cholelithiasis Adhi Dwiyana and complications

cholelithiasis Adhi Dwiyana and complications presentation

1. CHOLELITHIASIS Adhi Dwiyana

2. Predisposing factors Obesity Female sex hormones – estrogen & OCPs Increasing age Pregnancy Drugs- octreotide , clofibrate High fat diet Diabetes mellitus

3. Types of Gall stones Cholesterol stones – radiating crystal like appearance Mixed stones - Most common type of stones ; contains cholesterol, calcium salts of phosphates and carbonates, palmitate ,proteins and are multiple faceted. Pigment stones - small, black or greenish black, multiple and often sludge like

4. Pigment stones Black pigment stones Most common Formed in gall bladder Made of Calcium bilirubinate,phosphate,bicarbonate Common in hemolytic disorders,cirrhosis Multiple , small & hard in consistency Brown pigment stones Rarely form in gall bladder Formed in bile duct Related to bile stasis & infected bile E.coli, Bacteroides

5. Clinical features More common in females Fat,fertile,forty,flatulent 10% Gallstones are RADIO-OPAQUE Asymptomatic in 10 to 20% cases Symptoms- Biliary colic- Right hypochondrium & epigastrium, radiating to chest,back & shoulder, severe , on & off, spasmodic, occurs within hours after meal,usually self limiting and recurring,precipitated by fatty meal. vomiting Fever Increased WBCs

6. MURPHY’s SIGN Patient winces in pain with catch of breath when inflamed gall bladder strikes palpating fingers on inspiration

7. Complications of Gall stones In Gall Bladder- Acute cholecystitis Chronic cholecystitis Empyema of gall bladder Mucocele gall bladder Perforation – leading to biliary peritonitis Gangrene of gall bladder Carcinoma In Bile duct- Obstructive jaundice Cholangitis Acute pancreatitis In Intestine- Acute intestinal obstruction

8. Management Investigations USG abdomen – posterior acoustic shadowing Plain X RAY abdomen LFT- Increased conjugated bilirubin Increased Alkaline Phosphate, GGT, 5’-Nucleotidase TLC

9. D/D of radio-opaque shadow on x-ray Renal stone Calcified 12 th rib tip Phlebolith Faecolith Calcified lymph node Renal cell Ca - calcification Calcified Adrenal tumor

10. Treatment Medical therapy- GALL STONE DISSOLUTION Ursodeoxycholic acid (UDCA) – with a functioning Gall bladder with stone less than 10 mm 10-15 mg/kg/day Pigment stones are non responsive to medical therapy

11. Surgical therapy Laparoscopic cholecystectomy is ideal. Open cholecystectomy is done if patient unfit for laparoscopy through Right Sub-costal(KOCHERS’s) incision.