Stones of the gall bladder :
Objectives:
1-Anatomy & function.
2-pathogenisis.
3-Riskfactors.
4-Morphology.
5-Clinical picture.
6-Complications.
Anatomy:
**The gall bladder is a pear shaped organ measuring about 9 cm in length and has a capacity of approximately 50 ml.**located in the right upper abdominal quadrant. Hangs on it’s bed on the visceral surface of the liver with neck lying superiorly & fundus inferiorly .
**composed of :1-Fundus.2-Body.3-Neck that tapers into cystic duct which combines with the CHD forming the CBD which enters the second part of the duodenum.
The wall is composed of :
1- mucosal layer: of columnar smooth epithelium which becomes larger and more numerous at the neck.
2- smooth muscle layer of: inner longitudinal-middle oblique-outer circular.
3- perimuscular layer :of fibrous connective tissue.
4-Serosal layer :incomplete
Functions:
Storage and concentration of bile secreted by the liver and deliver it into the intestine for digestion and absorption of fat.
n.
incidence: affects 10-20% of adult population.
Types:
1-Cholesterol stones : more than 80%A- pure: rare.B-mixed : most common.2-pigment stones: 20%... due to excess circulating bile pigments eg. Chronic hemolytic anemia.
Pathogenesis:
1-cholesterolsupersaturation in bile.
2-Crystal nucleation. 3-Stone growth.
-Bile is composed of bile salts, phospholipids, cholesterol.
- If there is imbalance between those components cholesterol will precipitate out of solution (cholesterol super-saturation) .
- -GB hypo motility promotes formation of mucus sludge and nucleation of cholesterol into filaments.
- this hyper secretion of mucus traps the filaments permitting accretion into stones.
Risk factors:
Genetic: more in the first degree relatives.
Sex: females are twice> the males .
Age: more than 40.
Diet: obesity –lack of dietary fibers.
Hormonal: pregnancy & OCPs increase the hepatic cholesterol uptake and synthesis.
Drugs: treatment by hypocholesterolemic agents .
GIT diseases e.g. crhon’s disease, ilial resection, ilial bypass are associated with increase in hepatic cholesterol uptake.
hemolytic anemia ( pigment stones only):increase content of un conjugated bilirubin in bile.
Geographically: more in western world.
So…it is a disease of 5 f: Fatty ,Ferile ,Female, in their Fourtiesor Fifties.
Cholesterol stones Pigment stones
1- pure cholesterol stones:Solitary, oval, large, smooth, yellow
whiteC/S.:radiating glistening crystals.
2-Mixed: multiple faceted variable sized
C/S :laminated alternating dark pigment layer and and pale white layer.
Multiple ,small jet black,mullberry shaped,Gb is healthy, not inflammed and has normal thin wall
C/s:soft black(radioopaque)
Morphology:
Clinical picture:
80% are asymptomatic, sometimes, mild dyspepsia and constant or colicky striking biliary pain.
Symptomatic gallbladder disease develop only when complications develop.
complications:
1- Acute and chronic cholecystitis. 2-Cystic duct obstuction at the neck leading to mucocele or
empyema. 3-CBD obsruction …ascending cholangitis or acute pancreatitis. 4-Fistula formation and intestinal obstruction ( gall stone ileus). 5- Cancer of the gallbladder.
Mucocele of the GBMucocele of GB by US
Cholecystitis :
Definition: inflammmation of the gallbladder.it may be:1-Acute. 2-Chronic. 3-Acute on top of chronic.
I-Acute cholecystitis
In many ways ,similar to acute appendicitis, condition begins with obstruction leading to inflammation.
Etiopathogenisis: based on initial mechanism, occurs in two types of situations:1-Acute calculus cholecystitis.2-Acute acalulus cholecystitis.
Pathogenisis :
A-Acute calculus: is due to obstruction of the gall bladder neck or the cystic duct by a gall stone ,causing obstruction of the bile outflow which in turn leads to disruption of the protective glycoprotein layer, the inflammation is :
Initially due to release of prostaglandins from the wall.
Later..by 2ry bacterial infection chiefly E.Coli.
B-Acute acalculus cholecystitis
10% of cases.
Here , inflammation is due to dehydration, Gallbladder stasis, vascular compromise & bacterial contamination by variety of causes:
1-Previoys non biliary surgery.
2-Burns.
3-Multiple injuries.
4-Recent childbirth.
5- Severe sepsis.
6-Torsion of the gallbladder.
Clinical picture:
• 1-Severe upper abdominal pain radiating to the right shoulder with: guarding & tender palpable gallbladder.
2-Jaundice,fever, leucocytosis, are generally presentwhen CBD is obstructed.
• N.B. :In acute acalcular ,the same except that the symptoms are masked by the severe clinical condition.
• course:
A mild attack subsides spontainously over 1- 10 days,while 25 %require cholecystectomy
Morphology:
Except for the presence or absence of calculi, the 2 forms are morphologically similar:
1-Gross picture: GB is distended & tense,theserosal surface is coated with fibrinousexudate,lumen is filled with pus mixed with green bile.
2-M\p: the wall shows marked inflammatory edema, congestion and exudation, may be frank abscesses in the wall &gangrenous necrosis with rupture of the peritoneal cavity.
II- Chronic cholecystitis
The commonest type of clinical GB disease.
Pathogenisis:
It is a GB inflammation that has lasted along time. it almost always results from gall stones and from prior attacks of acute cholecystitis. Sometimes , it occurs de novo. the cause is super saturation of bile.
Morphology:
1-Gross picture:
GB is usually contracted but may be normal or enlarged with the wall thickened.
On cross section, opaque grey-white appearance.
2-Microscopic picture:
Thickened and congested mucosa.
Variable degree of chronic inflammatory reaction consisting of lymphocytes, plasma cells and microphages.
In severe cases: Sub epithelial and Sub serosal
fibrosis and mononuclear cell infiltration .
Clinical picture
Recurant attacks of constant or colicky dull aching pain in the right hypo-chondrium or the epigastrium.
Nausea and vomating .
Intolerance to fatty meals .
complications
Empyema , cholangitis, sepsis
Perforation due to gangrenous necrosis leading to local abscess formation or diffuse peritonitis
Intestinal fistula
Aggravation of the pre-existing medical illness.
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