Gallbladder Disorders

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Gallbladder Disorders. By: Dr. Wasfi Salayta Colorectal Surgeon – Royal Medical Servises - KHMC. Gallbladder Anatomy. is a pear-shaped sac …..length about 7.5 to 12.5 cm …..with an average capacity of 30 to 50 ml (the gallbladder can distend markedly and contain up to 300 ml) - PowerPoint PPT Presentation

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  • Gallbladder DisordersBy: Dr. Wasfi SalaytaColorectal Surgeon Royal Medical Servises - KHMC

  • Gallbladder Anatomyis a pear-shaped sac..length about 7.5 to 12.5 cm ..with an average capacity of 30 to 50 ml (the gallbladder can distend markedly and contain up to 300 ml)located on the inferior surface of the liver attached to it by loose areolar tissue. Rich in blood vessels and lymphatic.The Gallbladder covered by peritoneum reflected from Glisson Capsule Less 10% complete covered by peritoneum (mesentery) The gallbladder is divided into four anatomic areas: the fundus: the corpus (body), the infundibulum, and the neck.Supplied by the cystic artery which arise from the right hepatic artery . Venues drainage : drain into the right branch of portal vein.Lymphatic drainage: drain into cystic lymph node.

  • Anterior aspect of the biliary anatomy. a = right hepatic duct; b = left hepatic duct; c = common hepatic duct; d = portal vein; e = hepatic artery; f = gastroduodenal artery; g = left gastric artery; h = common bile duct; i = fundus of the gallbladder; j = body of gallbladder; k = infundibulum; l = cystic duct; m = cystic artery; n = superior pancreaticoduodenal artery. Note: the situation of the hepatic bile duct confluence anterior to the right branch of the portal vein, the posterior course of the right hepatic artery behind the common hepatic duct.

  • Gallbladder Physiology Bile is mainly composed of water (97%), bile salts (1-2%), (1%) phospho-lipids, cholesterol, bile pigments, and electrolytes, . Bile is alkaline and PH 5.7 8.6.The rate of bile secretion is 40 cc / hour.The normal adult consuming an average diet produces within the liver 500 to 1000 ml of bile a day.

  • Gallbladder FunctionBile storage.Bile concentration 5-10 times by active absorption of water and sodium decreasing the bile volume 80-90%.Secretion of mucin = 20 ml /day.

  • AnomaliesThe classic description of the extrahepatic biliary tree and its arteries applies only in about one third of patients.The gallbladder may have abnormal positions, be intrahepatic: A partial or totally intrahepatic gallbladder is associated with an increased incidence of cholelithiasis, or to the left of faciliform legament.It might be duplicated (one in every 4000 persons). Isolated congenital absence of the gallbladder is very rare, with a reported incidence of 0.03%.Small ducts (of Luschka) may drain directly from the liver into the body of the gallbladder. If present, but not recognized at the time of a cholecystectomy, a bile leak with the accumulation of bile (biloma) may occur in the abdomen. An accessory right hepatic duct occurs in about 5% of cases.

  • Anomalies of the hepatic artery and the cystic artery are quite common, occurring in as many as 50% of cases. In about 5% of cases, there are two right hepatic arteries, one from the common hepatic artery and the other from the superior mesenteric artery. In about 20% of patients, the right hepatic artery comes off the superior mesenteric artery. The right hepatic artery may course anterior to the common duct. The right hepatic artery may be vulnerable during surgical procedures, in particular when it runs parallel to the cystic duct or in the mesentery of the gallbladder. The cystic artery arises from the right hepatic artery in about 90% of cases, but may arise from the left hepatic, common hepatic, gastroduodenal, or superior mesenteric arteries.

  • Diagnostic StudiesAbdominal X- ray: Limited value in the diagnoses GB disorder but helpful to rule out other differential diagnoses. Gallbladder stone can be seen by x-ray in 15-20%.Oral Cholecystography:It involves oral administration of a radiopaque compound that is absorbed, excreted by the liver, and passed into the gallbladder.largely been replaced by ultrasonography.

  • UltrasonographyAn ultrasound is the initial investigation of any patient suspected of disease of the biliary tree. It is noninvasive, painless, does not submit the patient to radiation, and can be performed on critically ill patients.Computed TomographyAbdominal CT scans are inferior to ultrasonography in diagnosing gallstones. The major application of CT scans is to define the course and status of the extrahepatic biliary tree and adjacent structures. It is the test of choice in evaluating the patient with suspected malignancy of the gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of the pancreas. Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice.

  • Biliary Radionuclide Scanning (Hida Scan)Biliary scintigraphy provides a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information. The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis.The sensitivity and specificity for the diagnosis are about 95% each. Biliary leaks as a complication of surgery of the gallbladder or the biliary tree can be confirmed and frequently localized by biliary scintigraphy.

  • Percutaneous Transhepatic Cholangiographyhas little role in the management of patients with uncomplicated gallstone disease. useful in patients with bile duct strictures and tumors, as it defines the anatomy of the biliary tree proximal to the affected segment. complications are bleeding, cholangitis, bile leak, and other catheter-related problems.

  • Magnetic Resonance ImagingIt has a sensitivity and specificity of 95 and 89%, respectively, at detecting choledocholithiasis. MRI with magnetic resonance cholangiopancreatography (MRCP) offers a single noninvasive test for the diagnosis of biliary tract and pancreatic diseaseEndoscopic Retrograde Cholangiography and Endoscopic Ultrasound: This test is rarely needed for uncomplicated gallstone disease, but for stones in the common bile duct, in particular, when associated with obstructive jaundice, cholangitis, or gallstone pancreatitis, ERC is the diagnostic and often therapeutic procedure of choice.Complications of diagnostic ERC include pancreatitis and cholangitis, and occur in up to 5% of patients.

  • Gallstone DiseasePrevalence and Incidence :Gallstone disease is one of the most common problems affecting the digestive tract (Autopsy reports have shown a prevalence of gallstones from 11 to 36%.).The prevalence of gallstones is related to many factors:age, gender, and ethnic backgroundObesity, pregnancy, dietary factors,Crohn's disease, terminal ileal resection, gastric surgeryhereditary spherocytosis, sickle cell disease, and thalassemia

  • Women are three times more likely to develop gallstones than men.first-degree relatives of patients with gallstones have a twofold greater prevalence.Most patients will remain asymptomatic from their gallstones throughout life. For unknown reasons, some patients progress to a symptomatic stage, with biliary colic caused by a stone obstructing the cystic duct.Approximately 3% of asymptomatic individuals become symptomatic per year (i.e., develop biliary colic).Complicated gallstone disease develops in 3 to 5% of symptomatic patients per year.

  • Over a 20-year period, about two thirds of asymptomatic patients with gallstones remain symptom free.prophylactic cholecystectomy in asymptomatic persons with gallstones is rarely indicated.For elderly patients with diabetes, and in populations with increased risk of gallbladder cancer, a prophylactic cholecystectomy may be advisable.Porcelain gallbladder is an absolute indication for cholecystectomy.

  • Gallstone Formation;Gallstones form as a result of solids settling out of solution.The major organic solutes in bile are bilirubin, bile salts, phospholipids, and cholesterol.Gallstones are classified by their cholesterol content as either cholesterol stones or pigment stones.In Western countries, about 80% of gallstones are cholesterol stones and about 15 to 20% are black pigment stones. Brown pigment stones account for only a small percentageBoth types of pigment stones are more common in Asia.

  • Cholesterol Stones Pure cholesterol stones are uncommon and account for 70% cholesterol by weight. usually multiple, of variable size. Colors range from whitish yellow and green to black.Most cholesterol stones are radiolucent;
  • Pigment Stones Pigment stones contain
  • Symptomatic GallstonesChronic Cholecystitis (Biliary Colic) :About two thirds of patients with gallstone disease present with chronic cholecystitischaracterized by recurrent attacks of pain( biliary colic). develops when a stone obstructs the cystic ductThe pathologic changes, which often do not correlate well with symptoms,vary from an apparently normal gallbladder with minor chronic inflammation in the mucosa, to a shrunken, nonfunctioning gallbladder with gross transmural fibrosis and adhesions to nearby structures.The mucosa is initially normal or hypertrophied, but later becomes atrophied, with the epithelium protruding into the muscle coat, leading to the formation of the so-called Aschoff-Rokitansky sinuses

  • Clinical PresentationTypical presentation:The chief symptom is pain (constant and increases in severity over the first half hour or so and typically lasts 1 to 5 hours ). located in the epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapulaeThe pain is severe and comes on abruptly, typically during the night or after a fatty mealThe pain is episodic. The patient suffers discrete attacks of pain, between which they feel well.Physical examination may reveal mild right upper quadrant tenderness during an episode of pain. If the patient is pain free, the physical examination is usually unremarkableLaboratory values, such as WBC count and liver function tests, are usually normal