Page 221 - Medicine and Surgery

P1: KPE
BLUK007-05 BLUK007-Kendall May 25, 2005 8:52 Char Count= 0

Chapter 5: Disorders of the gallbladder 217

or treat cholangitis. Stones impacted at the papilla of Investigations
Vater may need to be removed atERCP. Ultrasound, percutaneous transhepatic cholangiogra-
Patients with empyema or acute ascending cholangitis phy (PTC), CT scan.

may require drainage procedures.
Cholecystectomy may be performed as an open or Management

laparoscopic procedure. It may be performed as an Surgical resection is often not feasible due to local spread
emergency (severe or complicated acute cholangi- and metastases. Sometimes aggressive segmental resec-
tis), early elective (during initial admission for acute tion of the liver and regional lymph nodes is carried out.
cholangitis) or delayed elective (following biliary Once jaundice occurs, resection is not curative and pal-
colic, acute pancreatitis, acute cholangitis or chronic liation by stenting or surgical bypass is needed.
cholangitis)
Prognosis
Five-year survival rate is <5%.
Prognosis
In acute cholecystitis 90% of patients settle with conser-
vative management within 4–5 days. Ascending cholan- Carcinoma of the bile ducts
gitishasamortalityofupto20%inseverecasesrequiring
emergency decompression. Definition
Carcinomas of the bile ducts are called cholangiocarci-
nomas. They may be intrahepatic or extrahepatic.
Carcinoma of the gallbladder
Incidence/prevalence
Definition
Uncommon. Increasing in frequency in the West.
Carcinoma of the gallbladder is rare, but almost always
associated with gallstones.
Age
Elderly
Age
Usually >70 years. Aetiology/pathophysiology
Predisposed by chronic inflammation (e.g. primary scle-
Sex rosing cholangitis associated with ulcerative colitis) and
F > M (4:1) chronic infection with the parasites Clonorchis and
Opisthorchis.Specific risk in patients with choledocal
cysts. The tumour can arise anywhere in the biliary sys-
Aetiology/pathophysiology tem and may be multifocal. It causes obstruction and
Unknown, but associated with gallstones and chronic hence dilatation of the proximal ducts.
cholecystitis. Histologically 90% of tumours are adeno-
carcinomas and 10% are squamous carcinomas.
Clinical features
The usual presentation is progressive obstructive jaun-
Clinical features dice. Other symptoms include vague epigastric or right
Patients may have a history of gallstone disease. Invasion upper quadrant pain, pruritus, anorexia and weight loss.
of the bile duct or porta hepatis leads to unremitting Obstruction of the gallbladder may cause a mucocele or
jaundice. A mass is often palpable in the right upper empyema presenting with biliary colic and a non-tender
quadrant. Many tumours are detected following chole- swelling in the right hypochondrium.
cystectomy for symptomatic gallstones. Direct invasion
of local structures, especially the liver, is almost invari- Macroscopy/microscopy
ableatpresentation.Spreadviathelymphaticsandblood The carcinoma commonly appears as a sclerotic stricture
occurs early. anywhere along the biliary tree from the intrahepatic