ A, B, C ✤ Blood Cultures ✤ IV Fluids & Abx ✤ Analgesia ✤ eCXR ✤ USS ✤ MRCP/ERCP
✤ Inflammation if the pancreas ✤ G-allstones ✤ E-thanol ✤ T-rauma ✤ S-teroids ✤ M-umps ✤ A-utoimmune (PAN) ✤ S-corpion stings ✤ H-yperlipidemia/ Hypercalcemia ✤ E-RCP ✤ D-rugs (including azathioprine and diuretics)
✤ Epigastric/RUQ Pain ✤ Radiating at the back ✤ N+V ✤ ?Diarrhoea ✤ Malaise
✤ A, B, C ✤ Bloods & ABG ✤ Score ✤ IV Fluids, Catheter ✤ Urine Output ✤ eCXR, AXR ✤ USS ✤ CT
✤ On admission and within 48h ✤ P-O2 < 8 ✤ A-ge >55 ✤ N-eutrophils (WCC >15) ✤ C-alcium <2mmol/L ✤ R-enal (Urea>16mmol/L) ✤ E-nzymes (LDH>600units/L) ✤ A-lbumin<32 g/L ✤ S-ugar >10 mmol/L
Score > 3 Severe Pancreatitis Consider ITU High Mortality
✤ Local
✤ Necrosis ✤ Infected Necrosis ✤ Abscess ✤ Pseudocyst
✤ Systemic
✤ Respiratory ✤ Cardiovascular ✤ Renal ✤ Metabolic ✤ GI
✤ 1/7 history of Abdominal pain ✤ Epigastric ✤ Colicky ✤ Radiating at the back ✤ Burning ✤ Worse with meals
Differential Diagnosis Biliary Colic Heartburn/Gastritis Ulcer Cholecystitis
✤ A, B, C ✤ Clinical examination ✤ Bloods?
Bloods NAD XRs NAD Discharge with OP USS
✤ 1/7 history of Abdominal pain ✤ Epigastric ✤ Colicky now constant ✤ Radiating at the back ✤ Burning ✤ Worse with movement
Differential Diagnosis Cholecystitis Pancreatits Heartburn/Gastritis Ulcer
✤ A, B, C ✤ Clinical examination ✤ Bloods
Bloods Elevated WCC and CRP LFTs Normal XRs NAD Admit for IV Abx and Analgesia USS
✤ 1/7 history of Abdominal pain ✤ Epigastric ✤ Colicky now constant ✤ Radiating at the back ✤ Burning ✤ Worse with movement ✤ Vomiting
Differential Diagnosis Cholecystitis Pancreatitis Heartburn/Gastritis Ulcer
✤ A, B, C ✤ Clinical examination ✤ Bloods
Bloods Elevated WCC and Amylase Bil 30 CXR Right pleural effusion Admit for IV Fluids and Analgesia Monitor Urine Output USS
USS +
CBD MRCP ERCP +
Surgery