Gallstones. Chronic Cholecyctitis. Chronic Pancreatitis.

Gallstones. Chronic Cholecyctitis. Chronic Pancreatitis. 1

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Components 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 4

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Gallstones • Bile pigments • Cholesterol • Calcium salts

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Predisposing factors for GBS cholesterol and mixed 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 GBS - pigment stones • • • •

Demography Chronic hemolysis Alcocholic cirrhosis Chronic biliary tract infections

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Cholelithiasis • = formation of gallstones • • • •

Physical characteristics of bile are altered: - cholesterol is less soluble - diminished contractility of bladder - infections

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GS formation 3 stages: - Physico-chemical - Latent - Clinical

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Mechanisms of GS formation • increased biliary secretion of cholesterol • defective vesicle formation • nucleation of cholesterol monohydrate crystals • biliary sludge

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Clinical course of GBS • • • • • •

Symptomless Biliary colic Obstructive jaundice Cholangitis Acute cholecystitis Chronic cholecystitis

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Complaints • 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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Examination • 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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Tests • Light hyperbilirubinemia • Increasing of WBC

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Diagnosed by • Ultrasonography • CT • MRI • Plain abdominal X-ray (opaque stones) with calcium • Oral cholecystogram

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Complications 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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Treatment • Medical Therapy - Gallstone Dissolution • Surgical Therapy - cholecystectomy

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Chronic cholecystitis

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Chronic 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 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 (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 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 images

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Complications • • • • • • •

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 30

Treatment • • • • •

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 Pancreatitis

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Pancreas 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 33

Chronic 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 34

Aetiology • 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 35

Aetiology • 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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Alcohol

Pathogenesis

viscous pancr.juice

plug formation

ductules’ obstruction

glandular ischemia

calcification

acinar ectasia, pseudocysts formation, atrophy pancreatic insufficiency 37

Chronic 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 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 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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Examination • Thin patient • Features of other alcohol- and smokingrelated 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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Tests • • • • • •

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 investigation • MRI • Sonography • ERCP (эндоскопическая ретроградная холангиопанкреатография) • CT • Plan abdominal X-ray

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Сa++

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ERCP

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ERCP

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Complications • 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) 47

Complications • 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

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Cholangitis and biliary cirrhosis Bone pain Pancreatic carcinoma Arthritis 48

Treatment 2 main aims: • Pain relief (opiate) • Malabsorption decreasing

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Treatment • • • • •

Diet - 5 Alcohol misuse (very difficult) Oral pancreatic enzyme Symptomatic treatment Surgical treatment

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