Gallbladder and Extrahepatic Biliary System

Chapter 32 Schwartz’s

Why Should You Care?

• Lap Chole = frequent 2nd year case• Anatomy can be tricky• Complications can be very bad!• Even if you don’t do this type of surgery, your

friends and family may have this type of surgery and come to you for info/advice

Anatomy

Anatomy

• The cystic artery which supplies the gallbladder is usually a branch of what artery?

Anatomy

• The cystic artery which supplies the gallbladder is usually a branch of what artery?

– The Right Hepatic Artery (90% of the time)– Course can vary, usually in triangle of Calot– Divides into posterior and anterior branches at

neck of gallbladder

Anatomy

• What are the boundaries of the Triangle of Calot?

Anatomy

• What are the boundaries of the Triangle of Calot?

– Cystic duct, common hepatic duct, liver margin

Anatomy

• Name the mucosal folds found in the cystic duct adjacent to the gallbladder neck.

• Extra credit: do they have any valvular function?

Anatomy

• The Spiral Valves of Heister, and no they do not have any valvular function.

Anatomy

• The arterial supply to the bile ducts is derived from which 2 major arteries and is oriented in what clock positions???

Anatomy

• The arterial supply to the bile ducts is derived from which 2 major arteries and is oriented in what clock positions???– Gastroduodenal and Right Hepatic Arteries, in the

3:00 and 9:00 positions (medial and lateral walls)

Ruggero Oddi

Described the Sphincter of Oddi while a student

Francis Glisson identified the sphincter 2 centuriesearlier

Inflammation of the sphincter of Oddi is calledodditis

Anatomy

• The classic description of the extrahepatic biliary tree and its arteries applies only in:– A. two thirds of patients– B. half of patients– C. one third of patients

Anatomy

• The classic description of the extrahepatic biliary tree and its arteries applies only in:– A. two thirds of patients– B. half of patients– C. one third of patients

Anatomy

• Name the small ducts which drain directly from the liver into the body of the gallbladder, and are a potential source of biloma post cholecystectomy

Anatomy

• Name the small ducts which drain directly from the liver into the body of the gallbladder, and are a potential source of biloma post cholecystectomy

–Ducts of Luschka

Anatomy

• Replaced Right: Right Hepatic Artery off the SMA; 20% of patients; can course anterior to common duct

• Cystic Artery can arise from the Left Hepatic, Common Hepatic, GDA, or SMA; 10% of patients

PhysiologyStimulates Gallbladder Contraction Stimulates Gallbladder Relaxation

CCK Atropine

Parasympathomimetics VIP

Vagus Nerve Splanchnic Sympathetic Activity

Antral distention of stomach Somatostatin

Physiology

• Which of the following factors are asscoiated with increased risk of gallstone development?– A. Obesity– B. Pregnancy– C. Crohn’s disease– D. Terminal ileal resection– E. Gastric surgery– F. Sickle Cell Disease

Physiology

• Which of the following factors are asscoiated with increased risk of gallstone development?– A. Obesity– B. Pregnancy– C. Crohn’s disease– D. Terminal ileal resection– E. Gastric surgery– F. Sickle Cell Disease

Physiology

• Which of the following is not a major component of bile?– Cholesterol– Bile Salts– Lecithin– Budweiser

Physiology

• Which of the following is not a major component of bile?– Cholesterol– Bile Salts– Lecithin– Budweiser

Gallstone Fun Facts

• In Western countries, Cholesterol stones are the most common type of gallstones

• Pigment stones are black or brown b/c of Ca bilirubinate; often d/t hemolytic disorders

• Brown stones usually d/t bacterial infection caused by bile stasis

• Black/brown stones more common in Asia

Imaging

• True or False: Ultrasound will show stones in the gallbladder with a sensitivity and specificity of >90%.

Imaging

• True or False: Ultrasound will show stones in the gallbladder with a sensitivity and specificity of >90%.

• TRUE

Imaging

• True or False: MRCP has 95% sensitivity and 89% specificity at detecting choledocholitiasis .

Imaging

• True or False: MRCP has 95% sensitivity and 89% specificity at detecting choledocholitiasis.

• TRUE

Imaging

• Your patient, a retired chemist/anatomy teacher, is suspected of having a bile leak following a laparoscopic cholecystectomy. Your team decides to order a HIDA scan, and the patient wants to know what the test is and how it works. Please explain…..

HIDA Scan

• ‘Biliary Scintigraphy’; gives anatomic/fxnal info. 99mTechnetium-labeled derivatives of dimethyl iminodiacetic acid (HIDA) IV, cleared by Kupffer cells,excreted in bile. Liver uptake detected w/in 10min. GB, bile ducts, duodenum seen in 60min in fasted pt.

HIDA Scan

• Acute Cholecystitis=non-visualized GB w prompt filling of CBD & duodenum

• False positives in pts w GB stasis/critically ill/TPN

• Absent duo filling=obstruction at ampulla

Surgical Treatment

• Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?

Surgical Treatment

• Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?

• NO

Surgical Treatment

• Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?

• NO• Advisable for elderly diabetics, pts isolated

from medical care, pts w increased risk of GB CA

• Porcelain GB is indication for cholecystectomy

Surgical Treatment of Gallstones

• Approx 3% of a’sxmatic pts become sx’matic per year

• Complicated gallstone dz develops in 3-5% of sx’matic pts per year

• Over 20 yr period, two thirds of a’sxmatic pts w gallstones remain sx free!

Surgical Tx of Gallstones

• A 45 yo WF presents to the ED with biliary colic for the second time in 2 weeks, repeat RUQ U/S shows no stones but sludge in the GB. Is cholecystectomy indicated in this pt?

Surgical Tx of Gallstones

• A 45 yo WF presents to the ED with biliary colic for the second time in 2 weeks, repeat RUQ U/S shows no stones but sludge in the GB. Is cholecystectomy indicated in this pt?

• Yes!• 2 or more occasions of pain/sludge• Cholesterolosis/adenomyomatosis/granulo-

matous polyps indication if causing sx’s

PEG

What do you call this?

Emphysematous Gallbladder

• Persistent obstruction>2ndary bacterial infxn>gas forming organisms involved>see gas in GB lumen/wall of GB

• GB can perforate, form cholecystoenteric fistula, lead to gallstone ileus, cause intrahepatic abscess, peritonitis, etc.

Surgical Tx of Gallstones

• 26 yo G1P0 presents to ED with symptomatic gallstones refractory to medical management, dietary modifications.

• Is lap chole safe???

Surgical Tx of Gallstones

• 26 yo G1P0 presents to ED with symptomatic gallstones refractory to medical management, dietary modifications.

• Is lap chole safe???

• YES

But does it really work doc?

• Approx. 90% of pts with typical biliary sx’s (epigastric/ruq pain, N/V episodes) and stones are sx free post-cholecystectomy

• Pts w atypical sx’s or dyspepsia (flatulence, belching, bloating, dietary fat intolerance) have less favorable results

Murphy’s Sign

• An inspiratory halt upon deep palpation of the R subcostal area, characteristic of acute cholecystitis

Mirizzi’s Syndrome

• Obstruction of the bile ducts by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the GB that mechanically obstructs the bile duct

DDx???

• 55 yo WF presents with 10 hours of RUQ pain radiating to back, +N/V, similar prior episodes lasted only a few hours and resolved completely. Started suddenly after fatty meal.

• Temp 101.9, otherwise VSS• Guarding in RUQ, +Murphy’s Sign• WBC# 15, LFT’s WNL

DDx• Acute Cholecystitis• Peptic Ulcer (w or w/o perforation)• Pancreatitis• Appendicitis• Hepatitis• Perihepatitis (Fitz-Hugh-Curtis Syndrome)• Myocardial Ischemia• Intercostal Nerve Herpes Zoster• Pneumonia• Pleuritis

Acute Cholecystitis Tx

• IV fluids, pain meds, Antbx (cover gram neg aerobes and anaerobes, 3rd gen cephalosporin)

• Cholecystectomy is definitive tx• Earlier the better!