Gallstones Composition of bile Synthesis of bile salts sterol-27-hydroxylase Cholesterol 7-α hydroxylase Bacterial transformation of bile salts Structure

of bile lipids Lipid aggregates in bile Secretion of cholesterol in bile Hypersecretion of cholesterol hydroxy-methyl-glutaryl Coenzyme A reductase acyl: cholesterol: lecithin transferase Cholesterol gallstone pathogenesis Cholesterol gallstone pathogenesis Cholecystography image of gallstones Cholesterol gallstone-Epidemiology Risk Factors The most frequent pathology of gallbladder lithiasis. More frequent in Western c ountries Prevalence: Italy 18.9% F, 9.5 M Europe 9-19% Risk Factors: Multiple pr egnancies Sex female Age Over weight Hypertriglyceridemia Low cholesterol diets repeated Familiarity DISEASE ASSOCIATED Diabetes Angina pectoris Myocardial infa rction peptic ulcer drugs: cholestyramine, clofibrate estrogen Gallstones Brown - Black Calculations Calculations brown blacks represent 25% of all forms of calculation . Risk factors for peptic ulcer resection liver cirrhosis last ileal loop Pathol ogy last ileal loop supply total parenteral chronic hemolytic syndromes of chron ic liver diseases Clinical picture Usually silent manifest symptoms 2-5% 16-30% require surgery right upper quadran t pain radiating region subscapular or right shoulder, epigastrium frequently at night, early morning. Nausea Vomiting Bilirubin increased Complications Jaundice Migration by calculating the bile duct. Urine Stool ipocoliche Itching Jaundice hyperpigmentation Gamma-GT Alkaline Phosphatase Bilirubin direct Transaminase Complications of Cholecystitis Inflammation of the gallbladder wall usually follows from the calculations in th e presence of light (over 90% of cases). In 50-10% of cases may have cholecystit is without stones. super infection by Escherichia coli, Klebiella, Streptococcus, Staphilococco, Cl ostridium. Murphy's sign positive diffuse abdominal tenderness up to the signs o f acute abdomen Fever Leukocytosis neutrophilic enzymes increased cytolysis and cholestasis Acute cholecystitis

Usually follows a biliary colic Pathophysiology - The calculation wedged into the cystic duct (present in over 96% of cases) res ults in a decrease in intraluminal fluid and an ischemic compression of arteries . - The mucosa of the gallbladder free phospholipase that transforms Lecithin li solecitina. The lisolecitina enrichment of bile acids in bile deidrossilati (mor e lipophilic) damage the mucous membrane - The biliary stasis favors the growth of bacteria normally present in bile Acute cholecystitis Inflammation of the gallbladder wall usually follows from the calculations in th e presence of light (over 90% of cases). In 50-10% of cases may have cholecystit is without stones. There may be a bacterial superinfection usually due to: Esche richia coli, Klebsiella, streptococci, staphylococci and clostridia Acute cholecystitis: Clinical Symptoms - - - - - - - Localized right upper quadrant pain and / or epigastrium Nausea an d Vomiting preceded by shivering fever polypnoea Defense abdominal mass palpable right upper quadrant maneuver positive Murphy Signs Acute cholecystitis: Surveys Biochemical - Neutrophilic Leukocytosis - Modest increase in indices of cytolysi s and cholestasis - Increased ESR Ultrasound gallbladder and bile ducts - Increa se the size of the gallbladder - thickening of the walls - Presence of gas in th e walls of the gallbladder - Presence of stones in the lumen often incarcerated in the cystic duct - Coexistence corpusculated material in the lumen of the gall bladder - Coexistence of calculations and dilatation of the choledochus Complications choledocholithiasis. Acute cholangitis 90% septic fever associated with chills Jaundice 60% Pain 50% in severe (5%) is an unsaturated framework with toxic signs of mental confusion and shock. Laborat ory tests: leukocytosis leukopenia 70% rarely. Elevation: bilirubin alkaline pho sphatase γGT transaminases. Positive blood cultures in 20-60% Instrumental investigations acute cholangitis The first ultrasound examination instrument to be executed, but its accuracy rem ains unsatisfactory for a diagnosis of common bile duct stones. Useful in differ entiating acute cholangitis and acute cholecystitis in highlighting any liver ab scess. Complications Hydrops of the gallbladder (cholecystitis often indolent palpable) symptomatic p ouchitis in terms of general empyema of the gallbladder (bile colonized pyogenic ) associated with emphysematous cholecystitis Drilling sepsis (bacteria gas prod ucers) Clostridium Welch perfringens, Escherichia coli gangrenous cholecystitis Biliary Pancreatitis Pancreatitis Biliary Complications The most common cause of acute pancreatitis A mylase Lipase Clinical picture related to the severity of pancreatitis