Beningn disorders of the gall bladder.pptx

ppt on beningn disorders of the gall bladder which includes cholecystitis,empyma,polys,choledochal cyst.

1. BENINGN GALL BLADDER DISEASES

2. Overview of Gallbladder Conditions

3. Cholelithiasis Gallstones are solid particles that form in the gallbladder, and there are three predominant types Cholesterol Stones: The most common, accounting for roughly 80% of cases, mainly composed of hardened cholesterol Pigment Stones: Typically found in individuals from non-Western countries and often linked to hemolysis, they comprise calcium bilirubinate Mixed Stones: These contain both cholesterol and calcium, often complicating treatment and management Proper classification of gallstones aids in the development of effective treatment strategies

4. Risk Factors for Cholelithiasis

5. Pathogenesis of Gallstones

6. METABOLIC FACTOR The solubility of bile cholesterol depends on the concentration of lithogenic (supersaturated) bile salts and phospholipids(lecithin predominantly) in the bile. Cholesterol is insoluble in aquaous solution. It is dissolved in bile acids into micelles along with phospholipids. The normal ratio of bile acid to cholesterol is 25:1. When this ratio fall to 13:1, the cholesterol precipitates and gallstone forms.

7. Composition of bile

8. Stasis factor

9. REFLUX FACTOR

10. INFECTIVE FACTOR Under “normal” conditions, the biliary tract is sterile Positive cultures found in- 11-30% symptomatic stones & chronic cholecystitis 46% of acute cholecystitis 58% with gallstones & CBD stones without cholangitis 94% with gallstones, CBD stones and cholangitis

11. Microbiology Gram-negative aerobes most common- E .coli, Klebsiella, Pseudomonas, Enterobacter Gram-positive aerobes- Enterococcus, Streptococcus viridans Anaerobes (~25% )-Bacteroides fragilis, Clostridium Fungal-Candida sp. Parasitic-Opisthorchis sp. (Thailand) (Liver fluke),Clonorchis sp. (China) Approximately 50% of positive cultures will have 2 or more different bacteria species present

12. PIGMENT STONES Hemolysis: - Increases bilirubin production thus forming PIGMENT STONES seen in-Hereditary spherocytosis, sickle cell anaemia , thalassaemia , malaria, mechanical destruction of red cells by prosthetic heart valves

13. Types of Pigment Stones

14. Non modifiable factors Increasing age Female gender Ethnicity Genetics, family history

15. Modifiable factors Pregnancy and parity Obesity Prolonged fasting Drugs: clofibrate, ceftriaxone Oral contraceptives Low-level physical activities Rapid weight loss (> 1.5 kg/ wk ) Hypertriglyceridemia/low high-density lipoprotein Metabolic syndrome Gallbladder stasis Specific diseases ( ie , cirrhosis, Crohn’s disease with severe ileal involvement/resection)

16. Complications of gallstones In the GB : Biliary colic Acute and chronic cholecystitis Empyema Mucocoele Carcinoma In the bile ducts : Obstructive jaundice Pancreatitis Cholangitis In the gut : Gallstone ileus

17. Effects and Complications of Gallstones Mirizzi’s Syndrome : A condition where a stone in the cystic duct compresses the common hepatic duct, causing obstructive jaundice Fistula Formation : Chronic inflammation can result in abnormal connections between the gallbladder and bile ducts Treatment Approaches : Surgical intervention, often through cholecystectomy, is commonly required, and additional reconstructive procedures may be needed in more severe cases

18. Cholecystitis Cholecystitis is an inflammatory condition of the gallbladder that can be categorized as follows Acute Cholecystitis : Sudden inflammation usually due to obstruction by gallstones Chronic Cholecystitis : Long-standing inflammation often resulting from recurrent acute episodes Acute on Chronic Cholecystitis : An exacerbation of chronic inflammation characterized by acute symptoms

19. Acute Cholecystitis Acute cholecystitis exists in two forms Acute Calculous Cholecystitis : The most prevalent form caused by obstruction from gallstones, leading to stasis and infection Acute Acalculous Cholecystitis-  This form occurs in critically ill patients without the presence of gallstones, often resulting from ischemia or severe infections

20. Acute Acalculous Cholecystitis This condition primarily affects critically ill individuals and has distinct risk factors Common Causes: Sepsis, prolonged hypotension, major trauma, and post-operative states can precipitate acalculous cholecystitis Pathophysiology: Impaired blood flow to the cystic artery leads to ischemia, causing inflammation and potential necrosis of the gallbladder wall

21. Biliary colic Site ------ RUQ Onset ------ sudden Timing ------- 30 min – 6 hrs Character ------ colicky Radiation------ +/- to epigastrium, back Severity ------- very Assoc symptom----- nausea & vomiting Aggrav /relieving factors----- fatty foods, analgesics

22. PHYSICAL FINDINGS

23. Murphy’s Sign Clinical Significance: Murphy’s sign is a practical diagnostic test for assessing acute cholecystitis Test Procedure: The examiner instructs the patient to take a deep breath while applying pressure to the right subcostal area

24. Pathology of Acute Cholecystitis Gross Features: The gallbladder may appear enlarged, tense, and erythematous, often covered with inflammatory exudate Microscopic Features: Histological examination reveals acute inflammation in the gallbladder wall, with possible findings of mucosal ulceration, gangrenous necrosis, or abscess formation, highlighting the severity of the condition

25. Chronic Cholecystitis Etiology: Chronic cholecystitis often arises from repeated episodes of acute inflammation or chronic irritation from gallstones or bile stasis Pathogenesis: Ongoing irritation from supersaturated bile leads to persistent inflammation, fibrosis, and structural changes in the gallbladder wall

26. Microscopic Features of Chronic Cholecystitis Histopathological Findings: Chronic inflammatory cell infiltration including lymphocytes and macrophages is noted within the gallbladder wall Rokitansky-Aschoff Sinuses: These outpouchings of the mucosal epithelium into the muscularis layer are commonly observed and signify chronic degeneration of the gallbladder wall

27. Variants of Chronic Cholecystitis Cholecystitis Glandularis: Characterized by the fusion of mucosal folds, leading to crypt-like structures within the wall Porcelain Gallbladder: Represents severe chronic inflammation resulting in calcification of the gallbladder wall Acute on Chronic: Exhibits a blend of acute exacerbation and chronic changes, making diagnosis and management particularly complex

28. INVESTIGATIONS HB ,TC DC LFT AMYLASE LIPASE USG ABDOMEN CT ABDOMEN ERCP MRCP

29. Usg vs Ct scan Ultrasonography: Non-invasive and cost-effective 95-98% sensitive, 98% specific for documenting presence of gallstones 80-95% sensitive, 78-80% specific for cholecystitis Operator dependent CT Scanning: Less sensitive than ultrasound for detecting stones (50-70%) or cholecystitis. More expensive However it does provide important information regarding the nature,extent and location of biliary dilatation and the masses in and around the biliary tract and pancreas

30. ERCP

31. ERCP

32. Plain Films

33. Treatment of Cholecystitis Initial management typically involves conservative measures NPO: Patients are kept nothing by mouth to rest the gallbladder IV Antibiotics and Analgesics: Address infection and pain management If clinical improvement occurs, an elective laparoscopic cholecystectomy is usually scheduled after approximately six weeks to prevent recurrence

34. Laparoscopic Cholecystectomy

35. Laparoscopic Cholecystectomy

36. Empyema Gallbladder Definition: Empyema refers to a severe condition in which the gallbladder is filled with pus, typically due to infection after cholecystitis Treatment Approach: Initial management may require drainage via cholecystostomy , followed by a laparoscopic or open cholecystectomy to prevent further complications

37. Gallbladder Polyps Definition: Polyps are protrusions of the gallbladder mucosa into the lumen, often found incidentally during imaging Incidence: Approximately 5% of adults have gallbladder polyps, but most are benign and do not pose significant health risks Concern for Malignancy: Only a small percentage of gallbladder polyps have the potential to become cancerous, necessitating careful monitoring and management

38. Risk Factors for Malignancy in Polyps Certain characteristics increase the likelihood of malignancy in gallbladder polyps Size of Polyp: Polyps larger than 10 mm are more likely to be cancerous, warranting closer evaluation Age and History: Patients over 50 years of age or those with a history of primary sclerosing cholangitis have a higher risk Ethnicity: Indian ethnicity has been associated with an elevated risk of malignant transformation of gallbladder polyps

39. Management of Gallbladder Polyps Surgical Intervention: Cholecystectomy is recommended for polyps larger than 10 mm due to the increased risk of malignancy Observation for Smaller Polyps: Polyps smaller than 10 mm may be managed conservatively, with follow-up imaging depending on symptoms and individual risk factors for cancer, ensuring any changes in size or characteristics are closely monitored

40. Choledochal Cyst Definition: Choledochal cysts are congenital dilations of the bile ducts that can present at various ages, often leading to complications Associated Risks: These cysts are linked to an increased risk of cholangiocarcinoma , necessitating early diagnosis and appropriate management to avoid further complications

41. Pathogenesis of Choledochal Cysts Mechanism: Choledochal cysts result from abnormal fusion of the pancreaticobiliary ducts, which causes a reflux of pancreatic secretions into the bile ducts Consequences: This maladaptive fusion leads to bile duct dilation, increasing the risk of inflammation, infections, and malignancy

42. TODANIS CLASSIFICATION

43. Investigations for Choledochal Cysts Diagnostic Imaging: Various imaging techniques are employed to diagnose choledochal cysts Ultrasound: Often used for initial assessment and identification of cysts Magnetic Resonance Cholangiopancreatography : Provides detailed visualization of biliary anatomy and can diagnose cyst types and complications CT Scan: Helpful in evaluating the extent of duct dilation and assessing surrounding structures for potential complications

44. Surgical Treatment of Choledochal Cysts Definitive Management: Surgical intervention is the primary treatment for choledochal cysts Excision: Complete removal of the extrahepatic biliary tree for types I, II, and IV Endoscopic Options: Type III cysts, which affect the duodenum, can be managed endoscopically Complex Cases: Type V cysts, which impact the liver, may lead to the need for liver transplantation

45. Miscellaneous Conditions Cholesterosis: A benign condition characterized by the deposition of cholesterol esters in the gallbladder wall, leading to a distinctive "strawberry" appearance on imaging Diverticulosis: A rare condition where outpouchings occur in the gallbladder, typically associated with pigment stones Torsion of the Gallbladder: A rare and urgent situation involving a twist in the gallbladder that compromises its blood supply, necessitating immediate surgical intervention

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