1. GALL BLADER & BILIARY TREE
DISEASES
BY TEMESGEN G/MARIAM(MD)
FEB.04/2013

2. Lecture Out line
 Anatomy & Physiologic highlights
 Clinical presentation of a patient with biliary ds
 Specific disease entities :
 CHOLELITHIASIS
 Acute cholecystitis
 Obstructive jaundice
 Gall bladder Ca

3. Anatomy OF THE Gallbladder
 The gallbladder is a pear-
shaped sac
 7 to 10 cm long, with an
average capacity of
30 to 50 Ml
 It has four parts

4. Anatomy of The Bile Ducts
• Cystic duct
Tortouse course,acute
angle of insertion
≈2-4cm long,3mm wide
•CHD
•CBD
•Variable length
•Upto 1cm in diameter

5. BLOOD SUPPLY

6. Anomalies
 The 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, be rudimentary, have anomalous forms, or be
duplicated

8. Physiologic highlights

9. • Storage
• Concentration (reabsoption )
• Secretion of mucus
•coordinated motor response of gallbladder
contraction and sphincter of Oddi
relaxation mediated by CCK

10. Clinical presentation of a patient with
biliary ds
 Pain

typical
 (RUQ,epigastric)
 Biliary colic
 Jaundice
 Associated symptoms
 Fever,chills & rigor
 Tightness/dullness
 Urine/stool discoloration
 Radiation
 pruritus
 Nausea/vomiting
 Atypical
 Indigestion,flatulence
 Dyspepsia,retrostern
al pain
 Constitutional symptoms
 Wt loss,anorexia,back pain

11. CHOLELITHIASIS/GALL STONE
DS
 Epidemiology
 one of the most common problems affecting the digestive
tract
 Varies depending on
 Age
 Sex
 Stone types
 Overall prevalence
 Western
 Asia
 Africa

14. Risk factors/etiology
Major risk factors for pigmented stones
• Infection
• Sickle cell anemia
• Hemolysis
• Stasis
• Parasitic infestation
5f:Fat, fertile,
flatulent, female of
fourty

15. Pathogenesis/ pathophysiology
 Super saturation of bile
 Drop in phospholipid
 Decrease in bile acid pool
 Increase cholesterol secretion
 Biliary stasis(drainage)
 Biliary dyskinesia/motility,TV,DM,pregnancy…
 Infection
 Predisposing factors

16. Composition of Bile

17.  Impaired GB function

Supersaturated bile
•
Age
•
Sex
• Absorption
•
Genetics
• Excretion
•
Obesity
•
Diet
• Emptying
Absorption/EHC
Nucleating agents
•Mucus
•Glycoprotein
•Infection
•Deoxycholate
•SBS
•Fecal flora
•Ileal resection

19. Clinical presentation of uncomplicated
gallstone
 Silent/incidental finding
 Typical /classical





Biliay “colic”
RUQ/ epigastic
post prandial (50%)
+ nausea/vomiting
Radiation to
 Atypical




Dyspepsia/indigestion
Flatulence
Belching
Atypical sites(retrosternal)

20.  Physical Examination
 Ultrasound
 No remarkable
 Most important modality
 May mild tenderness in
 First line of investigation
RUQ/epigastric area
 Laboratory
 CBC
 LFT
 Sensitive/specific()
 Superior to CT scan
 Characteristic finding
 Echogenic
 Acoustic shadow
 Move when pt change
position
 May
 Polp/stone in the cystic duct
 Stone<5mm ,sluge
 Obese,ascitic,bowel gas

21. Ultrasound pictures

22. Management
 Surgery the almost only option(cholecystectomy)
 Based on ultrasound finding & symptoms four categories
 Category I = stone+ asymptomatic
 Category II = stone+ typical symptoms
 Category III = stone+ atypical symptoms
 Category IV =no stone + typical symptoms

23. Category I
 Indication for surgery
 Porcelain
 Total parenteral nutrition
 Large stone(> 2.5cm)
 GB polp > 1cm
 Chronic
 No immediate access to
immunosuppresion
 Sickle cell anemia
 Bariatic surgery
 Small multiple stone
 Child
 ?DM
health care facility
 Incidental(intra operative)
 Non functional GB

24.  Category II
 Category III
 cholecystectomy
 Other causes IBS , PUD ,
 Good outcome (all
Diverticulosis , hiatal
hernia,…)should be R/o
 Endoscopic evaluation
 What if the service is not
there?
 Only sub groug of patient
relieved from their
symptoms after
cholecystectomy
relieved from their
symptom)

25. Category IV
 Further work for underlying causes
•Missed stone
•Sluge
•Biliary diskinesia
•choledocholelithiasis

26. Acute cholecystitis
 Secondary to gallstones in 90 to 95% of cases
 Acute acalculous cholecystitis
 In <1% of acute cholecystitis, the cause is a tumor
obstructing the cystic duct

27. Pathophysiology
 Impaction of stone at the
cystic duct/ hartman’s
pouch
 Chemical inflammation
 Secondary bacterial
infection

28. Bacteriologic profiles
 Secondary bacterial contamination is
documented in 15 to 30%

29. Clinical presentation
 Abdominal pain
 Similar to biliary colic but longer duration/severity
(greater than four to six hours)
 Fever
 Nausea/vomiting
 Physical exam
 GA: ill appearing, and lie still on the examining table
 Vital signs: febrile, and tachycardic
 RUQ tenderness/ Murphy sign

30. Investigation
 CBC
 Mild leukocytosis
 (15x103)
 WBC > 18x103
 Ultrasound
 Sensitivity/specificity(80)
 Evidences
 stone
 Empyema
 Thicken (edematous)wall
 perforationm
 Perichlecystic fluid
 Mild elevation of LFT
 bil , alk phospha
 Sonographic murphy sign
 HIDA (97 and 90%)
 highly sensitive and specific
for acute cholecystitis

32. Treament
 Conservative followed by interval /delayed
cholecystectomy
 Intravenous hydration and correction of any associated
electrolyte disorders
 NPO/NGT/ maintaince fluid
 ANALGESIC
 Antibiotic
 Choice/duration/route of administration
 Monitor response
 Early cholecystectomy

33. Obstructive jaundice
 Due to obstruction to the excretion of bilirubin
 Confirmation that is obstructive is essential
 Most frequent causes varies depending on
age,geography,sex,..
 Choledocholethiasis is most common(benign lesion) in
many countries
 Pancreatic head tumor commonest malignant

34. Classification of causes
I.
Excessive production (hemolytic jaundice):-
A. Inherited hemolytic anemia's
B. Acquired hemolytic anemia's
II.
Impaired transport to liver:-
-Gilbert’s syndrome
III.
Impaired hepatic conjugation:-
A. Inborn errors
B. Immaturity of enzymes
IV Impaired excretion(hepatocellular jaundice)
A. Acquired liver diseases
B.Intrahepatic cholestasis

35. V. Bile duct obstruction(obstructive jaundi)
A. Extra hepatic:1.Stone
2.Neoplasms
3.Stricture
4.Atresia,ect
B. Intrahepatic

37.  Pain similar to biliary colic
 Associated symptoms: fever/chills , pruritus , darken
urine , pale/ clay colored stool
 Physical exam
 No remarkable finding
 Jaundice,
 Vital signs
 Scratch marks
 Tenderness
 Corvesouires law
 Stigma for malignancy/liver disease

38. Laboratory

39. Imaging
 Abdominal ultrasound
 Important first line
 Sensitivity varies(55-91%)
 CBD Dilation > site> causes
 Combination of clinical ,biochemical & U/S
 Jaundice + biliary + gall stone + increased LFTS +
Dilated CBD
 As the No of criteria increases probability of stone in
the CBD increases

40. Other imaging (not routinely
used)
 MRCP
 ERCP
 Highly sensitive &
specific
 PTC
 EUS
 Helical CT scan
 HIDA

41. Management
 Endoscopic removal/drainage(ERCP
 Open/lap
 Choledochotomy
 Spincterotomy/ plasty
 Drainage
 Choledochduedunostomy
 choledochjejunostomy

42. Candidates for drainage
 Irremovable, impacted, distal CBD stones
 Markedly dilated CBD, >1.5cm
 Distal duct obstruction from tumor or
stricture
 Recurrence after previous duct exploration

43. Gall bladder Ca
 Incidence
–Un common (2-3 % of GI malignancies)
–Incidence varies
–Ethnicity , geographic
–High incidence in Israel ,chili ,native Americans
–M:F 1:3
–1% of cholecystectomy for gall stone.
–>75% of cases> 60 years

44. Risk factors
 Cholithiasis is the most important risk factor for




gallbladder carcinoma, and up to 95% of patients
with carcinoma of the gallbladder have gallstones
Porcelain gall bladder
Primary sclerosing cholangitis
Chledochal cyst
Association with gall stone

45. Pathology
 > (90%) adenocarcinoma
– Scirrhous (60%)
– Papillary(25%)
– Mucoid(15%)
 Spread
 Hemato
 Lymphatic
 direct

46.  Table 54-2 -- TNM Staging for Gallbladder Cancer
•T
–T1 lamina propria (T1a) or muscular (T1b) layer
–T2 perimuscular connective tissue, no extension beyond
the serosa or into the liver
–T3 perforates the serosa (visceral peritoneum) and/or
directly invades into liver and/or one other adjacent organ
or structure such as the stomach, duodenum, colon,
pancreas, omentum, or extrahepatic bile ducts
–T4 main portal vein or hepatic artery or invades multiple
extrahepatic organs and/or structures
•N
–N0 No lymph node metastases
–N1 Regional lymph node metastases
•M
–M0 No distant metastases
–M1 Distant metastases

47. Stage Grouping
 IA T1 N0 M0
 IB T2 N0 M0
 IIA T3 N0 M0
 IIB T1 N1 M0
 T2 N1 M0
 T3 N1 M0
 III T4 Any N M0
 IV Any T Any N M1

48. clinical features

49. Diagnostic work up
 Management/progosis
 Diagnostic work up
 •Abdominal U/S
 •CT SCAN
 •MRI/MRC
 •ERCP
•Surgery the only hope
•Incidental cholecystectomy
–Early stage , better outcome
– The 5-year survival rate of
all patients with gallbladder
cancer is <5%

50. THANK
U

51. References
 Schwartz's Principles of Surgery,9th ed
 Sabiston Textbook of Surgery, 18th ed
 Maingot's Abdominal Operations
 Upto date,18.2