35


10% 700,000 .

. . 60-69 6060-69 6040 3%.

22.4% 11.5%


10

(Nucleation)

 

 

7-alphaalphahydroxylase activity ( )

, OCPs

12 hydroxylase,

(Nucleation)


 

Nucleation factors

: Ca (80%)

 

 

20% 25 1-3% 0.1% , , ,

 

Gracie Friedman 100 80 60 40 20 0 0 5 10 15 20

% Symptoms

Follow-up

: (porcelain) (high cancer risk) , , Sickle cell disease

 

15

3 -6

95% 1/3

75%

 

>6 Involuntary Guarding Murphy 30% non Compared to a palpable non-tender GB (Courvoisiers sign of malignancy)

   

2 -3

  

: 12

: (gram negative bacteria)

85%

Charcot

70%

E. Coli, Klebsiella pneumonia, Streptococcus Coli, pneumonia, pneumonia, pneumonia, Enterococci species (15%)

 

12 Mirizzis Syndrome

   

Mirizzis Syndrome

 

MRC/MRCP ERCP

WBC Blood Cultures Hepatocyte inflammation and injury AST/ALT Biliary Obstruction and Cholangiocyte injury Total Bilirubin Alkaline Phosphatase Gallstone Pancreatitis Amylase (salivary, bowel)

WBC < 15 AST and ALT 2-3 xs normal 2 <4 Alk Phos
 

Normal labs unless stone impaction When obstruction occurs labs reflect either cholangitis, cholangitis, pancreatitis or both WBC lipase amylase Concomitant biliary obstruction


WBC > 15

AST/ALT >4 Alk-Phos Alk-

Normal labs

Ultrasound


Initial diagnostic imaging modality of choice

95% sensitivity for gallbladder stones >2 mm > 95% specificity with the post-acoustic shadow post-

Quick  Non-invasive Non Useful in the diagnosis of cholelithiasis, cholecystitis, choledocholithiasis, cholangitis  Accurate  Evaluates both hepatic, biliary and GB anatomy


Ultrasound of Gallstones

Ultrasound


Acute Cholecystitis
Pericholecystic fluid and/or stranding Thickened gall bladder wall Intramural gas Cholelithiasis and/or GB sludge Sonographic Murphys sign - PPV >90%

Choledocholithiasis
Extrahepatic stone localization Sensitivity 50% - Common Bile Duct stones Sensitivity 75% - dilated CBD > 7 mm intact gallbladder
>11 mm post-cholecystectomy post-

MRI (MRCP)
NonNon-invasive technique to visualize the biliary and pancreatic ductal systems  Recommended low pretest probability of disease  Provides anatomic information


Liver GB and pancreas Extrahepatic biliary anatomy Stones, Strictures, Ductal dilation

Endoscopic Retrograde Cholangiopancreatography: ERCP

     

Gold standard Choledocholithiasis, unresolving cholangitis or gallstone pancreatitis Both diagnostic and therapeutic potential Sensitivity - 95% Specificity - 95% Similar data for PTC

ERCP of Common Duct Stone

1.5% 2-3x

:
Pre-operative Pre Intra-operative Intra Post-operative Post

PrePre-operative
ERC (Endoscopic Retrograde Cholangiography), PTC (Percutaneous TransTranshepatic Cholangiography) Cholangiography)

IntraIntra-operative
( 80% , 7070)

PostPost-operative
ERC ( 95%)

Key Pathophysiologic points

Nucleation

Key Clinical Syndromes

Abdominal Radiographs U/S MRC/MRCP ERCP

RenY