Gall bladder disease

Cholelithiasis Gall-bladder stones- prevalence ~5% Cholesterol- >80% cholesterol Ca bilirubinate- <20% cholesterol Mixed F>M, incidence increases with age Risk factors- Obesity, prolonged fasting, rapid weight loss High-carbohydrate diet, insulin resistance, DM Drugs- ceftriaxone, octreotide, clofibrate Pregnancy, oral contraceptives, HRT Hemolysis

Manifestation Majority asymptomatic Biliary colic in ~10-25% over 10 years, acute

cholecystitis in ~3% Typical bil iary col ic-

sudden onset, severe RUQ pain; radiating to shoulder/scapular area; lasting for 1-4 hours; associated with vomiting; subsiding spontaneously

Can cause choledocholithiasis ± cholangitis & acute pancreatitis

GB carcinoma- rare, more common in Gangetic belt

Management Only if symptomatic Exception- calcified GB, single stone >3 cm,

± Gangetic belt Non-surgical- Oral ursodeoxycholic acid x >2 years Lithotripsy- single, radiolucent stone ERCP for CBD stones Surgical- Cholecystectomy- laparoscopic or open

Acute cholecystitis Associated with GB calculi in >90% GB inflammation due to obstruction Causes severe RUQ pain radiating to

shoulder + vomiting ± fever, jaundice, palpable GB

Ix- raised TLC, SGPT, ± raised bilirubin Dx- AxR/US for gallstones, HIDA scan Recurrence- ~10% in 1 mth & ~30% in 1 yr Complication- gangrene/perforation of GB

Treatment Supportive- Pain control- NSAIDs or opioids NPO, IV fluids & alimentation IV antibiotics- 3rd gen. Cephalosporin + Metronidazole Surgical- Cholecystectomy- within 2-4 days,

unless complicated

Choledocholithiasis CBD stones In ~15% patients with GB calculi May cause obstruction with cholangitis Charcot triad- RUQ pain, fever, jaundice;

suggests cholangitis Reynold pentad- + hypotension, altered

sensorium; suggests suppurative cholangitis R/O Acute pancreatit is

Management Ix- Raised TLC, bilirubin, SGPT, alkaline phosphatase US/CT/MRCP- dilated bile ducts, CBD stone ERCP- localizes stone, can be therapeutic Rx- Supportive- IVF, Abx ERCP with sphincterotomy- urgent if complicated Cholecystectomy- elective, when patient stabilizes

Carcinoma- of GB or biliary tract Progressive jaundice, anorexia, ± pain Tender hepatomegaly, palpable GB Raised bilirubin, alkaline phosphatase, SGPT Tumor marker- CA-19.9 US/CT/MRI/PET scan- GB calculi, mass,

dilated biliary tract, extension-LN, ascitis Rx- Rarely curative surgery Palliation- surgical bypass or stenting Poor response to radiation or chemotherapy

Carcinoma- of GB or biliary tract Progressive jaundice, anorexia, ± pain Tender hepatomegaly, palpable GB Raised bilirubin, alkaline phosphatase, SGPT Tumor marker- CA-19.9 US/CT/MRI/PET scan- GB calculi, mass,

dilated biliary tract, extension-LN, ascitis Rx- Rarely curative surgery Palliation- surgical bypass or stenting Poor response to radiation or chemotherapy