17- Gallbladder Stones
Content
GALLBLADDE R STONES Presented by:
Amer Amer AlQaisi Faisal Faisal AlEnezi
Supervised by Prof. Kamal Gharaibeh Gharaibeh :
OUTLINES 1.Anatomy
of gallbladder 2.Anatomy of biliary tree Physiology of biliary system 3.Physiology 4.Bilirubin metabolism cycle. 5.Congenital abnormalities 6.Gallstones .Com!lications of gallstones ".Clinical !resentation # $anagement %.Choledocolithiasis # cholangitis 'eo!lasms 1&.
OUTLINES 1.Anatomy
of gallbladder 2.Anatomy of biliary tree Physiology of biliary system 3.Physiology 4.Bilirubin metabolism cycle. 5.Congenital abnormalities 6.Gallstones .Com!lications of gallstones ".Clinical !resentation # $anagement %.Choledocolithiasis # cholangitis 'eo!lasms 1&.
Anatomy of Gallbladder Gallbladder is a !ear(sha!ed sac lying on the undersurface of the li)e *hich is .5(12 cm long and it has a ca!acity of 3&(5& ml. •
+t is di)ided to , ( -undus ( Body ( 'ec /he 0artmanns !ouch , is a dilatation in the gallbladder ust before the origin of cystic duct .
•
Relation: Anteriorly , the anterior abdominal *all and the inferior surface of the li)er
.
Posteriorly , the trans)erse colon!roimal 1st and 2nd !art of duodenum
.
/he fundus is usually !roects inferiorly at the le)el of the % th costal cartilage in the midcla)icular line and the nec directed u!*ard bac*ard.
Blood supply: ( by the cystic artery a branch from the right he!atic artery . ( cystic ein *hich drain directly into the !ortal )ein.
!he lymph draina"e: ( into the cystic lymph node of 7und *hich situated near the nec of the gallbladder.
#ere supply: su!!lied by 3 ty!es of inner)ation /he celiac ple$us su!!lies sym!athetic inner)ation the a"us nere su!!lies !arasym!athetic inner)ation and the ri"ht phrenic nere con)eys sensory information.
A#A!%&' %F B()(AR' !REE
/he ducts of biliary tree are ,
!he common hepatic duct , it is about 4 cm result from the union of 9t.# 7t he!atic duct *ystic duct , it is about 3." cm some*hat : sha!ed *hich connect the nec of the gallbladder *ith the common he!atic duct !he common bile duct , it is about " (1& cm that is result from the union of the common he!atic duct *ith the cystic duct
-
.
-
.
-
.
•
/he common bile duct descends behind the duodenum and !ancreas and usually oined by !ancreatic duct and together they o!en into a small am!ulla in the duodenal *all ampulla of ater +.
/here are a small ducts that drain bile directly into the gallbladder from the li)er called ,uct of )usch-a .
•
*ystohepatic trian"le an anatomic s!ace bordered by the common he!atic duct medially the cystic duct laterally and the inferior edge of the li)er su!eriorly.
*alots !rian"le : cystic duct the common he!atic duct and the cystic artery
•
P/'0(%)%G'
Gallbladder is under control of Cholecystoinin CC; and its functions are ,
Contraction of the gallbladder
9elaation of the :!hincter of <ddi
:lo*ing gastric em!tying
increase !ancreatic en=yme secretion
/he gall bladder is a reser)oir for bile. >uring fasting resistance to flo* through the s!hincter is high and bile ecreted by the li)er is di)erted to the gall bladder. After feeding the resistance to flo* through the s!hincter of <ddi is reduced the gall bladder contracts and the bile enters the duodenum. /hese motor res!onses of the biliary tract are in !art effected by the hormone CC;.
P/'0(%)%G' /he second main function of the gall bladder is concentration of bile by acti)e absor!tion of *ater sodium chloride and bicarbonate by the mucous membrane of the gall bladder. /he he!atic bile that enters the gall bladder becomes concentrated 5?1& times *ith a corres!onding increase in the !ro!ortion of bile salts bile !igments cholesterol and calcium. /he third function of the gall bladder is the secretion of mucus ? a!!roimately 2& ml is !roduced !er day. @ith total obstruction of the cystic duct in a healthy gall bladder a mucocele de)elo!s on account of this function of the mucosa of the gall bladder.
Bile Com!onents of bile, @ater %5 electrolytes bile salts lie cholic acid # chenodeoycholic acid !hos!holi!ids lie licithin bilirubin conugated fatty acids
/he function of bile is to emulsify fat.
Absence of bile causing malabsor!tion of fat and fat soluble )itamins A > ;
%5 of bile salts are reabsorbed in the terminal ileum !ass bac )ia the !ortal )enous drainage to the li)er and once again secreted in the bile 0C. :o resection of terminal ileum *ill decrease bile salts that *ill cause GB stones formation.
B()(R1B(# PR%,1*!(%# /eme proteins myo"lobin5 cytochromes (to 674 20)
/emo"lobin (to 234 70) /eme
/eme o$y"enase Bilierdin Bilierdin reductase Bilirubin
albumin
indirect uncon8u"ated pre9hepatic
B()(R1B(# PR%*E00(#G albumin9Bilirubin
albumin
li"andin
hepatocyte li"andin9Bilirubin 1,P9Glucuronyl transferase ER
Bilirubin di"lucuronide
bile "all bladder+
direct con8u"ated post9hepatic
B()(R1B(# E;*RE!(%# Bilirubin di"lucuronide "lucuronate 2
lier 90%
Bacterial enzyme Bilirubin Bacterial enzyme
intestines 1robilino"en
<--------idneys 10% 20% Bacterial enzymes
80% 0tercobilino"en
0tercobilin
1robilin
urine
feces
*%#GE#(!A) AB#%R&A)(!(E0 Absence of the "all bladder <ccasionally the gall bladder is absent. -ailure to )isualise the gall bladder is not necessarily a !athological !roblem. !he Phry"ian cap !resent of se!tum that incom!letely di)ides the GB. :+'G7 <9 $7/+P7
Floatin" "all bladder /he organ may hang on a mesentery *hich maes it liable to undergo torsion of GB to occur *ith conseDuent gangrene # ru!ture
Double gall bladder Rarely, the gall bladder is duplicated. One may be intrahepatic Absence of the cystic duct This is usually a pathological, the GB open directly ino the side of common bile duct A long cystic duct travelling alongside the common hepatic duct to open near the duodenal orice ( occur in !" of cases #
*/%)E,%*/A) *'0! :
Presence of cystic dilation in the biliary tree most commonly in CB> Classification according to the site of the cyst or dilatation
!ype (: $ost common )ariety "&(%& in)ol)ing saccular or fusiform dilatation of a !ortion or entire common bile duct CB> *ith normal intrahe!atic duct. !ype ((: +solated di)erticulum !rotruding from the CB>. !ype ((( or *holedochocele: Arise from dilatation of duodenal !ortion of CB> or *here !ancreatic duct meets. !ype (<a: Characteri=ed by multi!le dilatations of the intrahe!atic and etrahe!atic biliary tree. !ype (<b: $ulti!le dilatations in)ol)ing only the etrahe!atic bile ducts. !ype <: Cystic dilatation of intra he!atic biliary ducts.
B())(AR' A!RE0(A ( Biliary atresia BA is a !rogressi)e idio!athic fibro( obliterati)e disease of the etrahe!atic biliary tree that !resents *ith biliary obstruction eclusi)ely in the neonatal !eriod. ( /he etrahe!atic bile ducts are !rogressi)ely destroyed by an inflammatory !rocess *hich starts around the time of birth. /he aetiology is unclear. /he inflammatory destruction of the bile ducts has been classified into three main ty!es , E ty!e +, atresia restricted to the common bile ductF E ty!e ++, atresia of the common he!atic ductF E ty!e +++, atresia of the right and left he!atic ducts. (Associated anomalies include in about 2& of cases cardiac lesions !olys!lenia situs in)ersus absent )ena ca)a and a !reduodenal !ortal )ein.
*%&P)(*A!(%#0 : 9Ascending cholangitis +ntrahe!atic changes can occur and e)entually result in biliary cirrhosis and !ortal hy!ertension. ntreated death from the conseDuences of li)er failure occurs before the age of 3 years.
)ier transplantation is the main choice of treatment .
GA))0!%#E0
*holelithiasis means stones in the gallbladder. the most common biliary !athology affect more than 15 of adult in :A . Asym!tomatic most common "& :ym!tomatic com!licated 1&(2& , !ain aundice !ruritus fe)erHHetc. 1& of gallstones are radio(o!aDue .
Ris- factors :
/he big 5 , Ifi)e -s , female 3,1 forty 4& fat fertilefair.J
less common , (<ral Contrace!ti)es. ( 9a!id *eight loss. (0y!erli!idemia (Gallbladder stasis. (-amily history (+leal diseases or resection /y!es of GB stones , 1. Cholesterol 2& . 2. Pigmented Blac Bro*n 5 . 3. $ied 5
Patho"enesis: $ @hen bile is su!ersaturated *ith cholesterol unstable unilamelar !hos!holi!id )esicles are formed. Cholesterol "& $ /his leads to formation of cholesterol crystals. *haracteristics ,
Kello*ish greasy.
<)oid firm
:ingle or multi!le
$ost are radiolucent.
*/%)E0!ER%) 0!%#E0
Contains less than 3& cholesterol. Contain bilirubin and calicium
/*o ty!es , Blac and Bro*n.
Blac stones ,
Accom!anies hemolysis hereditary s!herocytosis sicle cell anemia.
Bro*n :tones ,
-orm in bile duct and related to bile stasis and infected bile.
Associated *ith the !resence of foreign bodies *ithin the bile ducts such as stents or !arasites .
P(G&E#!E, 0!%#E0
•
*haracteristic ,
Any*here in the biliary tree.
Blac, in sterile GB bile small numerous friable 5&(5 are radio(o!aDue
Bro*n, in infected intra( or etrahe!atic ducts single or fe* soft # greasy radiolucent
&(;E, 0!%#E0
+s the most common 5 cut surface is laminated *ith alternate dar #light =ones of !igment # cholesterol res!ecti)ely
=/A! ARE !/E *%&P)(*A!(%#0 %F GA))0!%#E0>
(n "allbladder : ( Acute cholecystitis. ( Chronic cholecystitis ( Biliary Colic ( m!yema. ( $ucocele. ( Perforation ( Carcinoma &.&"
(n the Bile ,ucts: ( <bstructi)e aundice ( Ascending cholangitis ( Acute !ancreatitis
(n the intestine ( Gallstone ileus intestinal obstruction
B()(AR' *%)(*
+t is a misnomer because the !ain increases in intensity then reaches a !lateau then decreases but ne)er disa!!ears . :o
not a true colic
*aused by: ( !ransient obstruction of the GB by a stone in 0artmannLs !ouch or cystic duct *hich leads to s!asm in the *all of GB
Presentation,
pain, :,9ight u!!er Duadrant. <, suddenly after fatty meals C, gri!!ing !ain dull. 9, referred to the ti! of the right shoulder and radiate to the bac A, Associated *ith ( 'ausea )omiting flatulence dys!e!sia . /, 7ess than 6 hours if more then it is acute cholecystitis.
A*1!E */%)E*'0!(!(0
1(acute calculous cholecystitis ? %5 2(acute Acalculous cholecysitis ? 5
A*1!E *A)*1)%10 */%)E*'0!(!(0
>efinition, +nflammation of the gallbladder that de)elo!s o)er hours usually resulting from a cystic duct obstruction by a gallstone.
/his form of gallbladder disease usually subsides *ithin 1 to days *ith a conser)ati)e !lan of treatment .
'ot e)eryone *ho has gallstones *ill go on to de)elo! cholecystitis .
Patho!hysiology
1
2
. t c u d c i t s y c n i e r e h * y n a r o 5 h c u o ! s L n n a m t r a 0 3 c e n r e d d a l b l l a g e h t " n o t s A ( • n i t c u r t s b o e
n o i t c e f n i l a i r e t c a b d e s o ! m i r e ! u s h t i * 6 e l i b d e t a r t n e c n o C d n a s i s a t 0 ( •
. a s o c u m o t * o l f d o o l b s e s i m o r ! m o c d n a e r u s s e r ! l a n i m u l a r t n i d e s a e r c n i g n i s u a c l l a * e h t n i n o i t n e t s i d d n a a m e d e o t d a e l l l i * s i h / . t l a s 3 e l i b d e t s e " n o c e h t y b a s o c u m e h t f o n o i t a m m a l f n i •
4
5
n e r " n a " l l a * B G f o s s e n t f o s e s u a c t a h t e o t d a e l n o i t c e f n i h t i * * o l f d o o l b e s a e r c e > ( •
5 s i t i n o t i r e ! l a c i m e h c d n a s s e c s b a g n i s u a c 3 n s u a c y a m e n e r g n a G ( • o i t a r o f r e p e
a m e y ! m n o i t a m r o f s u ! d n a n o i t c e f n i h t i * n o i t c u r t s b o d e ) e i l e r n •
6
e l e c o c u $ n o i t e r c e s s u c u m s u o u n i t n o c d n a n o i t c e f n i t u o h t i * 6 n o i t c u r t s b o d e ) e i l e r n •
*)(#(*A) PRE0E#!A!(%# A*1!E */%)E*'0!(!(0+ A"e , /y!ically 3&(6& year old. Presentation in younger !atients may be due to congenital hemolytic anemiasicle(cell disease often form !igment stones *hich may !reci!itate an attac of acute cholecystitis.
Gender , -emales are more commonly affected
Analysis of Pain: :, 9M <, sudden onset C, shar! 9, radiates to the bac close to the inferior angle of right sca!ula A, associated *ith nausea )omiting and fe)er /, continuous >uration of !ain usually 6 hours , aggra)ated by mo)ements and breathing :, se)ere N/he !atient $ay ha)e !re)ious history of flatulent dyspepsia or biliary colic .
P/'0(*A) E;A&(#A!(%#
General E$amination : O Patient a!!ears ill O shallo* breathing O /achycardia )e Pyreia )e
NN fe* !atients *ith AC ha)e 8aundice by t*o mechanisms , 1( stone !assed to the CB> Iobstucti)e aundiceJ 2( $irri=i syndrome , occur *hen the cystic duct is densely adhered to the CB> . the stone in the cystic duct cause com!ression of the CB> .
P/'0(*A) E;A&(#A!(%#
Abdominal E$amination :
90C mass and tenderness guardingQrigidity Racary(co!es sign , 90C fullness Boas :ign , hy!eraesthesia increased or altered sensiti)ity belo* the right sca!ula. $ur!hys sign , Cessation of breath at dee! ins!iration during the dee! !al!ation at the ti! of % th rib Bo*el sounds are normally !resent ece!t in biliary !eritonitisGB has infarctedQru!tured rare com!lication
=hat are the differences in the clinical presentation bet?een biliary colic and Acute cholecystitis >>> Biliary colic : !ain duration S 6 hrs Afebrile !atient )omiting once or t*ice mild tenderness Acute cholecystitis : !ain duration 6 hrs febrile !atient re!eated )omiting se)ere tenderness
(#<E0!(GA!(%# 1.
-ull blood count ( re)eals leuocytosis
2.
;-/
3.
7-/ ? bilirubin to detect bile duct obstuction
4.
Amylase and li!ase le)el for acute !ancreatitis
5.
: abdomen /0 G<7> :/A'>A9>
6.
0+>A scan if : is not diagnostic
.
T(ray not usefulonly1&(15 of stones are )isible
".
$9CP
%.
9CP
=hat are the ultrasonic features of ??Acute *holecystitis @+
,istended "all bladder
6+
Fluid surroundin" the "all bladder
+
Gall bladder ?all thic-enin" mm+
C+
,ilated cystic duct
7+
0tones in the "all bladder
$9CP , magnetic resonance cholangio!ancreatogra!hy
9CP , endosco!ic retrograde cholangio!ancreatogra!hy
Both are used for diagnosis .
9CP used also for thera!y of CB> stones .
0+>A scan , re)eal non(o!acification of the gallbladder from obstruction of the cystic duct.
A*1!E A*A)*1)%10 */%)E*'0!(!(0
+nflammation of the gallbladder in the absence of gall stone usually seen in seriously ill !atients after , maor surgeries trauma burns se!sis
(t occurs because of : 1 >ehydration 2 GB stasis 3 Uascular com!romise 4 Bacterial contamination
mostly Gram ?)e, (coli ;lebsiella nterobacter
*/R%#(* */%)E*'0!(!(0
Chronic inflammation of the gall bladder because of recurrent attacs of acute cholecystitis or biliary colic ending in thicening and fibrosis of its *all.
:tones are almost al*ays !resent.
0upersaturation of bile !redis!oses to chronic inflammation # stone formation.
Bacteria are isolated in 1Q3 of the cases.
PRE0E#!A!(%# (!!er abdominal !ain after eating. begins 15 to 3& mins after a meal and last for 3& to %& mins most common com!laint.
( flatulent dys!e!sia!ost(!randial belching ( 0eartburn
P/'0(*A) E;A&(#A!(%#
:igns of aundice
Abdomen loos normal
90C mass and tenderness
Percussion and auscultation should be normal
: ,,; %F R1Q PA(# Common, 1.
Perforated !e!tic ulcer
2.
0igh a!!endicitis
3.
Acute !ancreatitis
ncommon, 4.
Acute !yelone!hritis
5.
9ight lo*er lobe !neumonia
6.
$+inferior
&A#AGE&E#!
*onseratie mana"ement , %& of cases *ill res!ond 1 'il by mouth V'P<W 2 Gain +U access gi)e +U fluids 3 Administration of antibiotics 4Administration of analgesics 5 $onitoring of )ital signs 6 +f sym!toms subsided initially oral fluid intae is allo*ed then follo*ed by fat(free diet and lastly regular diet : ( to e)aluate *hether theres any local com!lications " Plan for cholecystectomy o!en or la!arosco!ic A arly *ithin 2 hours. B 7ate after 2(3 months. N:ometimes *e do Cholecystostomy in case of em!yema
*/%)E*'0!E*!%&' sually *e do it by laparoscopy but in the follo*ing cases *e do it by )aparotomy , 1.
not *ell defined anatomy
2.
uncontrolled bleeding
3.
bile duct inury
P%0! D %PERA!(<E *%&P(*A!(%#0 @9 hemorrha"e NNusually the source is from cystic artery. NN the !atient com!lains of !ersistent abdominal !ain or features of hy!o)olemic shoc
69 ?ound infection 9 bile leaC9bile duct stricture NNthe most dangerous com!lication leads to , cholangitis obstructi)e aundice secondary biliary cirrhosis and he!atic failure.
79post cholecystectomy syndrome
#E%P)A0&0
Beni"n tumors of the GB: !a!illoma myoma fibroma adenomyoma li!oma carcinoid . &ali"nant tumors of the GB : "& of the tumors are adenocarcinoma %& of !ts ha)e cholelithiasis Porcelain GB Carry a ris of 73 4 of malignancy calcification of GB due to ecessi)e stones.
P%R*E)A(# GB
*/%)E,%*%)(!/(A0(0 ( :tones !resent *ithin the biliary tree. ( :tones may be, 1 deri)ed from gallbladder 2 !rimary ductal # intrahe!atic stone formation
( Asym!tomatic in 1&
( :ym!toms due to, 1 cholangitis CharcotLs triad biliary obstruction <bstructi)e Xaundice >ar urine Pale stool itching 2 !ancreatitis 3 7i)er abscess 4 chronic li)er disease *ith secondary biliary cirrhosis 5 acute cholecystitis
*/%)E,%*/%)(!/(A0(0 *A# BE PR(&AR' %R 0E*%#,AR'
us 5 ER*P are the diagnostic modalities )ier function test are consistent *ith obstructi)e aundice 0ur"ical !! : *holecystectomy choledocotomy *B, e$ploration 5 ! tube placement operatie cholan"io"ram .
*/%)A#G(!(0 : (#FE*!(%# %F !/E B())(AR' !REE 9 Etiolo"y : 1. CB> stones. 2. !ost.o! stricture. 3. 'eo!lasm 4. sclerosing cholangitis. 5. billiary contrast studies . .
!reatment : 'P< +U antibiotics relief of the obstruction
*/%)A#G(%*AR*(#%&A
&ali"nant tumors of the bile duct may be associated ?ith : 1( :clerosing cholangitis. 2( chronic !arasitic infection of the bile duct. 3( Gall stones.
!he tumor may be located in , distal CB> common he!atic duct cystic duct left or right he!atic duct most common site
/reatment by , =hipple procedure.
Amer Amer AlQaisi Faisal Faisal AlEnezi
Supervised by Prof. Kamal Gharaibeh Gharaibeh :
OUTLINES 1.Anatomy
of gallbladder 2.Anatomy of biliary tree Physiology of biliary system 3.Physiology 4.Bilirubin metabolism cycle. 5.Congenital abnormalities 6.Gallstones .Com!lications of gallstones ".Clinical !resentation # $anagement %.Choledocolithiasis # cholangitis 'eo!lasms 1&.
OUTLINES 1.Anatomy
of gallbladder 2.Anatomy of biliary tree Physiology of biliary system 3.Physiology 4.Bilirubin metabolism cycle. 5.Congenital abnormalities 6.Gallstones .Com!lications of gallstones ".Clinical !resentation # $anagement %.Choledocolithiasis # cholangitis 'eo!lasms 1&.
Anatomy of Gallbladder Gallbladder is a !ear(sha!ed sac lying on the undersurface of the li)e *hich is .5(12 cm long and it has a ca!acity of 3&(5& ml. •
+t is di)ided to , ( -undus ( Body ( 'ec /he 0artmanns !ouch , is a dilatation in the gallbladder ust before the origin of cystic duct .
•
Relation: Anteriorly , the anterior abdominal *all and the inferior surface of the li)er
.
Posteriorly , the trans)erse colon!roimal 1st and 2nd !art of duodenum
.
/he fundus is usually !roects inferiorly at the le)el of the % th costal cartilage in the midcla)icular line and the nec directed u!*ard bac*ard.
Blood supply: ( by the cystic artery a branch from the right he!atic artery . ( cystic ein *hich drain directly into the !ortal )ein.
!he lymph draina"e: ( into the cystic lymph node of 7und *hich situated near the nec of the gallbladder.
#ere supply: su!!lied by 3 ty!es of inner)ation /he celiac ple$us su!!lies sym!athetic inner)ation the a"us nere su!!lies !arasym!athetic inner)ation and the ri"ht phrenic nere con)eys sensory information.
A#A!%&' %F B()(AR' !REE
/he ducts of biliary tree are ,
!he common hepatic duct , it is about 4 cm result from the union of 9t.# 7t he!atic duct *ystic duct , it is about 3." cm some*hat : sha!ed *hich connect the nec of the gallbladder *ith the common he!atic duct !he common bile duct , it is about " (1& cm that is result from the union of the common he!atic duct *ith the cystic duct
-
.
-
.
-
.
•
/he common bile duct descends behind the duodenum and !ancreas and usually oined by !ancreatic duct and together they o!en into a small am!ulla in the duodenal *all ampulla of ater +.
/here are a small ducts that drain bile directly into the gallbladder from the li)er called ,uct of )usch-a .
•
*ystohepatic trian"le an anatomic s!ace bordered by the common he!atic duct medially the cystic duct laterally and the inferior edge of the li)er su!eriorly.
*alots !rian"le : cystic duct the common he!atic duct and the cystic artery
•
P/'0(%)%G'
Gallbladder is under control of Cholecystoinin CC; and its functions are ,
Contraction of the gallbladder
9elaation of the :!hincter of <ddi
:lo*ing gastric em!tying
increase !ancreatic en=yme secretion
/he gall bladder is a reser)oir for bile. >uring fasting resistance to flo* through the s!hincter is high and bile ecreted by the li)er is di)erted to the gall bladder. After feeding the resistance to flo* through the s!hincter of <ddi is reduced the gall bladder contracts and the bile enters the duodenum. /hese motor res!onses of the biliary tract are in !art effected by the hormone CC;.
P/'0(%)%G' /he second main function of the gall bladder is concentration of bile by acti)e absor!tion of *ater sodium chloride and bicarbonate by the mucous membrane of the gall bladder. /he he!atic bile that enters the gall bladder becomes concentrated 5?1& times *ith a corres!onding increase in the !ro!ortion of bile salts bile !igments cholesterol and calcium. /he third function of the gall bladder is the secretion of mucus ? a!!roimately 2& ml is !roduced !er day. @ith total obstruction of the cystic duct in a healthy gall bladder a mucocele de)elo!s on account of this function of the mucosa of the gall bladder.
Bile Com!onents of bile, @ater %5 electrolytes bile salts lie cholic acid # chenodeoycholic acid !hos!holi!ids lie licithin bilirubin conugated fatty acids
/he function of bile is to emulsify fat.
Absence of bile causing malabsor!tion of fat and fat soluble )itamins A > ;
%5 of bile salts are reabsorbed in the terminal ileum !ass bac )ia the !ortal )enous drainage to the li)er and once again secreted in the bile 0C. :o resection of terminal ileum *ill decrease bile salts that *ill cause GB stones formation.
B()(R1B(# PR%,1*!(%# /eme proteins myo"lobin5 cytochromes (to 674 20)
/emo"lobin (to 234 70) /eme
/eme o$y"enase Bilierdin Bilierdin reductase Bilirubin
albumin
indirect uncon8u"ated pre9hepatic
B()(R1B(# PR%*E00(#G albumin9Bilirubin
albumin
li"andin
hepatocyte li"andin9Bilirubin 1,P9Glucuronyl transferase ER
Bilirubin di"lucuronide
bile "all bladder+
direct con8u"ated post9hepatic
B()(R1B(# E;*RE!(%# Bilirubin di"lucuronide "lucuronate 2
lier 90%
Bacterial enzyme Bilirubin Bacterial enzyme
intestines 1robilino"en
<--------idneys 10% 20% Bacterial enzymes
80% 0tercobilino"en
0tercobilin
1robilin
urine
feces
*%#GE#(!A) AB#%R&A)(!(E0 Absence of the "all bladder <ccasionally the gall bladder is absent. -ailure to )isualise the gall bladder is not necessarily a !athological !roblem. !he Phry"ian cap !resent of se!tum that incom!letely di)ides the GB. :+'G7 <9 $7/+P7
Floatin" "all bladder /he organ may hang on a mesentery *hich maes it liable to undergo torsion of GB to occur *ith conseDuent gangrene # ru!ture
Double gall bladder Rarely, the gall bladder is duplicated. One may be intrahepatic Absence of the cystic duct This is usually a pathological, the GB open directly ino the side of common bile duct A long cystic duct travelling alongside the common hepatic duct to open near the duodenal orice ( occur in !" of cases #
*/%)E,%*/A) *'0! :
Presence of cystic dilation in the biliary tree most commonly in CB> Classification according to the site of the cyst or dilatation
!ype (: $ost common )ariety "&(%& in)ol)ing saccular or fusiform dilatation of a !ortion or entire common bile duct CB> *ith normal intrahe!atic duct. !ype ((: +solated di)erticulum !rotruding from the CB>. !ype ((( or *holedochocele: Arise from dilatation of duodenal !ortion of CB> or *here !ancreatic duct meets. !ype (<a: Characteri=ed by multi!le dilatations of the intrahe!atic and etrahe!atic biliary tree. !ype (<b: $ulti!le dilatations in)ol)ing only the etrahe!atic bile ducts. !ype <: Cystic dilatation of intra he!atic biliary ducts.
B())(AR' A!RE0(A ( Biliary atresia BA is a !rogressi)e idio!athic fibro( obliterati)e disease of the etrahe!atic biliary tree that !resents *ith biliary obstruction eclusi)ely in the neonatal !eriod. ( /he etrahe!atic bile ducts are !rogressi)ely destroyed by an inflammatory !rocess *hich starts around the time of birth. /he aetiology is unclear. /he inflammatory destruction of the bile ducts has been classified into three main ty!es , E ty!e +, atresia restricted to the common bile ductF E ty!e ++, atresia of the common he!atic ductF E ty!e +++, atresia of the right and left he!atic ducts. (Associated anomalies include in about 2& of cases cardiac lesions !olys!lenia situs in)ersus absent )ena ca)a and a !reduodenal !ortal )ein.
*%&P)(*A!(%#0 : 9Ascending cholangitis +ntrahe!atic changes can occur and e)entually result in biliary cirrhosis and !ortal hy!ertension. ntreated death from the conseDuences of li)er failure occurs before the age of 3 years.
)ier transplantation is the main choice of treatment .
GA))0!%#E0
*holelithiasis means stones in the gallbladder. the most common biliary !athology affect more than 15 of adult in :A . Asym!tomatic most common "& :ym!tomatic com!licated 1&(2& , !ain aundice !ruritus fe)erHHetc. 1& of gallstones are radio(o!aDue .
Ris- factors :
/he big 5 , Ifi)e -s , female 3,1 forty 4& fat fertilefair.J
less common , (<ral Contrace!ti)es. ( 9a!id *eight loss. (0y!erli!idemia (Gallbladder stasis. (-amily history (+leal diseases or resection /y!es of GB stones , 1. Cholesterol 2& . 2. Pigmented Blac Bro*n 5 . 3. $ied 5
Patho"enesis: $ @hen bile is su!ersaturated *ith cholesterol unstable unilamelar !hos!holi!id )esicles are formed. Cholesterol "& $ /his leads to formation of cholesterol crystals. *haracteristics ,
Kello*ish greasy.
<)oid firm
:ingle or multi!le
$ost are radiolucent.
*/%)E0!ER%) 0!%#E0
Contains less than 3& cholesterol. Contain bilirubin and calicium
/*o ty!es , Blac and Bro*n.
Blac stones ,
Accom!anies hemolysis hereditary s!herocytosis sicle cell anemia.
Bro*n :tones ,
-orm in bile duct and related to bile stasis and infected bile.
Associated *ith the !resence of foreign bodies *ithin the bile ducts such as stents or !arasites .
P(G&E#!E, 0!%#E0
•
*haracteristic ,
Any*here in the biliary tree.
Blac, in sterile GB bile small numerous friable 5&(5 are radio(o!aDue
Bro*n, in infected intra( or etrahe!atic ducts single or fe* soft # greasy radiolucent
&(;E, 0!%#E0
+s the most common 5 cut surface is laminated *ith alternate dar #light =ones of !igment # cholesterol res!ecti)ely
=/A! ARE !/E *%&P)(*A!(%#0 %F GA))0!%#E0>
(n "allbladder : ( Acute cholecystitis. ( Chronic cholecystitis ( Biliary Colic ( m!yema. ( $ucocele. ( Perforation ( Carcinoma &.&"
(n the Bile ,ucts: ( <bstructi)e aundice ( Ascending cholangitis ( Acute !ancreatitis
(n the intestine ( Gallstone ileus intestinal obstruction
B()(AR' *%)(*
+t is a misnomer because the !ain increases in intensity then reaches a !lateau then decreases but ne)er disa!!ears . :o
not a true colic
*aused by: ( !ransient obstruction of the GB by a stone in 0artmannLs !ouch or cystic duct *hich leads to s!asm in the *all of GB
Presentation,
pain, :,9ight u!!er Duadrant. <, suddenly after fatty meals C, gri!!ing !ain dull. 9, referred to the ti! of the right shoulder and radiate to the bac A, Associated *ith ( 'ausea )omiting flatulence dys!e!sia . /, 7ess than 6 hours if more then it is acute cholecystitis.
A*1!E */%)E*'0!(!(0
1(acute calculous cholecystitis ? %5 2(acute Acalculous cholecysitis ? 5
A*1!E *A)*1)%10 */%)E*'0!(!(0
>efinition, +nflammation of the gallbladder that de)elo!s o)er hours usually resulting from a cystic duct obstruction by a gallstone.
/his form of gallbladder disease usually subsides *ithin 1 to days *ith a conser)ati)e !lan of treatment .
'ot e)eryone *ho has gallstones *ill go on to de)elo! cholecystitis .
Patho!hysiology
1
2
. t c u d c i t s y c n i e r e h * y n a r o 5 h c u o ! s L n n a m t r a 0 3 c e n r e d d a l b l l a g e h t " n o t s A ( • n i t c u r t s b o e
n o i t c e f n i l a i r e t c a b d e s o ! m i r e ! u s h t i * 6 e l i b d e t a r t n e c n o C d n a s i s a t 0 ( •
. a s o c u m o t * o l f d o o l b s e s i m o r ! m o c d n a e r u s s e r ! l a n i m u l a r t n i d e s a e r c n i g n i s u a c l l a * e h t n i n o i t n e t s i d d n a a m e d e o t d a e l l l i * s i h / . t l a s 3 e l i b d e t s e " n o c e h t y b a s o c u m e h t f o n o i t a m m a l f n i •
4
5
n e r " n a " l l a * B G f o s s e n t f o s e s u a c t a h t e o t d a e l n o i t c e f n i h t i * * o l f d o o l b e s a e r c e > ( •
5 s i t i n o t i r e ! l a c i m e h c d n a s s e c s b a g n i s u a c 3 n s u a c y a m e n e r g n a G ( • o i t a r o f r e p e
a m e y ! m n o i t a m r o f s u ! d n a n o i t c e f n i h t i * n o i t c u r t s b o d e ) e i l e r n •
6
e l e c o c u $ n o i t e r c e s s u c u m s u o u n i t n o c d n a n o i t c e f n i t u o h t i * 6 n o i t c u r t s b o d e ) e i l e r n •
*)(#(*A) PRE0E#!A!(%# A*1!E */%)E*'0!(!(0+ A"e , /y!ically 3&(6& year old. Presentation in younger !atients may be due to congenital hemolytic anemiasicle(cell disease often form !igment stones *hich may !reci!itate an attac of acute cholecystitis.
Gender , -emales are more commonly affected
Analysis of Pain: :, 9M <, sudden onset C, shar! 9, radiates to the bac close to the inferior angle of right sca!ula A, associated *ith nausea )omiting and fe)er /, continuous >uration of !ain usually 6 hours , aggra)ated by mo)ements and breathing :, se)ere N/he !atient $ay ha)e !re)ious history of flatulent dyspepsia or biliary colic .
P/'0(*A) E;A&(#A!(%#
General E$amination : O Patient a!!ears ill O shallo* breathing O /achycardia )e Pyreia )e
NN fe* !atients *ith AC ha)e 8aundice by t*o mechanisms , 1( stone !assed to the CB> Iobstucti)e aundiceJ 2( $irri=i syndrome , occur *hen the cystic duct is densely adhered to the CB> . the stone in the cystic duct cause com!ression of the CB> .
P/'0(*A) E;A&(#A!(%#
Abdominal E$amination :
90C mass and tenderness guardingQrigidity Racary(co!es sign , 90C fullness Boas :ign , hy!eraesthesia increased or altered sensiti)ity belo* the right sca!ula. $ur!hys sign , Cessation of breath at dee! ins!iration during the dee! !al!ation at the ti! of % th rib Bo*el sounds are normally !resent ece!t in biliary !eritonitisGB has infarctedQru!tured rare com!lication
=hat are the differences in the clinical presentation bet?een biliary colic and Acute cholecystitis >>> Biliary colic : !ain duration S 6 hrs Afebrile !atient )omiting once or t*ice mild tenderness Acute cholecystitis : !ain duration 6 hrs febrile !atient re!eated )omiting se)ere tenderness
(#<E0!(GA!(%# 1.
-ull blood count ( re)eals leuocytosis
2.
;-/
3.
7-/ ? bilirubin to detect bile duct obstuction
4.
Amylase and li!ase le)el for acute !ancreatitis
5.
: abdomen /0 G<7> :/A'>A9>
6.
0+>A scan if : is not diagnostic
.
T(ray not usefulonly1&(15 of stones are )isible
".
$9CP
%.
9CP
=hat are the ultrasonic features of ??Acute *holecystitis @+
,istended "all bladder
6+
Fluid surroundin" the "all bladder
+
Gall bladder ?all thic-enin" mm+
C+
,ilated cystic duct
7+
0tones in the "all bladder
$9CP , magnetic resonance cholangio!ancreatogra!hy
9CP , endosco!ic retrograde cholangio!ancreatogra!hy
Both are used for diagnosis .
9CP used also for thera!y of CB> stones .
0+>A scan , re)eal non(o!acification of the gallbladder from obstruction of the cystic duct.
A*1!E A*A)*1)%10 */%)E*'0!(!(0
+nflammation of the gallbladder in the absence of gall stone usually seen in seriously ill !atients after , maor surgeries trauma burns se!sis
(t occurs because of : 1 >ehydration 2 GB stasis 3 Uascular com!romise 4 Bacterial contamination
mostly Gram ?)e, (coli ;lebsiella nterobacter
*/R%#(* */%)E*'0!(!(0
Chronic inflammation of the gall bladder because of recurrent attacs of acute cholecystitis or biliary colic ending in thicening and fibrosis of its *all.
:tones are almost al*ays !resent.
0upersaturation of bile !redis!oses to chronic inflammation # stone formation.
Bacteria are isolated in 1Q3 of the cases.
PRE0E#!A!(%# (!!er abdominal !ain after eating. begins 15 to 3& mins after a meal and last for 3& to %& mins most common com!laint.
( flatulent dys!e!sia!ost(!randial belching ( 0eartburn
P/'0(*A) E;A&(#A!(%#
:igns of aundice
Abdomen loos normal
90C mass and tenderness
Percussion and auscultation should be normal
: ,,; %F R1Q PA(# Common, 1.
Perforated !e!tic ulcer
2.
0igh a!!endicitis
3.
Acute !ancreatitis
ncommon, 4.
Acute !yelone!hritis
5.
9ight lo*er lobe !neumonia
6.
$+inferior
&A#AGE&E#!
*onseratie mana"ement , %& of cases *ill res!ond 1 'il by mouth V'P<W 2 Gain +U access gi)e +U fluids 3 Administration of antibiotics 4Administration of analgesics 5 $onitoring of )ital signs 6 +f sym!toms subsided initially oral fluid intae is allo*ed then follo*ed by fat(free diet and lastly regular diet : ( to e)aluate *hether theres any local com!lications " Plan for cholecystectomy o!en or la!arosco!ic A arly *ithin 2 hours. B 7ate after 2(3 months. N:ometimes *e do Cholecystostomy in case of em!yema
*/%)E*'0!E*!%&' sually *e do it by laparoscopy but in the follo*ing cases *e do it by )aparotomy , 1.
not *ell defined anatomy
2.
uncontrolled bleeding
3.
bile duct inury
P%0! D %PERA!(<E *%&P(*A!(%#0 @9 hemorrha"e NNusually the source is from cystic artery. NN the !atient com!lains of !ersistent abdominal !ain or features of hy!o)olemic shoc
69 ?ound infection 9 bile leaC9bile duct stricture NNthe most dangerous com!lication leads to , cholangitis obstructi)e aundice secondary biliary cirrhosis and he!atic failure.
79post cholecystectomy syndrome
#E%P)A0&0
Beni"n tumors of the GB: !a!illoma myoma fibroma adenomyoma li!oma carcinoid . &ali"nant tumors of the GB : "& of the tumors are adenocarcinoma %& of !ts ha)e cholelithiasis Porcelain GB Carry a ris of 73 4 of malignancy calcification of GB due to ecessi)e stones.
P%R*E)A(# GB
*/%)E,%*%)(!/(A0(0 ( :tones !resent *ithin the biliary tree. ( :tones may be, 1 deri)ed from gallbladder 2 !rimary ductal # intrahe!atic stone formation
( Asym!tomatic in 1&
( :ym!toms due to, 1 cholangitis CharcotLs triad biliary obstruction <bstructi)e Xaundice >ar urine Pale stool itching 2 !ancreatitis 3 7i)er abscess 4 chronic li)er disease *ith secondary biliary cirrhosis 5 acute cholecystitis
*/%)E,%*/%)(!/(A0(0 *A# BE PR(&AR' %R 0E*%#,AR'
us 5 ER*P are the diagnostic modalities )ier function test are consistent *ith obstructi)e aundice 0ur"ical !! : *holecystectomy choledocotomy *B, e$ploration 5 ! tube placement operatie cholan"io"ram .
*/%)A#G(!(0 : (#FE*!(%# %F !/E B())(AR' !REE 9 Etiolo"y : 1. CB> stones. 2. !ost.o! stricture. 3. 'eo!lasm 4. sclerosing cholangitis. 5. billiary contrast studies . .
!reatment : 'P< +U antibiotics relief of the obstruction
*/%)A#G(%*AR*(#%&A
&ali"nant tumors of the bile duct may be associated ?ith : 1( :clerosing cholangitis. 2( chronic !arasitic infection of the bile duct. 3( Gall stones.
!he tumor may be located in , distal CB> common he!atic duct cystic duct left or right he!atic duct most common site
/reatment by , =hipple procedure.
