Gallstones.

Chronic
Cholecyctitis.
Chronic Pancreatitis.
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 Components of bile
• water (82 %)
• bile acids (12 %)
• lecithin and other phospholipids (4 %)
• unesterified cholesterol (0.7 %)

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 Autopsy data
Gallstones revealed in

• - 20 % women > 40 year

• - 8 % men > 40 y.

• - 1 million new cases of cholelithiasis

develop each year in USA
• - 38% among Swedish
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 Gallstones
• Bile pigments
• Cholesterol
• Calcium salts

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Predisposing factors for GBS -
cholesterol and mixed stones
• Demography
• Obesity
• Weight loss
• Female sex hormones
• Ileal disease or resection
• Increasing age
• Gallbladder hypomotility leading to stasis and
formation of sludge
• Clofibrate therapy
• Decreased bile acid secretion
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Predisposing factors for GBS
- pigment stones
• Demography
• Chronic hemolysis
• Alcocholic cirrhosis
• Chronic biliary tract infections

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 Cholelithiasis
• = formation of gallstones

• Physical characteristics of bile are altered:

• - cholesterol is less soluble
• - diminished contractility of bladder
• - infections

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 GS formation
3 stages:

- Physico-chemical
- Latent
- Clinical

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 Mechanisms of GS formation
• increased biliary secretion of cholesterol
• defective vesicle formation
• nucleation of cholesterol monohydrate
crystals
• biliary sludge

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 Clinical course of GBS

• Symptomless
• Biliary colic
• Obstructive jaundice
• Cholangitis
• Acute cholecystitis
• Chronic cholecystitis

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 Complaints
• Biliary colic - begins quite suddenly and may
persist with severe intensity for 1 to 4 h
• Acute pain in the right hypochondrium with
irradiation to the back, thoracic girdle
• Nausea and vomiting

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 Examination
• Light icterus (in 25 %)
• Light palpation – tension in the right
hypochondrium
• Deep palpation – acute pain in the point of
gallbladder projection to anterior
abdominal wall (Kerr’s point)

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 Tests
• Light hyperbilirubinemia
• Increasing of WBC

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 Diagnosed by
• Ultrasonography
• CT
• MRI
• Plain abdominal X-ray (opaque stones) -
with calcium
• Oral cholecystogram

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 Complications of GBS
• Acute and chronic cholecyctitis
• Cancer of GB
• Choledocholithiasis
• Chronic Pancreatitis
• Fistulae formation between the GB and
Duodenum or Colon

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 Treatment

• Medical Therapy - Gallstone Dissolution

• Surgical Therapy - cholecystectomy

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 Chronic
cholecystitis

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 Chronic Cholecyctitis
• = chronic inflammation of the gallbladder
wall
• Is almost always associated with the
presence of gallstones

• from persistent mechanical irritation of the

gallbladder wall
• Repeated acute cholecystitis 25
 Clinical features
• may be asymptomatic for years
• may progress to symptomatic
gallbladder disease or to acute
cholecystitis
• may present with complications

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 Complaints (if present)
• Repeared not severe pain un the right
hypochondrium
• Occurring or Increasing after fat intake
• Nausea
• Transient yellowish of stools (in GBS)
• “Angina pectoris”-like pain

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 Examination data
• Tongue with brownish fur
• Light abdominal palpation – normal
• Deep palpation – pain in the right
hypochondrium, and rarely –
epigastrium
• + Kerr's symptom
• + Lepene’s symptom
• + Orthner-Grekov’s symptom 28
Ultrasound images

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 Complications
• See “complications of GBS” and
• Empyema and Hydrops of GB
• Gangrene and Perforation of GB
• Fistula Formation
• Gallstone Ileus
• Limey (Milk of Calcium) Bile
• Porcelain Gallbladder

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 Treatment
• Low-cholesterol diet
• Weight normalization
• Prokinetics drug (motilium,…)
• Spasmolytics (no-spa, …)
• Treatment those disorders which lead to
GBS formation
• And see “GBS treatment”

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 Chronic
Pancreatitis

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 Pancreas
EXOCRINE function –
• 1500-3000 ml of isosmotic alkaline (pH
>8.0) fluid (juice) per day containing about
20 enzymes and zymogens
• Secretes amylolytic, lipolytic, and
proteolytic enzymes

ENDOCRINE function – secretion of

insulin, glucagone
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 Chronic Pancreatitis
• Inflammation of the pancreas leads to
pancreatic failure causing
malabsorption and diabetes
mellitus
• The condition in which morphological
changes present after elimination
of aetiology factors

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 Aetiology
• Alcoholism
• GBS
• Blunt abdominal trauma
• Metabolic causes (hypercalcemia, renal failure,…)
• Infections (mumps, viral hepatitis, ascariasis,…)
• Drugs (thiazide diuretics, furosemide,
sulfonamides, tetracycline, NSAIDs,…)
• Oral contraceptives
• Hereditary

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 Aetiology
• Vascular causes and vasculitis (after
cardiac surgery, atherosclerotic emboli,
necrotizing angiitis, connective tissue
disorders
• Penetrating peptic ulcer
• Obstruction of Vater’s ampulla
• Cystic fibrosis
• Tropical pancreatits
• Tumours
• Idoophatic 36
 Pathogenesis
Alcohol viscous pancr.juice

plug formation ductules’ obstruction

glandular ischemia calcification

acinar ectasia, pseudocysts formation,

atrophy

pancreatic insufficiency
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 Chronic Pancreatitis
Common features and complaints
• continuous, relentless, slowly progressive
chronic abdominal pain without acute
exacerbations (35%)
• increasing pancreatic failure – no pain, but
presents with diarrhoea (65%)
• Weight loss
• Anorexia, belching
• Nausea and vomiting 38
 Pain’s reasons
• Increased pressure within the pancreatic
ducts
• Increased juice volume
• Ischemia of pancreas
• Compression of neighboring organs
• Direct involvement of pancreatic and
peripancreatic nerves by the inflammatory
process

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 Pain localization
• Upper abdomen
• Girdle sensation (bind-like) опоясывающая
боль
• Irradiation to the left part of abdomen, left
scapulae, neck
• Increase after fatty food and alcohol

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 Examination
• Thin patient
• Features of other alcohol- and smoking-
related diseases
• Icterus sometimes (pressing of common bile duct and
pancreatic duct)
• Deep palpation – pain in projection of
pancreas to anterior abdominal wall

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 Tests
• Increasing of WBC and ESR
• Low albumin, Ca++ , vit B12 , serum trypsinogen
• Incr. fast glucose
• Impaired glucose tolerance
• Incr. of serum amylase and lipase sometime
• marked excretion of fecal fat (steatorrhea)

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 Instrumental investigation
• MRI
• Sonography
• ERCP (эндоскопическая ретроградная
холангиопанкреатография)
• CT
• Plan abdominal X-ray

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Сa++

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ERCP

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ERCP

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 Complications
• Vit B12 malabsorption
• Impaired glucose tolerance and
secondary DM
• Pleural, pericardial, or peritoneal
effusions containing high concentrations
of amylase
• Gastrointestinal bleeding (pseudocyst
eroding into the duodenum)
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 Complications
• Icterus
• - edema of the head of the pancreas, which compresses the
common bile duct
• - by chronic cholestasis secondary to a chronic inflammatory
reaction around the intrapancreatic portion of the common bile
duct
• Cholangitis and biliary cirrhosis
• Bone pain
• Pancreatic carcinoma
• Arthritis
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 Treatment
2 main aims:
• Pain relief (opiate)

• Malabsorption decreasing

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 Treatment
• Diet - 5
• Alcohol misuse (very difficult)
• Oral pancreatic enzyme
• Symptomatic treatment
• Surgical treatment

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