Biliary Stones Chapter XI K00-K93 Digestive System นพ.บิัก์ เจิญิล์ ก่มงานัลยกรรม รพ.สวรร์ประชาัก์ นครสวรร์ 1 2 Biliary Stones Biliary Stones ำิิจัยทางคิิก (Clinical Diagnosis) Gallbladder Common Bile Duct Intrahepatic Duct Gallbladder Common Bile Duct Intrahepatic Duct Gallstones CBD stones IHD stones Gallbladder stone Choledocholithiasis Choledocholithiasis Gallstones CBD stones IHD stones Cholelithiasis Gallbladder stone Choledocholithiasis Choledocholithiasis Cholelithiasis Summary Diagnosis With Infection No Infection K80.0 [acute] Gallstone K80.2 K80.1 [chronic] K80.3 [cholangitis] Common bile duct stone K80.5 K80.4 [cholecystitis] Intrahepatic duct stone K70.5 [liver abscess] K80.5 3 4 Biliary Infections Biliary Infections ำิิจัยทางคิิก (Clinical Diagnosis) ำิิจัยทางคิิก (Clinical Diagnosis) Gallbladder Common Bile Duct Intrahepatic Duct Gallbladder Cholecystitis Cholangitis Cholangitic liver abscess Cholecystitis Acute cholecystitis Acute cholangitis Acute cholecystitis Empyema gallbladder Ascending cholangitis Empyema gallbladder Suppurative cholecystitis Toxic cholangitis Suppurative cholecystitis Gangrenous cholecystitis Suppurative cholangitis Gangrenous cholecystitis Gangrenous gallbladder Recurrent cholangitis Gangrenous gallbladder Chronic cholecystitis Post-ERCP cholangitis Chronic cholecystitis no stone no stone with IHD stone no stone with Gallstone with CBD stone with Gallstone with CBD stone with CBD stone 5 6 Biliary Infections Disease of Liver Gallbladder Common Bile Duct Intrahepatic Duct Acute cholecystitis Acute cholangitis Cholangitic liver abscess Alcoholic Liver Disease Chronic cholecystitis Cholangitis Toxic Liver Disease Cholecystitis Hepatic Failure Summary Diagnosis With Stone No Stone Chronic Hepatitis Acute cholecystitis K80.0 K81.0 Cirrhosis Chronic cholecystitis K80.1 K81.1 Fatty Liver Cholecystitis K80.1 K81.9 Cholangitis K80.3 K83.0 Cholangitic liver abscess K80.3 + K75.0 K75.0 #CBD stone with cholecystitis ใ้รัส K80.4 [พบ้อยในเวชปิัิ] exclude Infectious disease 7 8 Non-Infectious Hepatitis Alcoholic hepatitis, Toxic hepatitis Alcohol Drugs : acetaminophen, methotrexate, methyldopa, halothane, nacrotics, ketoconazole, chlorpromazine, methimazole, sulfonamide Other : Wilson’s disease, herbs, carbon tetrachloride, chloroform 9 10 Transaminases Alcoholic Liver Disease ‘AST’ ‘SGOT’ / ‘ALT’ ‘ SGPT’ Maximal metabolism of alcohol 160-180 g/day AST Normal liver : Liver, Heart, Muscle, Kidney, Brain : Not storage organ for fat, normal concentration ~5% : Released into serum when any of those tissues damaged Heavy alcohol drinking for 20 years: at risk for alcohol problems ALT : Men >6 drinks/day : Liver : Women >2 drinks/day : Released into serum when liver injury, fairly specific indicator of liver Alcohol Liver Disease [ALD] : Alcoholic fatty liver : Alcoholic hepatitis NOT…..Transminitis in Summary Discharge : Alcoholic cirrhosis 1 standard drink = 10 g alcohol 11 12 Acute Hepatic Injury Laboratory Test Peak ALT AST/ALT Peak Bilirubin PT prolong Disease (x URT) ratio (mg%) (sec) Viral hepatitis 10-40 <1 <15 <3 Fatty Liver [Steatosis] Alcoholic hepatitis 2-8 >2 <5 1-3 Yellow, greasy, enlarged liver Fatty vacuoles displace hepatocellular nuclei peripherally Alcoholic Hepatitis [Steatohepatitis] Toxic hepatitis >40 >1 (early) <5 >5 (transient) Associated with extreme fatty change and sometimes with cirrhosis Swelling of hepatocytes, necrosis, cholestasis and beginning fibrosis Alcoholic Cirrhosis Ischemic injury >40 >1 (early) <5 >5 (transient) Enlarged liver with micronodular formation End stage resembles post-necrotic cirrhosis 13 14 Progression in ALD Alcoholic Fatty Liver Excessive deposition of triglycerides in liver cells Alcohol consumption AASLD Practice Guideline : >21 drinks/week in men; >14 drinks/week in women: >2-year Diagnosis : Elevated liver enzyme [ALT 2-4 times, AST/ALT <1] : Exclude viral hepatitis - serology : Imaging - fatty infiltrate [US, CT, MRI, LSM (fiboscan)] 15 16 Fatty Liver Hepatic steatosis Alcoholic Hepatitis Normal liver Steatohepatitis : Not storage organ for fat, normal concentration ~5% Alcohol consumption Nonalcoholic Fatty Liver Disease (NAFLD) : >21 drinks/week in men; >14 drinks/week in women: >2-year : Metabolic syndrome : nonspecific - anorexia, weight loss, abdominal pain, N/V : Malnutrition, Rapid weight loss, Weight reduction surgery : severe - liver stigmata, fever, encephalopathy : Medications - steroids, estrogen, amiodarine, tamoxifen, methotrexate Diagnosis Alcoholic Fatty Liver : Elevated liver enzyme [<500 IU/ml, AST/ALT >2] (viral hepatitis <1) : Earliest stage of alcohol-related liver disease : Elevated GGT (gamma-glutamyl-transpeptidase) Acute Fatty Liver of Pregnancy : Macrocytic anemia : Symptoms begin in 3rd trimester : Hyperbilrubinemia [conjugated] : Improved after delivery and no lasting effects 17 18 Predictive Models Hepatic steatosis Non-Infectious Liver Disease Maddrey’s Discriminate Function [MDF] (1989) : 4.6 x [patient’s PT - control PT] + total bilirubin Summary Diagnosis ICD-10 : MDF >32 associated with a high short-term mortality Alcoholic fatty liver [AFL] K70.0 Model for End-Stage Liver Disease [MELD] score (2001) Non-alcoholic fatty liver disease [NAFLD] K76.0 : bilirubin, INR, creatinine Fatty liver K76.0 : MELD >21 have 90-days mortality Alcoholic hepatitis K70.1 Glasgow Alcoholic Hepatitis Score (2005) Non-alcoholic hepatitis K71.6 : age, bilirubin, BUN, PT ratio, WBC Non-alcoholic steatohepatitis [NASH] K71.6 Non-alcoholic acute hepatitis K71.2 : >9 have 28-days mortality Hepatitis K75.9 Lille Model Acute hepatitis B71.9 : age, creatinine, albumin, PT, bilirubin : 6-months survival 19 20 Chronic Hepatitis Autoimmune Hepatitis Active, Persisting and Ongoing Inflammation >6 months old name ‘Lupoid hepatitis’ Classification hy Etiology Common in young or middle-aged women Chronic viral hepatitis Insidious onset, remission and relapsed Autoimmune hepatitis Fatigue, malaise, anorexia, amennorrhea, acne, arthralgia, Drug induced hepatitis jaundice, arthritis, colitis, pericarditis, anemia, cirrhosis Cryptogenic hepatitis Laboratory features Classification hy Pathology - serum AST 100-1000 units Chronic persistant hepatitis - mild activity - serum bilirubin normal to 10 mg/dL Chronic lobular hepatitis - mild to moderate fibrosis - prothrombin time prolonged Chronic active hepatitis - moderate to severe fibrosis - hypergammaglobulinemia >2.5 g/dL - Antinuclear Ab, Smooth muscle Ab, Anti-LKM1 Ab 21 22 Chronic Hepatitis [K73] based on histological distinction · viral ( B15-B19 ) K73.0 Chronic persistent hepatitis, not elsewhere classified K73.1 Chronic lobular hepatitis, not elsewhere classified K73.2 Chronic active hepatitis, not elsewhere classified Lupoid hepatitis NEC K73.8 Other chronic hepatitis, not elsewhere classified K73.9 Chronic hepatitis, unspecified K74 FibrosisOld…………..…Classification and cirrhosis of liver Not…Correlate with Prognosis Now…………Much Less Used 23 24 Cirrhosis Cirrhosis ‘kirrhos = tawny’ the orange-yellow colour + osis = condition ‘kirrhos = tawny’ the orange-yellow colour + osis = condition Drugs and Toxins : Alcohol, Methotrexate, Isoniazid, Methyldopa อาการและอาการแสดงของับแ็ง อ่าง้อย 3 ้อ Infections Jaundice, Spider nevi, Palmar erythema, Gynecomastia or : Hepatits B, Hepatitis C, Schistosoma or Testicular atrophy or Decrease of libido, Enlarged parotid Autoimmune disorders gland, Portal hypertension [caput medusa, hemorrhoids, : Primary biliary cirrhosis, Primary sclerosing cholangitis esophageal varix, gastric varix], Small liver or Splenomegaly Metabolic disorders กรีพบอาการและอาการแสดง้อยก่า 3 ้อ ้องี : Wilson’s disease, Hemochromatosis, Porphyria • ผลการำงานของับ่ิดปกิ [LFT, prolong PT] Biliary obstruction • ผลตรวจทางังีิทยา [U/S, CT, MRI,…Fibroscan] : Biliary atresia, Cystic fibrosis, Gallstones • ผลการ่าัด ่ระุักษณะของับแ็ง Cardiovascular disorders • ผลตรวจทางพยาิิทยา : Chronic right heart failure, Budd Chiari syndrome 25 26 Cirrhosis Hepatitis C Virus Infection ‘kirrhos = tawny’ the orange-yellow colour + osis = condition Alcoholic cirrhosis : ีประัิ่มุราปิมาณมากและเ้อังเ็นเวลา 5-15 ี : ักเ็น micronodular cirrhosis (<3 mm) Hepatitis virus cirrhosis : ักเ็น macronodular cirrhosis (>3 mm) Cardiac cirrhosis : เิดจากภาวะเือด่งเ้อัง่ับจากัวใจ้องขวาวายเ้อัง : เ้อับขาดออกิเจนและตาย Biliary cirrhosis : เิดจากระบบูิ้มันำลาย่อำีในับเ็น Primary biliary cirrhosis : เิดจากทางเิน้ีุด้นเ็น Secondary biliary cirrhosis 27 28 Primary Biliary Cirrhosis Cirrhosis Summary Diagnosis ICD-10 Alcoholic cirrhosis K70.3 Toxic cirrhosis K71.7 Hepatitis B cirrhosis B18.1 + K74.6 Hepatitis C cirrhosis B18.2 + K74.6 Cryptogenic cirrhosis K74.6 Macromodular cirrhosis K74.6 Micronodular cirrhosis K74.6 Liver cirrhosis K74.6 Cirrhosis K74.6 29 30 Cirrhosis Summary Diagnosis ICD-10 Congenital cirrhosis P78.8 Cardiac cirrhosis K76.1 Cholestatic cirrhosis K74.3 Biliary cirrhosis K74.5 Primary biliary cirrhosis K74.3 Secondary biliary cirrhosis K74.4 31.