Gall bladder

The Gall Bladder and Bile Ducts

Surgical Anatomy and Physiology
The gall bladder is:
Pear shaped, 7.5 – 12 cm long
30 to 50 mL capacity
Fundus, body, neck, and infandibulum
The cystic duct:
3cm in length
1-3 mm in diameter
Valves of Heister

The common hepatic duct:

2.5 cm in length
Union of R & L hepatic ducts
The common bile duct:
7.5cm in length
Union of cystic and CHD
4 parts;


Blood supply of gall bladder:
The cystic artery a branch of R hepatic artery
Accessory CA from GD art.
In 15% RHA anterior to CHD
Toutuous RHA and short CA, Caterpillar turn or Moynihan’s hump.
Lymphatics:
Subserosal and submucus lymphatics to the cystic LN of Lund hilum of liver coeliac LN
Subserosal lymphatics to subcapsular lymphatics of liver
Surgical physiology
The Bile: secreted from the liver at rate of 40ml hour
Mainly compose of 97% water
Other constituents ;Bile salts 1-2%, bile pigments 1%, cholestrol, and fatty acids
Functions of gall bladder:
Reservoir
Concentration of bile, 5 - 10 times
Secretion of mucus– 20ml/day
Investigations of the biliary tract

Ultrasound; stones and size

Plain radiograph; calcification
MRCP; anatomy and stones
CT scan; cancer and anatomy
HIDA scan; function
ERCP; stones, and strictures
Ultrasonography:
Non-invasive
Standard initial imaging for patient suspected to have a gall stone and in jaundiced patients.
Ultrasonography:can demonstrate
Gall stones
GB size, thickness of its wall, presence of inflammation around it, pericystic edema.
Size of CBD, occasionally stones in it.
Gall stone





Endoscopic ultrasound;
Stone and obstruction of lower CBD

Plain radiogaph:

Radiopaque gall stones in 10%
Porcelain GB.. calcified GB..25% CA.
Limey bile
Gas in the wall, emphysematous cholecystitis
Gas in the biliary tree; seen in
After Endoscopic sphincterotomy
In patients underwent Surgical bilio-enteric anastomsis
In patients having Internal biliary fistula

Porcelain GB

Radiopaque Gall stones

Oral cholecystography:

Once was the first choice in the
diagnosis of gall bladder problems.

Intravenous cholangiography

Radioisotope scanning:
Tc 99m labelled with derivatives of iminodiactic acid (HIDA, PIPIDA), that are excreted in the bile.
Dx of acute cholecystitis GB not visulized
Bile Leakage, assessment

CT scan;

limited useful in investigating the biliary tree
Only when there is a possibility of cancer of gall bladder or bile ducts
Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice

MRCP:

Standard for biliary tree investigation
Contrast is not needed

Endoscopic retrograde cholangiopanreatography (ERCP)

Side veiwing endoscopie
Cannulation of ampulla of Vater
Injection of contrast to visualize the bile ducts
Also bile can be taken for cytological and microbiological tests
Brushings from strictures to decide whether benign or malignant

Percutaneous Transhepatic Cholangiography (PTC):

Preparation;
Normal PT
Antibiotics
DX and therapy;
Visulization of biliary tree
Placement of; catheter, Stenting
choledochoscope

sdssds

Peroperative cholangiography:

Operative biliary endoscopy (choledochoscopy)

Diseases of Gall Bladder and Biliary Passages

Congenital

Acquired





Congenital abnormalities of the GB and biliary tree
Absence of GB
The phrygian cap
Floating GB
Double GB
Absence of CD
Low insertion of CD
An accessory cholecystohepatic duct ( small ducts of Luschka)
Extrahepatic biliary atresia
Aetiology and pathology:
1 per 14000 live birth
Equal and female
If untreated the child dies before the age of 3 years
20% associated anomalies, cardiac, situs inversus, absent vena cava

Classification:

Type I: atresia restricted to the CBD
Type II: atresia of the CHD
Type III: atresia of the right and left HD

Clinical features:

1/3 jaundiced at birth
All jaundiced by the end of first week
Meconium little bile stained
Pale stool and dark urine
Osteomalacia
Pruritis
Clubbing, skin xanthoma
Diff. Dx.:
Alpha 1 antitrypsin deficiency
Choledochal cyst
Inspissated bile syndrome
Neonatal hepatitis
Treatment:
Roux-en Y anastomosis
Kasai procedure
Choledochal cyst
Weaknes of part or whole of the wall of the CBD
Anomalous junction of the biliary pancreatic junction;
High amylase
Repeated attacks of panreatitis
Treatment:
Radical excision of the cyst and reconstruction of the biliary tract using Roux en Y jejunal loop
Trauma
Iatrogenic
Accidental, is rare, penetrating or crushing
Presentation of acute abdomen
Treatment:
GB—cholecystectomy
Bile ducts:
Drainage using T tube
–Roux-en-Y


Gall stones (CHOLELITHIASIS)
Most common pathology affecting about 10–15% of the adult population.
Mostly asymptomatic in >80%
cholecystectomy one of the most common operations performed by general surgeons.

Aetiology of gallstones

Risk factors associated with formation of gall stones
Age > 50 years
Female sex (twice risk in men)
Genetic or ethnic variation
High fat, low fibre diet
Obesity
Pregnancy (risk increases with number of pregnancies)
Hyperlipidaemia
Bile salt loss (ileal disease or resection)
Diabetes mellitus
Cystic fibrosis
Antihyperlipidaemic drugs (clofibrate)
Gallbladder dysmotility
Prolonged fasting
Total parenteral nutrition
Types of Gall stones:
Cholesterol
Pigment stones
Mixed stones
Gall stones
Types of Gall stones:
Cholesterol stones;
Contain mainly pure cholesterol
Mostly single ( cholesterol solitaire)
Obesity,
high-calorie diets
certain medications
Pigment stones: < 30% cholesterol
Black stones
insoluble bilirubin pigment polymer mixed with calcium phosphate and calcium bicarbonate.
Hemolysis;
Hereditary spherocytosis
Sickle cell anaemia
Brown stones:
calcium bilirubinate, calcium palmitate and calcium stearate, as well as cholesterol
form in the bile duct and are related to bile stasis and infected bile.
Mixed stones:
Cholesterol major component
Ca bilirubinate, Ca palmitate, Ca carbonate, Ca phosphate, and proteins
Account for 90%
Multiple
Faceted

Incidence of Gall stones

Female
Fat
Fertile
Fifty
Flatulent
Causal factors in gall stone formation
Metabolic
Infective
Stasis

Metabolic:

Cholesterol

Bile salts Phospholipid

High cholesterol “Supersaturated” or “lithogenic” bile

Aging
Female contraceptives
Obesity Clofibrate
Interruption of enterohepatic circulation of bile salts lead to low bile salts


Infection:
Unclear
Radiolucent centre of stone mucus plug as nidus for stone formation
B glucuronidase unconjugated insoluble bilirubin.
Bile stasis:
Decrease contractility of gall bladder
Estrogen in pregnancy
Parenteral nutrition
Truncal vagatomy

Effects and complications of gall stones

In the GB:
Silent up to 80%
Chronic cholecystitis
Acute cholecystitis
Gangrene
Perforation
Empyema
Mucocele
carcinoma
In the bile ducts:
Obstructive jaundice
Cholangitis
Acute panreatitis
In the intestine:
Acute intestinal obstruction ( gall stone ileus)


cholecystitis

Biliary Colics

Acute cholecystitis
Chronic cholecystitis

Acute cholecystitis

Right hypochondrial pain
Radiate to back, shoulder, chest
Occ. Start at epigastrium or left subcostal
Start at night
Other symptoms;
Dyspeptic symptoms
Vomiting
fever

Acute cholecystitisBiliary colicSeveral hours to few daysFeverleucocytosisFew minutes to few hoursNo fever


Differential DX
Common:
Appendicitis
Perforated peptic ulcer
Acute pancreatitis
Uncommon:
Acute pyelonephritis
MI
Pneumonia, right lower lobe

Physical examination:

Murphy’s sign
Palpable tender gall bladder.

Diagnosis

Ultrasound
Liver function test
Bilirubin
WBC
CXR pneumonia ,air under diaphragm
ECG
GUE and urine culture
Treatment
Conservative
Early cholecystectomy
Conservative treatment followed by cholecystectomy
NPO with IV fluids
NG tube
Analgesia
Antibiotics
Follow up
Conservative Treatment
90% respond to conservative treatment.
Subsequent treatment:
Early cholecystectomy next op. list 5-7 days
Elective cholecystectomy 6 weeks
When to stop conservative treatment:
Increasing pain and tenderness
Increasing pulse and temperature
Conservative treatment is not advised
Uncertinity about the dx
EMPYEMA OF THE GALL BLADDER
Pus filled gall bladder
A sequel to acute cholecystitis or Mucocele
Treatment:
Cholecystectomy
Disturbed anatomy---- drainage (Cholecystostomy) later cholecystectomy
Acalculous cholecystitis
Acute or chronic
Dx by:
Oral cholecystography in chronic
Radioisotope in acute cholecystitis
Acute acalculous can occur in patients after major surgery, trauma, burn
Cholecystectomy
Indications
Preperation
procedure
Preparation for operation
■ Full blood count
■ Renal profile and liver function tests
■ Prothrombin time
■ Chest X-ray and electrocardiogram (if over 45 years or medically indicated)
■ Antibiotic prophylaxis
■ Deep vein thrombosis prophylaxis
■ Informed consent
Cholecystectomy
Laparoscopic cholecystectomy
Gold standard
Open colecystectomy
complications of laparoscopic cholecystectomy
access complications
bile duct injuries
Biliary injury:
Bile leakage
Local collection or excessive bile drainge if drain is present
Biliary peritonitis
Causes of pain after cholecystectomy
Incorrect preoperative diagnosis - for example, irritable bowel syndrome, peptic ulcer, gastro.oesophageal reflux
Retained stone in the CBD or CD stump
Iatrogenic biliary injury
stricture of common bile duct
Papillary stenosis or dysfunctional sphincter of Oddi
Incorrect preoperative diagnosis - for example, irritable bowel syndrome, peptic ulcer, gastro.oesophageal reflux
Retained stone in the CBD or CD stump
Iatrogenic biliary injury
stricture of common bile duct
Papillary stenosis or dysfunctional sphincter of Oddi
Alternative treatment
Criteria for non-surgical treatment of gall stones
Cholesterol stones < 20 mm in diameter
Fewer than 4 stones
Functioning gall bladder
Patent cystic duct
Mild symptoms
Summary points
Gall stones are the commonest cause for emergency hospital admission with abdominal pain
Laparoscopic cholecystectomy has become the treatment of choice for gallbladder stones
Risk of bile duct injury with laparoscopic cholecystectomy is around 0.2%
Asymptomatic gall stones do not require treatment
Cholangitis requires urgent treatment with antibiotics and biliary decompression by endoscopic retrograde cholangiopancreatography
Management of CBD obstrucdtion
Following cholecystectomy
Jaundice ---- immediate action
Ultrasound
Dilatation
Collection at porta hepatis
Biochemical investigations
Immediate ERCP:
If stone detected endoscopic extraction
If CBD obstruction surgery
If bile leakage :
Percutaneous drainage
Stenting
Stones in the CBDSeveral years after cholecystectomyCBD infestation by Ascaris lumbricoides or clinorchis sinensis


Stones in the CBDClinical presentation:AsymptomaticJaundiceCholangitis ( Charcoat triad )Fever and rigorJaundicePain

Signs:

Tenderness upper abdomen and RUQ
Management:
Dx
Ultrasound
Liver function test
Liver biopsy
MRCP
ERCP
Resuscitaion
Relief of obstruction
Resuscitaion
Rehydration
Broad spectrum Antibiotics
Attention to clotting Vit K
Relief of obstruction
Endoscopic sphincterotomy
Extraction of stone by Dormia basket or balloon catheter
Some times stent placement
Percutaneous transhepatic cholangiography:
then drainage
Percutaneous choledochoscopy
Surgery:
Choledochotomy
CholedochotomyIndications:Preoperative:Stone in CBDDilatation of CBDHistory of jaundicePeroperative:Palpable stoneDilated CBD
Stricture of CBD
Benign stricture:
80% postoperative
20% inflammatory
Malignant stricture
Causes of benign biliary stricture
Congenital
■ Biliary atresia
Bile duct injury at surgery
■ Cholecystectomy
■ Choledochotomy
■ Gastrectomy
■ Hepatic resection
■ Transplantation
Inflammatory
■ Stones
■ Cholangitis
■ Parasitic
■ Pancreatitis
■ Sclerosing cholangitis
■ Radiotherapy
Trauma
Idiopathic
Postoperative stricture
Technical error during cholecystectomy
Blind control of bleeding in Calot triangle
Failure to identify the anatomy at Calot triangle
Acute inflammation
Mirizzi syndrome
Short or absent cystic duct
Anatomical anomalies
CBD obstruction
Deeping jaundice
Partial obstruction delayed jaundice
Radiological investigations:
Ultrasound
MRCP
Cholangiography
Through tube
PTC
ERCP

Postoperative stricture:

Treatment
Supportive
Relief of obstruction
Temporary:
ERCP stenting
Transhepatic external drainage and stenting
For strictures of recent onsent:
ERCP --- guide wire---- balloon dilatation---stent placement
Definite relief of obstruction:
Choledocho-jejunostomy

Complications of cholecystectomy

Inraoperative:
Biliary injuries
Iatrogenic injuries to near by organs
Bleeding.
Early postoperative:
CBD obstruction
CBD injury
Bleeding
Missed stone in CBD
Late complications:
CBD stricture
Stone in CBD
Post cholecystectomy pain "syndrome"
Wrong preoperative diagnosis
Complication of cholecystectomy
PARASITIC INFESTATION OF THE BILIARYBiliary TRACT
ascariasis
The round worm, Ascaris lumbricoides, commonly infests the intestine
Complications:
strictures,
suppurative cholangitis,
liver abscesses and empyema of the gall bladder
Hydatid disease
Jaundice:
Cyst near porta hepatis pressure from out side
Rupture of cyst into the biliary passages –daughters inside
TUMOURS OF THE BILE DUCT
Benign tumours of the bile duct:
Rare
Symptoms not distinguished from common biliary problems
Malignant tumours of the bile duct
Rare, but incidence increasing
Presents with jaundice and weight loss
Diagnosis by ultrasound and CT scanning
Jaundice relieved by stenting
Surgical excision possible in 5%
Prognosis poor – 90% mortality in 1 year


The tumour is usually an adenocarcinoma (cholangiocarcinoma). predominantly in the extrahepatic biliary
Risk factors
ulcerative colitis, hepatolithiasis, choledochal cyst ,sclerosing cholangitis.
liver fluke infestations in the Far East
Clinical featuresJaundiceAbdominal pain, early satietyweight losspalpable gall bladder
InvestigationsBiochemical investigationstumour marker CA19-9ultrasound and CT scanning define: the level of biliary obstruction the locoregional extent of disease the presence of metastasespercutaneous transhepatic cholangiographyERCP
TreatmentMost patients are inoperable, but 10–15% are suitable for surgical resection
Carcinoma of gall bladder
Risk factors
Comon in india Incidence 9%
Gall stones less than 1%
90% of Ca GB have gall stones
Pathology:
Schirrous adenocarcinoma
Squamous cell
Mixed sq adenocarcinoma
Spread:
Direct invading the liver
Lymphatics
Peritoneal seedlings
Clinical features:
Mostly elderly 70 years
Females more than males 5:1 ratio
Same as cholecystitis
Suspected during cholecystectomy then preoved by histopathology
Jaundice:
Mass in liver late sign
Investigation
non-specific findings such as anaemia, leucocytosis, mild elevation
in transaminases and increased erythrocyte sedimentation
rate (ESR) or C-reactive protein (CRP).
Elevated CA19-9
US and CT scan
percutaneous biopsy
Laparoscopy
Treatment:
Usually discovered after cholecystectomy and so no further surgical treatment required If tumor confined to mucosa good prognosis
transmural disease, a radical en bloc resection of the gall bladder fossa and surrounding liver along with the regional lymph nodes.