Behzad Nakhaei, M.D. , FICS
Fellowship in HepatoBiliary Surgery Mc Gill University
RUQ & Upper Abdomen
Inflammation & Infection
GallBladder & Biliary System Disorders
( A Problem Solving Lecture )
For Medical Students
Common Clinical Presentations
In RUQ & Upper Abdomen
Due to Inflammation & Infection
• Pain & Fever
• Jaundice & Fever
• Mass & Fever
• (One / Two Symptoms Dominate in each of these )
Signal the need for:
•
•
•
•
•
•
•
Complete Blood Count
Liver Function Test
Serum Amylase
PT , PTT
Blood Culture
Chest & Abdominal X ray
Abdominal Ultrasonography
3 Most common Scenario :?
• Acute Cholecystitis?
• OR
• Acute Cholangitis?
• OR
• Acute Pancreatitis?
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.
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
Cholecystitis ?
• Acute Calculous
• Acute Acalculous
• Emphysematous
• Hydrops
• Empyema
• Chronic
Risk Factors of Gangrene & Perforation
in Acute Cholecystitis
• Systemic Toxicity
• Emphysematous Cholecystitis
• Acalculous Cholecystitis
Fever & Jaundice ?
•
•
•
•
• If the Patient Presents with :
Fever > 38.5 & Jaundice
Leukocytosis & Positive Blood Culture
Stone & Biliary tree dilatation on Sono
Reynolds, Pentad
• ( Abdominal Pain, Fever&Chills,Jaundice,
Hypotension,Mental confusion )
• Dx is Acute Cholangitis
Cholangitis?
• Infection within Biliary tree Due to :
• Choledocholithiasis
• Choledochal cysts
• Bile Duct CA
• Sphincteroplasty
• Instrumentation of Biliary tree
Cholangitis ?
• Acute Suppurative Cholangitis
• Cholangiohepatitis
• Sclerosing Cholangitis
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
Cholangiohepatitis
•
•
•
•
•
•
•
Most common in China & Hong Kong
Clonorchiasis
Ascariasis
Malaria Hemolysis
E coli & Klebsiella
Toxic Condition
Emergency surgery
Sclerosing Cholangitis
•
•
•
•
•
•
Involve Extra & Intrahepatic Biliary tree
Association with Ulcerative colitis&Crohn
HIV infection has been noted
Most common in middle age men
By Pass operation for Palliation
Liver Transplantation for Cure
Fever & Abdominal Mass?
• The origin of Pathology is in the :
• GallBladder
• Or
• Liver
Fever & Abdominal Mass?
– Possible Diagnosis Are :
• Empyema of GB
• Hydrops of GB
• Pyogenic Liver Abscess
• Liver infected Cysts
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
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
YOU!!!!!!!!
• Try to BE
A Sophisticated Person