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Gallstones.Gallstones.Chronic Chronic

Cholecyctitis.Cholecyctitis.Chronic PancreatitisChronic Pancreatitis..

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CComponents of bileomponents of bile

• water (82 %)

• bile acids (12 %)

• lecithin and other phospholipids (4 %)

• unesterified cholesterol (0.7 %)

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Autopsy data

Gallstones revealed in

• - 20 % women > 40 year

• - 8 % men > 40 y.

• - 1 million new cases of cholelithiasis develop each year in USA

• - 38% among Swedish

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66

GallstonesGallstones

• Bile pigments

• Cholesterol

• Calcium salts

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Predisposing factors for GBS - Predisposing factors for GBS - cholesterolcholesterol and and mixedmixed stones stones

• Demography• Obesity• Weight loss• Female sex hormones• Ileal disease or resection• Increasing age• Gallbladder hypomotility leading to stasis

and formation of sludge• Clofibrate therapy• Decreased bile acid secretion

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Predisposing factors for GBSPredisposing factors for GBS - - pigmentpigment stones stones

• Demography

• Chronic hemolysis

• Alcocholic cirrhosis

• Chronic biliary tract infections

1010

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CholelithiasisCholelithiasis• = formation of gallstones

• Physical characteristics of bile are altered:

• - cholesterol is less soluble

• - diminished contractility of bladder

• - infections

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GS formationGS formation

3 stages:

- Physico-chemical

- Latent

- Clinical

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Mechanisms of GS formationMechanisms of GS formation

• increased biliary secretion of cholesterol

• defective vesicle formation

• nucleation of cholesterol monohydrate crystals

• biliary sludge

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CClinical courselinical course of GBS of GBS

• Symptomless

• Biliary colic

• Obstructive jaundice

• Cholangitis

• Acute cholecystitis

• Chronic cholecystitis

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ComplaintsComplaints

• Biliary colic - begins quite suddenly and may persist with severe intensity for 1 to 4 h

• Acute pain in the right hypochondrium with irradiation to the back, thoracic girdle

• Nausea and vomiting

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ExaminationExamination

• Light icterus (in 25 %)

• Light palpation – tension in the right hypochondrium

• Deep palpation – acute pain in the point of gallbladder projection to anterior abdominal wall (Kerr’s point)

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TestsTests

• Light hyperbilirubinemia

• Increasing of WBC

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Diagnosed byDiagnosed by

• Ultrasonography • CT

• MRI

• Plain abdominal X-ray (opaque stones) - with calcium

• Oral cholecystogram

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Complications of GBSComplications of GBS

• Acute and chronic cholecyctitis

• Cancer of GB

• Choledocholithiasis

• Chronic Pancreatitis

• Fistulae formation between the GB and Duodenum or Colon

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TreatmentTreatment

• Medical Therapy - Gallstone Dissolution

• Surgical Therapy - cholecystectomy

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Chronic Chronic cholecystitischolecystitis

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Chronic CholecyctitisChronic Cholecyctitis

• = chronic inflammation of the gallbladder wall

• Is almost always associated with the presence of gallstones

• from persistent mechanical irritation of the gallbladder wall

• Repeated acute cholecystitis

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Clinical featuresClinical features

• may be asymptomatic for years

• may progress to symptomatic gallbladder disease or to acute cholecystitis

• may present with complications

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Complaints Complaints (if present)(if present)

• Repeared not severe pain un the right hypochondrium

• Occurring or Increasing after fat intake

• Nausea

• Transient yellowish of stools (in GBS)

• “Angina pectoris”-like pain

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Examination dataExamination data

• Tongue with brownish fur

• Light abdominal palpation – normal

• Deep palpation – pain in the right hypochondrium, and rarely – epigastrium

• + Kerr's symptom

• + Lepene’s symptom

• + Orthner-Grekov’s symptom

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Ultrasound imagesUltrasound images

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ComplicationsComplications

• See “complications of GBS” and

• Empyema and Hydrops of GB

• Gangrene and Perforation of GB

• Fistula Formation

• Gallstone Ileus

• Limey (Milk of Calcium) Bile

• Porcelain Gallbladder

3131

TreatmentTreatment

• Low-cholesterol diet

• Weight normalization

• Prokinetics drug (motilium,…)

• Spasmolytics (no-spa, …)

• Treatment those disorders which lead to GBS formation

• And see “GBS treatment”

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Chronic Chronic PancreatitisPancreatitis

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PancreasPancreas

EXOCRINE function –• 1500-3000 ml of isosmotic alkaline (pH

>8.0) fluid (juice) per day containing about 20 enzymes and zymogens

• Secretes amylolytic, lipolytic, and proteolytic enzymes

ENDOCRINE function – secretion of insulin, glucagone

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Chronic PancreatitisChronic Pancreatitis

• Inflammation of the pancreas leads to pancreatic failure causing malabsorption and diabetes mellitus

• The condition in which morphological changes present after elimination of aetiology factors

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AetiologyAetiology• Alcoholism

• GBS• Blunt abdominal trauma• Metabolic causes (hypercalcemia, renal failure,

…)• Infections (mumps, viral hepatitis, ascariasis,…)• Drugs (thiazide diuretics, furosemide,

sulfonamides, tetracycline, NSAIDs,…)• Oral contraceptives• Hereditary

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AetiologyAetiology• Vascular causes and vasculitis (after

cardiac surgery, atherosclerotic emboli, necrotizing angiitis, connective tissue disorders

• Penetrating peptic ulcer

• Obstruction of Vater’s ampulla

• Cystic fibrosis

• Tropical pancreatits

• Tumours

• Idoophatic

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PathogenesisPathogenesisAlcohol viscous pancr.juice

plug formation ductules’ obstruction

glandular ischemia calcification

acinar ectasia, pseudocysts formation, atrophy

pancreatic insufficiency

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Chronic PancreatitisChronic Pancreatitis

Common features and complaints• continuous, relentless, slowly progressive

chronic abdominal pain without acute exacerbations (35%)

• increasing pancreatic failure – no pain, but presents with diarrhoea (65%)

• Weight loss

• Anorexia, belching

• Nausea and vomiting

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Pain’s reasonsPain’s reasons

• Increased pressure within the pancreatic ducts

• Increased juice volume• Ischemia of pancreas• Compression of neighboring organs• Direct involvement of pancreatic and

peripancreatic nerves by the inflammatory process

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Pain localizationPain localization

• Upper abdomen• Girdle sensation (bind-like) опоясывающая

боль

• Irradiation to the left part of abdomen, left scapulae, neck

• Increase after fatty food and alcohol

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ExaminationExamination

• Thin patient

• Features of other alcohol- and smoking-related diseases

• Icterus sometimes (pressing of common bile duct and pancreatic duct)

• Deep palpation – pain in projection of pancreas to anterior abdominal wall

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TestsTests

• Increasing of WBC and ESR• Low albumin, Ca++, vit B12, serum

trypsinogen

• Incr. fast glucose• Impaired glucose tolerance • Incr. of serum amylase and lipase

sometime • marked excretion of fecal fat

(steatorrhea)

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Instrumental investigationInstrumental investigation

• MRI

• Sonography

• ERCP (эндоскопическая ретроградная холангиопанкреатография)

• CT

• Plan abdominal X-ray

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Сa++

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ERCPERCP

4646

ERCPERCP

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ComplicationsComplications

• Vit B12 malabsorption

• Impaired glucose tolerance and secondary DM

• Pleural, pericardial, or peritoneal effusions containing high concentrations of amylase

• Gastrointestinal bleeding (pseudocyst eroding into the duodenum)

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ComplicationsComplications

• Icterus • - edema of the head of the pancreas, which compresses

the common bile duct• - by chronic cholestasis secondary to a chronic

inflammatory reaction around the intrapancreatic portion of the common bile duct

• Cholangitis and biliary cirrhosis

• Bone pain

• Pancreatic carcinoma

• Arthritis

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TreatmentTreatment

2 main aims:

• Pain relief (opiate)

• Malabsorption decreasing

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TreatmentTreatment

• Diet - 5

• Alcohol misuse (very difficult)

• Oral pancreatic enzyme

• Symptomatic treatment

• Surgical treatment