Causal factors in gallstone formation(multifactorial).

(1) metabolic; (2) infective; and (3) bile stasis.

Effects and complications of gallstones

· In the gall bladder: Silent stones, Chronic cholecystitis, Acute cholecystitis, Gangrene, Perforation, Empyema, Mucocele, Carcinoma.

· In the bile ducts: Obstructive jaundice, Cholangitis, Acute pancreatitis

· In the intestine: Acute intestinal obstruction (‘gallstone ileus)

CHOLECYSTECTOMY:

· open cholecystectomy

· Laparoscopic cholecystectomy

Indications for choledochotomy(laparoscopically or open):

· palpable duct stones;

· there is jaundice or a history of jaundice or cholangitis

· the common bile duct is dilated

· the liver function tests are abnormal, in particular, the alkaline phosphatase is raised.

Stones in the bile duct

The patient may be asymptomatic but usually has bouts of pain, jaundice and fever. The patient is often ill and feels unwell. The term ‘cholangitis’ is given to the triad of pain, jaundice and fevers sometimes known as ‘Charcot’s triad’, on examination:Tenderness may be elicited in the epigastrium and the right hypochondrium. In the jaundiced patient it is useful to remember Courvoisier’s law — ‘in obstruction of the common bile duct due to a stone, distension of the gall bladder seldom occurs;

Stricture of the bile duct

· BenignStricture:Postoperative (80%),Inflammatory (20%),

· Malignant Stricture

Parasitic infestation of the biliary tract

· Biliary ascariasis (The round worm, A. lumbnicoides, common in Asia, Africa and Central America.

· Clonorchiasis (asiatic cholangiohepatis)

· Hydatid disease

TUMOURS OF THE BILE DUCT

· Benign tumour:Papillomatosis

· malignant:Carcinoma of the bile duct

Aetiology: bile-duct stones,sclerosing cholangitis and ulcerative colitis.,choledochal cyst,,Clinorchis sinensis

CARCINOMA OF THE GALL BLADDER

· This is rare in the Western world but, the incidence is high (in Patna, India).

· The tumour is found in less than I per cent of gall-bladder operations.

· In over 90 per cent of instances gallstones are present. The patients are usually in their late 70s, with a female to male ratio of 5:1.

Types of tumour are: usually scirrhous, but squamous cell and mixed squamous adenocarcinomas are found. Spread is by direct invasion through the mucosa to the serosa and into the liver, the lymphatics and the veins.

Clinical features: Most present either with an extensive mass in the liver during investigations for jaundice, or at cholecystectomy at the time the histology is received.

Treatment and prognosis

· Those that are diagnosed at cholecystectomy and confined to the mucosa have a good prognosis. It is debated whether such patients should have a wide excision with resection of adjacent liver and lymph nodes.

· For those tumours that involve the serosa, the prognosis is poor and chemoradiotherapy is all that can be offered.

The Survival Rate is less than 5 per cent at 5 years and the median survival is 12 months.

Дата добавления: 2015-11-16