In laparoscopic CBD exploration there are two ways. One with less morbidity is the transcystic approach in which cystic duct is dilated and stones are removed through the cystic duct. After the procedure the cystic duct is clipped as in laparoscopic cholecystectomy. This procedure has the least morbidity as CBD is not opened. Indications of Choledochotmy are
Unsuccessful transcystic exploration
CBD diameter more than 8 mm
Multiple large stones
Ampullary diverticulum on IOC
ERCP unavailable or contraindication of ERCP
Previous Billroth II gastrectomy
Dieulafoy's lesion of the stomach is not an uncommon cause of upper GI bleeding. Its incidence in all patients with upper GI bleed range from 0.3 to 7%. The cause of such bleeding is a large tortuous vessel in submucosa which leads to ulceration of the over lying mucosa. The lesions occur at 6-10 cm from the cardia near the GE junction. Endoscopy is the diagnostic modality of choice and lesion is controlled by electrocoagulation, heatre probes or photo coagulation
Ref Sabiston 19th edition page 1222
0.2-0.6 g of bile salts are secreted by liver each day in the form of cholic acid and dexoy cholic acid.
Only 5% of bile salt is excreted per day and 95% is absorbed by the portal vein
Bile is stored and concentrated in the gall bladder
Gall bladder fills by retrograde mechanism by contraction of sphincter of oddi.
Haematogenous route is the most common route for acquiring splenic abscess (70%). Risk factors inculde polycythemia vera, malignancies, IV drugs etc. Unilocular splenic abscess has mortality rates of 15-20% and multiloculated abscess about 80%. Typical symptoms are fever, pain abdomen, pleuritic chest pain. Splenomegaly is uncommon.
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