Presentant: Dr. Arli Suryawinata Fasilitator: Dr. M.Iqbal Rivai, SP.-KBD

Presentant: dr.
Arli Suryawinata
Fasilitator: dr. M.Iqbal Rivai, Sp.-KBD

A schematic picture showing the side-viewing
endoscope in the duodenum and a catheter in the
common bile duct
Gallstone Formation
 a result of solids settling out of solution

 major organic solutes  bilirubin, bile salts, phospholipids, and cholesterol
Cholelithiasis Sites of
Pain
 a stone obstructs the cystic duct
 progressive increase of
tension in the gallbladder wall
as it contracts in response to a
meal  recurrent attacks of
pain
Treatment
 Patients with symptomatic
cholelithiasis should be offered
elective cholecystectomy
 If surgery has to be postponed  the
patient should be advised to avoid
dietary fats and large meals
Acute Cholecystitis
• Biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium
• Febrile, complains of anorexia, nausea, and vomiting
Clinical
Manifestations
• PX  tenderness and guarding are usually present in the right upper quadrant
• Murphy’s sign
• Elevated WBC (12.000-15.000/mm3)
• Ultrasonography  sensitivity and specificity of 70% to 90%
Diagnosis
• IV fluids, broad-spectrum antibiotics, and analgesia

• Definitive treatment  Cholecystectomy
Treatment
Ultrasonography from a patient
with acute cholecystitis
Choledocholithiasis
Clinical Manifestation
• complete or incomplete obstruction manifest with cholangitis or gallstone pancreatitis
• Pain
• Nausea and vomitting
• Mild epigastric or right upper quadrant tenderness
Diagnosis
• USG  determining the size of the common bile duct
• Magnetic resonance cholangiopancreatography (MRCP) excellent anatomic detail and has a
sensitivity and specificity of 95% and 89%
• Endoscopic retrograde cholangiopancreatography (ERCP)  effective at diagnosing choledocholithiasis
and in experienced hands
Treatment
• symptomatic gallstones and suspected common bile duct stones  bile duct clearance and
cholecystectomy are indicated
Cholangitis
• a mild, self-limited episode to a fulminant, potentially life-threatening septicemia, Fever,
epigastric or right upper quadrant pain, and jaundice (Charcot’s triad)  Reynolds’ pentad
Clinical
Manifestation
• Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases

• USG  gallbladder stones, demonstrate dilated ducts, and possibly pinpoint a site of
obstruction
Diagnosis • CT scanning & MRI  pancreatic and periampullary masses  ductal dilatation
• broad-spectrum IV, fluid resuscitation, and rapid biliary decompression

• ERCP
Treatment
Gallstone Pancreatitis Gallstone Ileus
 Gallstones  acute pancreatitis   a large gallstone directly into the
transient or persistent obstruction intestine  choledochoenteric fistula
of the pancreatic duct  Proximal stones  gastric outlet
 Management  supportive obstruction (Bouveret syndrome)
 Imaging  ultrasound, CT, or
 Management relieving the intestinal
obstruction and removing the stone
MRCP is essential to confirm the
diagnosis  Imaging  plain films, Ultrasound,
CT
Cholangiohepatitis
 Recurrent pyogenic cholangitis
 etiology bacterial contamination (E coli, Klebsiella species,
Bacteroides species, or Enterococcus faecalis), associated with
biliary parasites (Clonorchis sinensis, Opisthorchis viverrini, and A
lumbricoides)
 Manifest Pain in the right upper quadrant or epigastrium,
fever, and jaundice
 Emaging  ERCP or MRCP
PROCEDURAL INTERVENTIONS FOR
GALLSTONE DISEASE
Percutaneous Transhepatic Cholecystostomy Tubes
Endoscopic Interventions
Laparoscopic Cholecystectomy
Common Bile Duct Exploration
Biliary enteric anastomoses
OTHER BENIGN DISEASES AND LESIONS
Biliary Dyskinesia and Sphincter of Oddi

Dysfunction
 Dysfunction Biliary dyskinesia  affecting the normal motility
and function of the gallbladder and sphincter of Oddi
 Sphincter of Oddi dysfunction a primary presentation of
episodic biliary type pain, abnormal liver function tests
 A benign stenosis  associated with inflammation, fibrosis, or
muscular hypertrophy
Acalculous Cholecystitis
An acute inflammation of the gallbladder  absence of gallstones
Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or
prolonged illness with multiple organ system failure are at risk for developing acalculous cholecystitis
Pathologic examination edema of the serosa and muscular layers, with patchy thrombosis of
arterioles and venules
Ultrasonography and CT scanning
Acalculous cholecystitis requires urgent intervention as rapid deterioration can occur include early broad-
spectrum antibiotics and fluid resuscitation
Choledochal (Biliary) Cysts
Congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree
The typical clinical triad of biliary cysts includes abdominal pain, jaundice, and
a palpable mass
Choledochal cysts are classified into five types depending on the location and
structure of the cysts
Bile Duct Strictures
 related to operative injury,

most commonly during
cholecystectomy
 present with isolated jaundice
without infection
 treatment  depends on the
location and the cause of the
stricture
INJURY TO THE BILIARY TRACT
Gallbladder
Injuries to the
gallbladder 
Treatment 
uncommon  can occur
cholecystectomy.
in the setting of
penetrating trauma
Prognosis  typically
good but depends on
the extent of related
injury, as damage to
nearby organs is not
uncommon
Extrahepatic Bile Ducts
Diagnosis Management Outcome
• intraoperative bile • Management  • Good results 

leakage  the depends on the when the injury is
correct anatomy, or type, extent, and recognized
an abnormal level of the injury, immediately and
cholangiogram as well as the repaired by an
• Obstruction or timing of its experienced biliary
stricture  diagnosis tract surgeon
suspected in • In the most severe
patients with cases, patients with
progressive refractory strictures
elevations of liver and deteriorating
function tests or liver function may
jaundice after become candidates
cholecystectomy for liver transplant
TUMORS
Clinical manifestation
Treatment Prognosis
and diagnosis
• Abdominal • Surgical resection • Most patients with
discomfort, right remains gallbladder cancer
upper quadrant • late diagnosis  have unresectable
pain, nausea and palliative disease at the time
vomiting, jaundice, procedures for of diagnosis
weight loss, unresectable cancer • Recurrence 
anorexia, ascites, occurs most
and abdominal commonly in the
masses liver or in the celiac
• Laboratory, USG, CT or retropancreatic
scan nodes
Bismuth-Corlette classification
Cholangiocarcinoma
• Painless jaundice, Pruritus, mild right upper quadrant pain, anorexia, fatigue, and weight loss
• Physical examination is usually normal
Clinical • ultrasound or CT scanning
Manifestation • fine-needle aspiration (percutaneous or endoscopic), and biliary brushings
and diagnosis
• Surgical excision
• For curative resection the location and local extension of the tumor dictates the extent of the surgery
required
• neoadjuvant chemoradiation and adjuvant chemotherapy
Treatment
• Most patients with perihilar cholangiocarcinoma present with advanced, unresectable disease
• The greatest risk factors for recurrence after resection are the presence of positive margins and lymph node–
positive tumors.
Prognosis
Terima Kasih!

Presentant: Dr. Arli Suryawinata Fasilitator: Dr. M.Iqbal Rivai, SP.-KBD

Uploaded by

Copyright:

Available Formats

Presentant: Dr. Arli Suryawinata Fasilitator: Dr. M.Iqbal Rivai, SP.-KBD

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Presentant: Dr. Arli Suryawinata Fasilitator: Dr. M.Iqbal Rivai, SP.-KBD

Uploaded by

Copyright:

Available Formats

Presentant: dr.

Fasilitator: dr. M.Iqbal Rivai, Sp.-KBD

 a result of solids settling out of solution

• IV fluids, broad-spectrum antibiotics, and analgesia

• Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases

• broad-spectrum IV, fluid resuscitation, and rapid biliary decompression

Biliary Dyskinesia and Sphincter of Oddi

An acute inflammation of the gallbladder  absence of gallstones

Ultrasonography and CT scanning

Congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree

 related to operative injury,

• intraoperative bile • Management  • Good results 

You might also like