of the gallbladder and biliary tract digied的胆囊和胆道疾病数码课件

A 95 year-old woman presented with upper abdominal pain and jaundice; A 95 year-old woman presented with upper abdominal pain and jaundice; ultrasound demonstrated gallstones. Symptoms were short in duration, and ultrasound demonstrated gallstones. Symptoms were short in duration, and jaundice began to clear rapidly. In view of her age and improving condition, jaundice began to clear rapidly. In view of her age and improving condition, she was treated conservatively for cholecystitis. However, she then she was treated conservatively for cholecystitis. However, she then developed protracted vomiting; endoscopy demonstrated several stones in developed protracted vomiting; endoscopy demonstrated several stones in the duodenum.the duodenum. What is the most likely cause this type of complication?What is the most likely cause this type of complication? a. Malignancy extending into duodenuma. Malignancy extending into duodenum b. Perforation of gallbladderb. Perforation of gallbladder c. Carolis syndromec. Carolis syndrome d. Metastasis from another primary tumord. Metastasis from another primary tumor Diseases of the Gallbladder Diseases of the Gallbladder and Biliary Tractand Biliary Tract Driss Raissi, MDDriss Raissi, MD New York State UniversityNew York State University Downstate Lecture SeriesDownstate Lecture Series Normal Biliary PhysiologyNormal Biliary Physiology Liver produces 500-1500 mL of bile/dayLiver produces 500-1500 mL of bile/day Major physiologic role of biliary tract and Major physiologic role of biliary tract and GB is to concentrate bile and conduct it in GB is to concentrate bile and conduct it in well-timed aliquots to the intestine.well-timed aliquots to the intestine. In the intestine:In the intestine: n n bile acids participate in normal fat digestionbile acids participate in normal fat digestion n n Cholesterol and other Cholesterol and other endogenous/exogenous cmpds in bile endogenous/exogenous cmpds in bile excreted in feces.excreted in feces. Biliary PhysiologyBiliary Physiology Complex fluid secreted by hepatocytesComplex fluid secreted by hepatocytes Passes through hepatic bile ducts into common hepatic ductPasses through hepatic bile ducts into common hepatic duct Tonic contraction of sphincter of Oddi during fasting diverts 1/2 of Tonic contraction of sphincter of Oddi during fasting diverts 1/2 of bile through the cystic duct into the GB stored and concentrated.bile through the cystic duct into the GB stored and concentrated. CCKCCK released after food ingestion released after food ingestion n n GB contracts, sphincter of Oddi relaxesGB contracts, sphincter of Oddi relaxes n n Allows delivery of timed bolus of bile into intestine.Allows delivery of timed bolus of bile into intestine. Bile acids Bile acids detergent moleculesdetergent molecules n n Have both fat and water soluble moietiesHave both fat and water soluble moieties n n Convey phospholipids and cholesterol from liver to intestine Convey phospholipids and cholesterol from liver to intestine n n Cholesterol undergoes fecal excretionCholesterol undergoes fecal excretion Enterohepatic circulationEnterohepatic circulation Bile acids Bile acids solubilize dietary solubilize dietary fat and promote fat and promote its digestion and its digestion and absorptionabsorption Enterohepatic Enterohepatic circulation:circulation: n n Bile acids Bile acids efficiently efficiently reabsorbed by SI reabsorbed by SI mucosa (terminal mucosa (terminal ileum) ileum) recycled to liver recycled to liver for re-excretionfor re-excretion CholelithiasisCholelithiasis Normal GallbladderNormal Gallbladder Velvety green mucosaVelvety green mucosa Thin wallThin wall Tall columnar cells lining Tall columnar cells lining mucosal folds (right)mucosal folds (right) Submucosa and Submucosa and muscularis at the left. muscularis at the left. CholelithiasisCholelithiasis Gallstones:Gallstones: n n MCC biliary tract MCC biliary tract disease in US (20-disease in US (20- 35% by age 75)35% by age 75) n n 2 types:2 types: CholesterolCholesterol (75%) (75%) PigmentPigment n n Calcium bilirubinate Calcium bilirubinate and other calcium and other calcium saltssalts Cholesterol StonesCholesterol Stones Cholesterol:Cholesterol: n n Insoluble in waterInsoluble in water n n Normally carried in bile solubilized by bile acids and Normally carried in bile solubilized by bile acids and phospholipidsphospholipids n n In most individuals, bile contains cholesterol than can be In most individuals, bile contains cholesterol than can be maintained in stable solutionmaintained in stable solution “supersaturated” with cholesterol “supersaturated” with cholesterol microscopic cholesterol crystals microscopic cholesterol crystals formform Interplay of Interplay of nucleation nucleation (mucus, stasis) and “anti-nucleating” (mucus, stasis) and “anti-nucleating” (apolipoprotein A-I) factors determine whether cholesterol gall (apolipoprotein A-I) factors determine whether cholesterol gall stones formstones form Gradual deposition of cholesterol layers Gradual deposition of cholesterol layers n n macroscopic cholesterol stonesmacroscopic cholesterol stones Cholesterol StonesCholesterol Stones Gallbladder: Gallbladder: n n key to stone formation key to stone formation n n Area of bile stasis Area of bile stasis slow crystal growth slow crystal growth n n Provides mucus or other material to act as a nidus for initiating Provides mucus or other material to act as a nidus for initiating cholesterol crystal.cholesterol crystal. n n Mexican Americans and several American Indian tribes, Mexican Americans and several American Indian tribes, particularly the Pima Indians in the Southwestparticularly the Pima Indians in the Southwest high prevalence rates of cholesterol gallstoneshigh prevalence rates of cholesterol gallstones bile acid secretion is believed to be the common denominator in bile acid secretion is believed to be the common denominator in these ethnic groupsthese ethnic groups Pigment stonesPigment stones Pathophysiology less well understoodPathophysiology less well understood n n production of bilirubin conjugates (hemolytic production of bilirubin conjugates (hemolytic states)states) n n biliary Ca biliary Ca2+ 2+ and CO and CO 3 3 2-2- n n Cirrhosis Cirrhosis n n Bacterial deconjugation of bilirubin to less Bacterial deconjugation of bilirubin to less soluble formsoluble form Predisposing FactorsPredisposing Factors Factors that increase biliary cholesterol saturation:Factors that increase biliary cholesterol saturation: n n EstrogensEstrogens n n MultiparityMultiparity n n OCPsOCPs n n ObesityObesity n n Rapid weight lossRapid weight loss n n Terminal ileal disease (decreases bile acid pool)Terminal ileal disease (decreases bile acid pool) Factors that increase bile stasis:Factors that increase bile stasis: n n Bile duct stricturesBile duct strictures n n Parenteral hyperalimentationParenteral hyperalimentation n n FastingFasting n n Choledochal cystsCholedochal cysts n n Pregnancy (GB hypomotility)Pregnancy (GB hypomotility) Clinical ManifestationsClinical Manifestations Most are asymptomaticMost are asymptomatic Duct obstruction - Duct obstruction - underlying cause of all manifestationsunderlying cause of all manifestations n n Cystic duct obstructionCystic duct obstruction distends GB distends GB biliary pain biliary pain Superimposed inflamm/ifx Superimposed inflamm/ifx acute cholecystitisacute cholecystitis n n Common duct obstructionCommon duct obstruction pain, pain, jaundice, jaundice, ifx(cholangitis), ifx(cholangitis), pancreatitis, pancreatitis, and/or and/or hepatic damage 2hepatic damage 2 to biliary cirrhosis to biliary cirrhosis Asymptomatic GallstonesAsymptomatic Gallstones 60-80% patients with gallstones in US60-80% patients with gallstones in US n n Over 20-year period:Over 20-year period: 18% of these develop biliary pain18% of these develop biliary pain 3% require cholecystectomy3% require cholecystectomy Prophylactic cholecystectomy considered in 3 Prophylactic cholecystectomy considered in 3 high-risk groups:high-risk groups: n n 1. 1. Diabetics Diabetics 10-15% greater mortality10-15% greater mortality n n 2. 2. Calcified (porcelain) GB Calcified (porcelain) GB Associated w/CA of GBAssociated w/CA of GB n n 3. 3. Sickle cell anemia Sickle cell anemia hepatic crisis difficult to differentiate vs. acute cholecystitishepatic crisis difficult to differentiate vs. acute cholecystitis Porcelain GallbladderPorcelain Gallbladder Treatment of Asx GallstonesTreatment of Asx Gallstones Chenodeoxycholic acid or Ursodeoxycholic acidChenodeoxycholic acid or Ursodeoxycholic acid n n Dissolution of cholesterol stonesDissolution of cholesterol stones Expectant management Expectant management then cholecystectomy if then cholecystectomy if symptomatic disease develops = more cost effectivesymptomatic disease develops = more cost effective Alternatives:Alternatives: n n Dissove cholesterol stones:Dissove cholesterol stones: Instill Instill Methyl-tert-butyl-ether Methyl-tert-butyl-ether or or ethyl propionateethyl propionate into GB into GB n n Fragment stones:Fragment stones: extracorporeal shock wave lithotripsyextracorporeal shock wave lithotripsy Extracorporeal Shockwave Extracorporeal Shockwave LithotripsyLithotripsy Chronic Cholecystitis and Biliary PainChronic Cholecystitis and Biliary Pain Nonacute sx. caused by presence of gallstonesNonacute sx. caused by presence of gallstones Biliary Pain (misnamed biliary colic)Biliary Pain (misnamed biliary colic) GB from symptomatic patients may be grossly normal GB from symptomatic patients may be grossly normal Mild histologic inflammation with fibrosis and thickening often from Mild histologic inflammation with fibrosis and thickening often from previous attacks of acute cholecystitis.previous attacks of acute cholecystitis. SymptomsSymptoms: : n n From contraction of GB during transient obstruction of cystic duct by From contraction of GB during transient obstruction of cystic duct by gallstones.gallstones. n n Steady ache in epigastrium or RUQ Steady ache in epigastrium or RUQ comes on quickly comes on quickly plateau over a few minutes plateau over a few minutes subsides gradually over subsides gradually over 30 min-several hours30 min-several hours Referred pain at tip of scapula or right shoulderReferred pain at tip of scapula or right shoulder N/V can accompany. (no fever, leukocytosis, or palpable mass)N/V can accompany. (no fever, leukocytosis, or palpable mass) Attacks occur at variable intervals (days years)Attacks occur at variable intervals (days years) Nonspecific symptoms: Nonspecific symptoms: n n Dyspepsia, fatty food intolerance, bloating and flatulence, heartburn, belchingDyspepsia, fatty food intolerance, bloating and flatulence, heartburn, belching DiagnosisDiagnosis UltrasonographyUltrasonography n n Sensitivity and specificity 95%Sensitivity and specificity 95% Oral cholecystograpyOral cholecystograpy n n 90% sensitivity, 75% specificity90% sensitivity, 75% specificity n n Reserved for ensuring cystic duct patency in pts Reserved for ensuring cystic duct patency in pts whom dissolution therapy or extracorporeal shock whom dissolution therapy or extracorporeal shock wave lithotripsy is plannedwave lithotripsy is planned TreatmentTreatment Laparoscopic cholecystectomyLaparoscopic cholecystectomy n n Treatment of choice for recurrent biliary painTreatment of choice for recurrent biliary pain n n May need preoperative endoscopic or radiologic examination of May need preoperative endoscopic or radiologic examination of CBD for concomitant choledocholithiasisCBD for concomitant choledocholithiasis Open cholecystectomyOpen cholecystectomy n n Mortality rate 60 with Almost entirely confined to patients 60 with serious associated diseases and those with serious associated diseases and those with supparative complicationssupparative complications ComplicationsComplications n n InfectionInfection n n Cholecystoenteric fistula Cholecystoenteric fistula results in results in gallstone ileus.gallstone ileus. Choledocholithiasis Choledocholithiasis and Cholangitisand Cholangitis Choledocholithiasis A 95 year-old woman presented with upper abdominal pain and jaundice; ultrasound demonstrated gallstones. Symptoms were short in duration, and ultrasound demonstrated gallstones. Symptoms were short in duration, and jaundice began to clear rap