Curtis Peery MD Sanford Health Surgical Associates Sioux Falls SD 605-328-3840 [email protected] Diseases of the Gallbladder COMMON ISSUES HEALTH CARE PROVIDERS WILL SEE!!! OBJECTIVES Discuss Biliary Anatomy and Physiology Discuss Benign Biliary disease Identify and diagnose common biliary conditions Clinical Scenarios Update in surgical treatment Purpose of Bile Aids in Digestion Bile salts aid in fat and fatty vitamin absorption Optimizes pancreatic enzyme function Eliminates Waste Cholesterol Bilirubin Inhibits bacterial growth in small bowel Neutralizes stomach acid in the duodenum Biliary Anatomy Gallbladder Function Storage for Bile Between Meals Concentrates Bile Contracts after meals so adequate bile is available for digestion CCK is released from the duodenum in response to a meal which causes the gallbladder to contract Gallbladder Disease Gallstones- Cholesterol or pigment stones from bilirubin Cholelithiasis- gallstones in the gallbladder Biliary colic- pain secondary to obstruction of the gallbladder or biliary tree Choledocholithiasis – presence of a gallstone in the CBD or CHD Cholecystitis- Inflammation of the gallbladder secondary to a stone stuck in the neck of the gallbladder Cholangitis- infection in the biliary tree secondary to CBD stone(May result in Jaundice) Gallstone Pancreatitis- pancreatitis secondary to stones passing into the distal CBD Biliary dyskinesia- disfunction of gallbladder contraction resulting in biliary colic GALLSTONES Typically form in the gallbladder secondary to the concentration of bile Cholesterol stones 80% of all gallstones The 4 Fs Pigment stones Bilirubin Increased turn over of hemoglobin E. coli cirrhosis CHOLELITHIASIS The presence of gallstones within the gallbladder Incidence 15-20% Frequently are asymptomatic 20% of incidentally found gallstones develop symptoms Complications of G a l l s t o n e s Biliary Colic Chronic Cholecystisis Biliary Dyskinesia Acute Cholecystisis Pain greater than 6 hours Empyema/Gangrene/Perforation Hydrops Requires Urgent Surgical Consultation Choledocholithiasis Painful Jaundice Ascending Cholangitis Gallstone Pancreatitis G A L L S T O N E ILEUS Rare Fistula between gallbladder and small bowel Presents as a bowel obstruction May require 2 surgeries ASCENDING CHOLANGITIS Charcot’s Triad Pain Jaundice Fever Reynold’s Pentad Hypotension Altered Mental Status Indication of sepsis Requires biliary decompression prior to surgery ERCP IR drainage CLINICAL SYMPTOMS Pain Very nonspecific Significant variability Nausea Long differential Vomiting Common things are common Diarrhea Should prompt a basic Bloating evaluation Dark Urine LFTs U/S Clay colored stools +/- additional testing EKG Trial of acid blocker ULTRASOUND FINDINGS Gall Stones Thickened Gallbladder Wall Pericholecystic fluid Dilated gallbladder Sludge Murphy’s Sign Clinical Scenario #1 40yo Hispanic female 6 months of RUQ pain with nausea and occasionally loose stool Sx occur after meals occasionally and sometimes at night She has 3 children Otherwise healthy but bmi of 38 Only medication is oral contraceptive Clinical Scenario #1 40yo Hispanic female 6 months of RUQ pain with nausea and occasionally loose stool Sx occur after meals occasionally and sometimes at night She has 3 children Otherwise healthy but bmi of 38 Only medication is oral contraceptive HIDA SCAN Findings of Gallbladder Disease Non visualization of gallbladder Acute cholecystitis or Hydrops Delayed Filling of gallbladder Chronic Cholecystitis Ejection Fraction Low= Biliary Dyskinesia High(greater than 80%)= Hyperkinetic Biliary Dyskinesia Clinical Scenario #2 51yo white male Presents to the ER with epigastric pain Has had several times before Radiated to chest EKG was negative CT was normal Resolved after several hours with pain medication On medication for HTN and elevated cholesterol Overweight Stress Test is negative Clinical Scenario #2 Ultrasound shows a polyp, CBD mildly dilated LFTs-Normal except mildly elevated AST, ALT, Alk. Phos. Clinical Scenario #3 28yo Hipster leaving to go to PERU in 2 weeks Presents to the ER with severe episode of RUQ pain with radiation to the back plus N/V Never drinks but daily Marijuana use Family History of Gallstones US positive form multiple stones Alk. Phos. Mildly elevated Lipase-370 Pain resolve in ER after 2 hours with narcotics He wants to go home for outpatient follow up Update in Surgical Removal of Cholecystectomy Laparoscopic Cholecystectomy Replaced open cholecystectomy Safe Small but real risk of Bile Duct Injury(BDI) 3-10xs greater than Open Surgery Attempt at decreasing BDI has not improved the rate in over 30 years Routine intraoperative cholangiograms Critical view of saftey 252 patients with bile duct “… what is needed is injury analyzed a simpler method of 97% of injuries-error in locating the course of visual perception the ductal system 3% errors were technical during the operation, skill something simpler Only 25% injuries were than recognized at the index cholangiography or operation ultrasonography.” FLUORESCENT CHOLANGIOGRAPHY Cheat Code Cheap ICG around $30 No need for IOC($700- 800) Safe Iodine Allergy? Saves Time Does not answer question if patient has Choledocholithiasis Available technology on robotic and laparoscopic platforms Curtis Peery MD Sanford Health Surgical Associates Sioux Falls SD 605-328-3840 [email protected] https://vimeo.com/user65254991.