Behzad Nakhaei, M.D. , FICS Fellowship in HepatoBiliary Surgery Mc Gill University

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Behzad Nakhaei, M.D. , FICSFellowship in
HepatoBiliary Surgery Mc Gill University

• RUQ Upper Abdomen
• Inflammation Infection
• GallBladder Biliary System Disorders
• ( A Problem Solving Lecture )
• For Medical Students

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Common Clinical PresentationsIn RUQ Upper
AbdomenDue to Inflammation Infection

• Pain Fever
• Jaundice Fever
• Mass Fever
• (One / Two Symptoms Dominate in each of these )

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Signal the need for

• Complete Blood Count
• Liver Function Test
• Serum Amylase
• PT , PTT
• Blood Culture
• Chest Abdominal X ray
• Abdominal Ultrasonography

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3 Most common Scenario ?

• Acute Cholecystitis?
• OR
• Acute Cholangitis?
• OR
• Acute Pancreatitis?

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Pain Fever?

• Upper Abdomen Sepsis RUQ Pain Fever
• In 2/3 of Cases Biliary Origin
• (Acute Cholecystitis, Biliary Colic, Acute
  Cholangitis)
• Acute Pancreatitis
• Pneumonia
• Hepatitis , Herpes Zoster
• Other gastrointestinal Disease
• Sono is the most important Screening test for
  Acute Biliary Infections.

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Pain Fever

• Diagnosis
• Acute Cholecystitis
• Biliary Colic
• Acute Cholangitis
• Acute Pancreatitis

• Sono Finding
• Stone Thickening of wall
• Stone in Biliary Tree
• Stone Dilatation of CBD
• Pancreas Enlargement

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Cholecystitis ?

• Acute Calculous
• Acute Acalculous
• Emphysematous
• Hydrops
• Empyema
• Chronic

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Risk Factors of Gangrene Perforationin Acute
Cholecystitis

• Systemic Toxicity
• Emphysematous Cholecystitis
• Acalculous Cholecystitis

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Fever Jaundice ?

• If the Patient Presents with
• Fever gt 38.5 Jaundice
• Leukocytosis Positive Blood Culture
• Stone Biliary tree dilatation on Sono
• Reynolds, Pentad
• ( Abdominal Pain, FeverChills,Jaundice,
  Hypotension,Mental confusion )
• Dx is Acute Cholangitis

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Cholangitis?

• Infection within Biliary tree Due to
• Choledocholithiasis
• Choledochal cysts
• Bile Duct CA
• Sphincteroplasty
• Instrumentation of Biliary tree

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Cholangitis ?

• Acute Suppurative Cholangitis
• Cholangiohepatitis
• Sclerosing Cholangitis

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Acute Suppurative Cholangitis?

• Pus within the Biliary tract
• Complicated by Obstructive Jaundice
• Charcot triad Jaundice, Chill , Fever
• Age Over 70
• ERCP or PTC
• Surgical Intervention

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Cholangiohepatitis

• Most common in China Hong Kong
• Clonorchiasis
• Ascariasis
• Malaria Hemolysis
• E coli Klebsiella
• Toxic Condition
• Emergency surgery

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Sclerosing Cholangitis

• Involve Extra Intrahepatic Biliary tree
• Association with Ulcerative colitisCrohn
• HIV infection has been noted
• Most common in middle age men
• By Pass operation for Palliation
• Liver Transplantation for Cure

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Fever Abdominal Mass?

• The origin of Pathology is in the
• GallBladder
• Or
• Liver

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Fever Abdominal Mass?

• Possible Diagnosis Are
• Empyema of GB
• Hydrops of GB
• Pyogenic Liver Abscess
• Liver infected Cysts

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Biliary Enteric Fistula Gallstone Ileus

• Between GB Duodenum 85
• Between GB Colon 15
• Can cause Mechanical Obstruction
• Most often in Terminal Ilum
• Past history of Cholelithiasis is present

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Mirizzi,s Syndrome?

• A fistula between Hartmann's Pouch CBD
• A Stone in the Ampulla of the GB can erode the
  CBD and can destroyed CBD Partially or Completely

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YOU!!!!!!!!

• Try to BE
• A Sophisticated Person