Gall bladder lecture

Gallbladder Disease

By:Mohammad Mujib MunirzaiAmiri Medical Complex

Date:12/Nov/2016

Anatomy of Gallbladder• Location:

– between• Junction of the right ninth

costal cartilage• Lateral border of the rectus

abdominis .

• It is a pear shaped sac– lying on the inferior

surface of the liver – in a fossa between– Right and quadrate lobes– Capacity of about 30 to

50 mL.

Surface Anatomy• Direct contact

– superior part of the duodenum

– transverse colon.• Parts:

– Neck – Body– Fundus

Blood Supply of the Gall Bladder

• The cystic artery, supplying the gallbladder and cystic duct commonly arises from the right hepatic artery.

CYSTOHEPATIC TRIANGLE OF CALOT

Variations to the Cystic Artery

CONGENITAL ANOMALIES OF GALLBLADDER

Venous Drainage of the Gallbladder• The cystic veins,

– draining the neck of the gallbladder and cystic duct,

– enter the liver directly or drain through the portal vein to the liver,

– The veins from the fundus and body of the gallbladder pass directly into the visceral surface of the liver and drain into the hepatic sinusoids.

Lymphatic Drainage of Gallbladder

Nerve Supply• Celiac nerve plexus (sympathetic and

visceral afferent [pain] fibers)• The vagus nerve (parasympathetic)• The right phrenic nerve (actually somatic

afferent fibers).

Functions• Gall bladder

– It stores Bile– It concentrates bile– Ejects bile into lumen

• Bile– Emulsify dietary lipids– Formation of micelles with products of lipid digestion.

BILE• Bile is produced at a rate of 500–1500 mL/d by the hepatocytes

and the cells of the ducts• Composition of bile:

• Bilirubin (by-product of haem degradation)• Cholesterol (kept soluble by bile salts and lecithin)• Bile salts/acids (cholic acid/chenodeoxycholic acid):

mostly reabsorbed in terminal ileum(entero-hepatic circulation).

• Lecithin (increases solubility of cholesterol)• Inorganic salts (sodium bicarbonate to keep bile alkaline

to neutralise gastric acid in duodenum)• Water (makes up 97% of bile)

Secretion and enterohepatic circulation of bile salts

CHOLELITHIASIS• Presence of one or more calculi

(gallstones) in the gallbladder.

Types of gallstone• 20% are Cholesterol Stones.• 5% are Pigment Stones.• 75% are Mixed… … …

• In Asia 80% Pigment Stones.

• In Europe 80% Cholesterol Stones.

Pigment stone

Cholesterol Imbalance between bile salts/lecithin and cholesterol allows cholesterol to

precipitate out of solution and form stones Pigment

Occur due to excess of circulating bile pigment (e.g. Heamolytic anaemia) Mixed

Same pathophysiology as cholesterol stones

Other Factors Stasis (e.g. Pregnancy) Ileal dysfunction (prevents re-absorption of bile salts) Obesity and hypercholesterolaemia

Pathogenesis

Risk Factors• BIG 4..?

1. Female.2. Forty.3. Fertile.4. Fatty.

Risk Factors• Pregnancy.• OCP.• Hemolytic Anemia.• Cirrhosis.• Infection.• IBD/Terminal Ileal Resection.• TPN.• Hyperlipidemia.

Pathological Effects1. Silent Gallstones.2. Obstruction of the Cystic Duct.3. Movement of Stone into CBD.4. Ulceration of Stone through Gallbladder

Wall.

Cholelithiasis

Asymptomatic cholelithiasis

Symptomaticcholelithiasis

Chronic calculous

cholecystitis

Acute calculous

cholecystitis

Clinical Presentation1. Biliary Colic.2. Acute Cholecystitis.3. Chronic Cholecystitis.4. Gallstone Pancreatitis.5. Obstructive Jaundice.6. Acute Cholangitis.7. Gallstone Ileus.8. Mucocele / Empyema of the Gallbladder.

Definitions

• Biliary colic

– postprandial epigastric/RUQ pain due to transient

cystic duct obstruction by stone

– No fever, No leukocytosis, Normal LFT

• Differential Diagnosis:– Renal Colic.– Intestinal Obstruction.– Angina.

• Pain Episode may Resolve when Stone is Passed into CBD / Falls Back into the Gallbladder.

Gall bladder ultrasound• Shows

gallstones→

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