Plain x ray GB stone in 10 % Gas in biliary tree Gall stone ileus Gas in GB wall Porcilin GB
Radiological investigationsOral Cholecystography • We comment on • Site • Size • Shape • Filling Defect • Function • Concentration of dye • contractility
Investigations Imaging techniques Ultrasound this is most useful • Most important to show intrahepatic bile ducts dilatation • Measure the diameter of CBD (normal up to 7 mm) • Comment on the status of the GB and its stones • Visualize CBD diameter, stones or areas of narrowing • Tumors in the region of the pancreas is seen CT (conventional or helical) competes with the U/S especially as regards the pancreatic tumors.
cholangiogram • Preoperative cholangiogram • IV cholangiogram • PTC • ERCP • Intra operative • T tube ( post operative )
Investigations for a case of obstructive jaundice ERCP • ERCP is an outpatient procedure that combines endoscopic and radiologic modalities to visualize both the biliary and pancreatic duct systems. • Endoscopically, the ampulla of Vater is identified and cannulated. • A contrast agent is injected into these ducts, and • x-ray images are taken to evaluate their caliber, length, and course. • ERCP is used to • get a final diagnosis and • do biopsy of ampullary tumors, or brush cytology.
Investigations for a case of obstructive jaundice ERCP • It can be also therapeutic for • stone extraction by Dormia basket or • insertion of a stent, both are preceded by sphincterotomy. • It has its risks • ascending infections, • perforations, • pancreatitis, an • bleeding due to sphincterotomy done routinely before CBD cannulation
Congenitalcaroli’s syndrome congenital intrahepatic dilated bile ducts
Investigations for a case of obstructive jaundice MRCP • a sensitive noninvasive method of detecting biliary and pancreatic duct stones, strictures, or dilatations within the biliary system. • It is also sensitive for helping detect cancer.
Investigations for a case of obstructive jaundice MRCP (contraindications) Absolute include • the presence of a cardiac pacemaker, • cerebral aneurysm clips, • ocular or cochlear implants • ocular foreign bodies. Relative contraindications include • the presence of cardiac prosthetic valves, • neurostimulators, • metal prostheses, • penile implants
Investigations for a case of obstructive jaundice PTC • performed by a radiologist using fluoroscopic guidance. • The liver is punctured to enter the peripheral intrahepatic bile duct system. • An iodine-based contrast medium is injected into the biliary system and flows through the ducts. • Obstruction can be identified on the fluoroscopic monitor.
Investigations for a case of obstructive jaundice PTC • It is especially useful for lesions proximal to the common hepatic duct. • Still, ERCP is generally preferred. • PTC is reserved for use if ERCP fails or when altered anatomy precludes accessing the ampulla.
Investigations for a case of obstructive jaundice PTC Complications of this procedure include • the possibility of allergic reaction to the contrast medium. • peritonitis. • intraperitoneal hemorrhage, sepsis • cholangitis. • subphrenic abscess. • lung collapse. • Severe complications occur in 3% of cases
Investigations for a case of obstructive jaundice • Endoscopic ultrasound (EUS) combines endoscopy and US to provide remarkably detailed images of the pancreas and biliary tree. • It uses higher-frequency ultrasonic waves compared to traditional US (3.5 MHz vs 20 MHz) • allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-FNA).
Acute Cholecystitis • Acute obstructive (Calcular) • Acute Acalcaus • Acute emphysematous
Acute obstructive (Calcular)(Pathology) • Calcular obstruction • GB become hyperemic, oedematous & distended • Chemical inflammation • Release of Phosphlipases • Act on lecithin which is a mucosal protector transforming it into • Lysolecithin (mucosal toxin • Arachidonic acid (PG precursor) (inflammation) • Sepsis • Ecoli, klebsilla & strept which occur later on
Acute obstructive (Calcular)(Pathology) • Following acute inflammation the condition end by one of the following • Resolution • Mucocele • Empyema • Gangrene And perforation • Bilo-enteric fistula
Acute Acalcular Cholecystitis • It form 8 % • Risk factors are • Sepsis • Starvation • Prolonged TPN • Ileus • Morphine use > 6 days
Acute Acalcular Cholecystitis • Pathology is not knowen • Prolonged distention of GB , Bile stasis & inspissations lead to mucosal injury and vessel thrombosis • Hypersensitivity to concomitant antibiotics • Gangrene occur in 25 % of cases
Acute emphysematous GB • Caused by mixed poly-microbial infection including gas forming bacteria • 70% male , diabetics • Thrombosis of cystic artery is the cause • It lead tom • Gangrene in 75 % • Perforation in 15 %
Clinical picture • Patient 5 F • General • High fever with shivering • Nausea, vomiting & biliary dyspepsia • Local • Biliary colic • Tenderness • Murphy’s sign • Boa’s sign • Complication
Clinical picture • The attack of biliary colic is the start with visceral type of pain (diffuse, colicky, radiating, and associated with vomiting) • Later on after 6 to 8 hours, the pain localizes to the right hypochondrium, and become associated with tenderness, rebound T, and rigidity and mild fever (somatic pain) • The presence of distended gall bladder is the hallmark of the disease, either discovered clinically or by U/S • In 25% of cases the bilirubin rises, due to compression of the CBD (Mirrizi syndrome) or less commonly due to an associated stone CBD • Serum amylase should be a routine as well as plain X ray abdomen (pancreatitis, and perforation or gas in biliary system