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Disease of billary system.

Diseases of biliary system

  • Congenital abnormalities of biliary tract are not very common.
    • They do matter in diagnosis and during difficult operations.
  • A few are as follow;
    • –Absence of gall bladder.
    • –Double gall bladder.
    • –Absence of cystic duct.
    • –Low insertion of cystic duct.
    • –An accessory cholecystohepatic duct.
    • –Biliary atresia
    • Choledochal cyst
  • Extra hepatic biliary atresia
    • Progressive jaundice with cholestatic picture is the feature.
    • Liver biopsy and radionuclide excretion scans are diagnostic.
    • Adequate biliary drainage is required e.g. portoenterostomy.
    • Liver transplantation is one choice
  • Choledochal cyst
    • Congenital dilatation of intra- and/or extra-hepatic biliary system.
    • Jaundice, fever, abdominal pain are symptoms.
    • Right upper quadrant mass on examination.
    • Radical excision with Roux-en-Y loop of jejunum is treatment of choice
  • The cholecystoses
    • (cholesterosis’polyposis, adenomyomatosis and cholecystitis glanularis proliferans) all these are indications for cholecystectomy.
  • Typhoid gall bladder
    • In typhoid, gall bladder is commonly affected and even perforate spontaneously, than need cholecystectomy.
  • Trauma
    • of biliary system is rare and treated accordingly.
  • Torsion of gall bladder
    • is very rare and treated with cholecystectomy.
  • Gallstones (Cholelithiasis)
    • Gallstones  may be cholesterol, pigment (brown/black) or mixed stones depending on concentration of cholesterol.
  • Clinical features are
    • Pain in right upper quadrant or epigastrum that may radiate to back.
    • Dyspepsia, flatulence, food intolerance, particularly to fats, and some alteration in bowel frequency.
    • Severe biliary colic associated with nausea and vomiting.
    • Obstructed jaundice, bowel obstruction are complication of gall stones.

 

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Complications of gall stones

  • In the gall bladder
    • Biliary colic, acute and chronic cholecystitis, empyema of gall bladder, mucocele, perforation, etc.
  • In the bile duct
    • Biliary obstruction, acute cholangitis, acute pancreatitis
  • IN the intestine
    • Intestinal obstruction ( gallstone ileus)

 

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Differential diagnosis of cholecystitis

  • Common are
    • Appendicitis, perforated peptic ulcer, acute pancreatitis
  • Uncommon are
    • Acute pyelonephritis, myocardial infarction, pneumonia right sided.
  • Rare are
    • Harpies zoster

 

Diseases of biliary system

  • Stones in the bile duct
    • May be primary or secondary.
    • May be asymptomatic or symptomatic (pain, jaundice and fever).
    • Courvoisier’s law
      • In obstruction of the common bile duct due to stone, distention of the gallbladder seldom occurs; as the GB is usually shriveled.
    • Relief of obstruction is essential, under antibiotic cover.
    • Treatment options are
      • Endoscopic papillotomy with sphincterotomy, removal of stones using a Dormia basket
      • Or the placement of a stent if stone removal is not possible.
      • Or one hole cholecystectomy with choledochotomy.

 

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Diseases of biliary system

  • Stricture of the bile duct
    • Causes of benign biliary stricture
      • Congenital
        • Biliary atresia
      • Bile duct injury at surgery
        • Cholecystectomy, choledochotomy, gastrectomy, hepatic resection.
      • Inflammatory
        • Stones, cholangitis, parasitic, pancreatitis, sclerosing cholangitis, radiotherapy.
      • Trauma,
        • Idiopathic
    • Radiological investigations help in defining the cause, site nature, extend of stricture, and back pressure effect.
    • Treated according to cause, bypassing, stenting, etc.