GALLBLADDER

Pear shape sac 7-10 cm long with an average capacity

of 30-50 ml
Divided into 4 anatomic areas: the fundus, the
corpus(body), infundibulum and the neck.
Blood supply: cystic artery- branch of the right hepatic
artery(90%)
The course of cystic artery may vary, but it nearly
always is found within the hepatocystic triangle
bounded by cystic duct, common hepatic duct and the
liver margin.
Main function is to concentrate and store hepatic bile
and deliver bile into the duodenum in response to meal.

THE BILE DUCTS

The extrahepatic ducts consist of the right

and left hepatic ducts, common hepatic duct,
the cystic duct, and the common bile duct.
The common hepatic duct is 1-4 cm in length
and has a diameter of approximately 4 mm.
It lies in front of the portal vein and to the
right hepatic artery.
The common hepatic duct is joined at an
acute angle by the cystic duct to form the
common bile duct.
The common bile duct is about 7-11 cm in
length and 5-10 mm in diameter.

BILE FORMATION AND COMPOSITION

The normal adult consuming an average diet produces

within the liver 500-1000 ml of bile per day. The
secretion of bile is responsive to neurogenic, humoral,
and chemical stimuli.
Bile is mainly composed of water, electrolytes bile salts,
proteins, lipid and bile pigments
The primary bile salts: cholate and chenodeoxycholate ,
are synthesized in the liver from cholesterol, conjugated
with taurine and glycine, and act within the bile as
anions that are balanced by sodium.
80% of conjugated bile acids are adsorbed in the
terminal ileum and the remainder by the gut bacteria
5% is excreted in the stool.

DIAGNOSTIC STUDIES

Blood test: complete blood count and liver function test

Ultrasonography: non invasive, painless and does not
submit patient to radiation.
Oral cholecystography
Biliary radionuclide scanning(HIDA Scan) : provides a non
invasive evaluation of the liver, gallbladder, bile ducts,
and duodenum with both anatomical and functional
information.
Computed tomography: define the course and status of
extrahepatic biliary tree and adjacent structures
Endoscopic retrograde cholangoigraphy and endoscopic
ultrasound: direct visualization of the ampullary region
and direct access to distal common bile duct with
possibility of therapeutic intervention.
Magnetic resonance imaging

GALLSTONE DISEASE

One of the most common problem

affecting the digestive tract
Prevalence: age, gender and ethnic
background.
Risk factors: obesity, pregnancy, dietary
factors with women more affected than
men, and first degree relatives of
patients with gallstones have a twofold
greater prevalence

GALLSTONE FORMATION

Gallstone form as a result of solids settling in a solution. The

major organic solutes in bile are bilirubin, bile salts,
phospolipids and cholesterol.
Classified by their cholesterol content as either cholesterol
stones or pigment stones.
Cholesterol stones: uncommon, <10%., most are radiolucent
and <10% are radiopaque.
Pigment stones contains less than 20% cholesterol and are
dark because of the presence of calcium bilirubinate.
Black pigment stones are usually small, brittle, black and
sometimes spiculated. They are formed by supersaturation
of Ca bilirubinate,carbonate,PO4.
Brown stones are usually less than 1 cm in diameter,
brownish yellow, soft, and often mushy. Form either in the
GB or in the bile ducts usually secondary to bacterial
infection and bile stasis

SYMPTOMATIC GALLSTONES

Chronic cholecystitis- about 2/3 of patient with

gallstone disease present with chronic
cholecystitis characterized by recurrent attacks of
pain
Clinical presentation: chief symptom is pain which
develops when stone obstruct the cystic duct
which is constant and increases in severity over
the first half hour and typically last 1-5 hrs.
Diagnosis: depends on the presence of typical
symptoms and demonstrations of stones on
diagnostic imaging.
Management: surgery

Acute cholecystitis: secondary to gallstone in

90-95% of cases, in <1%, it is caused by tumor
obstructing the cystic duct.
Clinical manifestation: patient often complain
of pain in the right upper quadrant area or
epigastrium, fever,anorexia,nausea, vomiting.
Mild to moderate leukocytosis.
Diagnosis: ultrasonography is the most useful
radiologic test
Management: cholecystectomy

Choledocholithiasis: common bile duct stones may be small or large, single

or multiple and are found in 6-12% of patients with stones in the gallbladder.
Majority of ductal stones are formed within the gallbladder and migrate
down the cystic duct to the common bile duct.
Endoscopic cholangiography is the gold standard for diagnosing common
bile duct stones with distinct advantage of providing a therapeutic option at
the time of diagnosis.
Treatment: For patients with symptomatic gallstones and suspected CBD
stones, either preoperative endoscopic cholangiography or an
intraoperative cholangiogram will document the bile duct stones.
Retained or recurrent stones following cholecystectomy are best treated
endoscopically
Stones diagnosed shortly after cholecystectomy are classified as retained
stones while recurrent stones are diagnosed after months or years later.

Cholangitis: is an ascending bacterial infection in association with

partial or complete obstruction of the bile ducts.
Gallstones are the most common cause of obstruction in
cholangitis and the most common organisms cultured include:
E.coli, klebsiella, Strep. pneumoniae and B. fragilis.
Clinical presentation: fever, epigastric or right upper quadrant
pain and jaundice, a classic symptoms known as charcots triad
present in about 2/3 of patients and may progress with septicemia
and disorientation known as Reynolds pentad.
Diagnosis and management: Leukocytosis, hyperbilirubinemia and
elevation of alkaline phosphatase and transaminase are common.
The initial treatment includes IV antibiotics and fluid ressucitation
and patients may require ICU monitoring and vasopressor support.
Bilary decompression may be accomplished endoscopically via
percutaneous transhepatic route or surgically.
mortality rate is approximately 5%.

Cholangiohepatitis: also known as

recurrent pyogenic cholangitis.
Affects both sexes equally and occurs in
most frequently in the 3rd and 4th decades
of life and is caused by bacterial
contamination of the biliary tree,and
often is associated with biliary parasites.
Patients usually presents with pain in the
right upper quadrant and epigastrium,
fever and jaundice.

OPERATIVE INTERVENTIONS

Cholecystostomy: decompresses and drains the

distended, inflammed, hydropic, or purulent GB. It
is applicable if patients is not fit to tolerate an
abdominal operation.
Cholecystectomy: open or laparoscopic approach
Symptomatic gallstone are the main indication for
cholecystectomy.
In elective setting, conversion for open procedure
is needed in about 5% of patients and the
mortality rate for laparoscopic cholecystectomy is
about 0.1%.
Choledochal exploration