gall bladder

5/7/2018 Gall Bladder

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Gall Bladder & BD short note by S.Wichien (SNG KKU)Anatomy-pear shape-30-50 cc--obstruct-- 300 cc-fundus,body,infundi/hartman,neck-neck--spiral of heister-lack rn.mucosa/subrnucosa-vein--direct to liver-n-vaqus/celiac plexus

Physiology1.Bile-500-1000 ml-vagus---ve splanchnic--+veBile salt-excrete by hepatocyte-80%absorb in ileum-enterohepatic circu--portal vein

Cystic a-calot triangle-cystic d--CHO--liver margin-at neck--ant+post divisionVariation1.RHA--80-90%2.replaced RHA--10%3.two cystic a--RHA+LHA or CHA4.two cystic a--RHA5.cystic a ant to CBOCystic duct variantl.Iow jxn 2.hi jxn 3.adhere CHO4.drain to RHO 5.long duct to duo6.no cystic d 7.post to CHO8.across ant CHO to post CHO

2.FunctionAbsorption-fasting--bile is stored in GB-absorption-dec pressureSecretion1.mucous glycoprotein:protect mucosa:obstr--colorless or white bile2.H+iron:dec bile pH:promote ca solu--prevent ca saltCCK-most potent GB contraction-relax sphincter of oddi-is mediated by vagal n-vagotomy--dec CCKVIP/somatostatin-GB relaxation-somatostati noma-GS

CBOCBO+PO-->ampulla of vater70%--join outside duodenum20%--join within duodenum10%--separate openingArtery to CBO-GOA+RHA-rnedial+lateral wall CBO--3,9 0 clockCHO-4 mm-rt ant HO-segment 5,8-rt ant HO-segment 6,7

Imagingt.u/s2.oral cholecystography-oral radiopaque-absorb/excrete by liver-GS--filling defect3.biliary radionuclide scan-HIDA (jx), DISIDA-Tc is cleared by kupffer cell-most sensitive dx ACOx-AC--non visual GB/BO-ca ampulla--no fill duodenum-bile leak4.PTC-dx--cholangiogram-Tx--biliary drain/stent placement5.CT, MRI, ERCP6.EUS

Anomaly1.congenital absence-rare-tlt: intrahepa GB, anomalous position2.duplicate GB2 GB+ 2cystic d2 GB+ 2cystic d merge before CBO3.Lt side GB-cystic d to It HO/CBO4.small duct of Luschka-drain from liver direct to GB-bile leak after cholecystectomy5.accessory rt HO--5% of case


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Gall Bladder & BD short note by S.Wichien (SNG KKU)Gall stone-women>men 3x-3% of asymp = symptom/year3-5% of symp = c/p GS/year

GSsx1.cholecystostomy-us guide drainage--pigtail cath-pt not fit to open sx-LC--Iater

Riskobesity,pregnancy,dietary,crohn dz,terminal ileal resection,gastric sx,HS,sickle cell anemia, thalassemia

Prophylactic cholecystectomyno in asymp.GSl.elderly pt+DM2.inc risk of ca

2.LC-Tx of choice for symp GS-conversion rate:elective--5% emer--10-30%-mortality 0.1%Absolute C/I-uncontrol coagulopathy-end stage liver dz-severe COPD, CHF EF


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Acute cholecystitis-2nd to GS in 90-95% of case-GBwall thickening/reddish-mucosa--hyperemia, patchy necrosis-subserosal hmg-pericholecystic fluid-emphysematous GB:2bact infect (gas forming organism)-gangrenous--empyema--perforate-cholecystoenteric fistula

Clinical-80%have chronic cholecystitis hx-biliary colic pain but not subside-fever,n/v-Murphy sign +ve-mild elevate bilirubin 4)-OM,elderly : subtle presentationOOX-PU,pancreatitis,appendicitis,Hepatitis perihepatitis (Fitz Hughe- Curtis)MI,pneumonia,pleuritisOxu/s-sen/spec 95%-most useful dxBiliary radionuclide scan-lack of filling of GB after 4hr-normal HIDA = can excludeCT scan-less sen than u/sTxEarly cholecystectomy-in 2-3d-prefer> interval cholecystectomy-LC is procedure of choiceInterval cholecystectomy-present late 3-4d-20% fail med--required OR-2mo later--LC can be attemptPecutaneous cholecystostomy-under LA, unfit pt for sxAcute cholecystitis in pregnancy1st trimester-conservative-7LC 2nd trimester2nd trimester-LC3rd trimester-conservative-7LC post labor

Gall Bladder & BD short note by S.Wichien (SNG KKU)Acute acalculous cholecystitis-critical ill pt in ICU-pt on parenteral nutrition csevere burn,sepsis,major OR,multiple trauma, MOO-factor--bile stasis/ischemia-edema of serosa and muscular layer-patchy thrombosis of arteriole/venuleSISAlert pt-as calculous cholecystitisSedated pt-fever-leukocytosis-elevate ALP,biliIxu/s=ix of choice-distend GB-thick wall-biliary sludge-pericholecystic fluidTx-urgent intervention1.percu cholecystostomy-u/s.cr guide-Tx of choice in unfit sx pt-if uncertain dx+dx+ Tx procedure2.other steps-not improve--open cholecystostomy

GS pancreatitisl.mild GSpancreatitis-Ranson2-Tx-aggressive Tx in ICU-if improve-as 1Role of urgent ERCP+ESl.severe GS pancreatitis+Of/cholanqitis2.within 72 hr3.hi-risk


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Mirizzi syndromeTypel-impact stone at Hartmann pouch-obstruct CHD-7jx-open cholecystectomy (fundus downward)Type2-stone erode CHD-CHD-GB fistula-partial cholecystectomy then:small fistula- T tube:Iarge fistula-Roux en Y CDJ*should frozen fistula rIo ca GB*DDx aerobilial.GS ileus2.Mirizzi synd T23.previous EST/biliary bypass

Gall stone ileus-elderly women-small bowel obstruction-IC valve-aerobiliaTxTwo stage operationl.EL-midline incision-milked back GS to uneffected segment-remove stone2.interval cholecystectomy+closed fistula

*Post cholecystectomy syndromel.not relief symptom-other pathology2.retained CBD stone3.long cystic duct stump> lcm-can stone4.bile duct injS.malignancy

Gall Bladder & BD short note by S.Wichien (SNG KKU)Chronic cholecystitisMucosa-initial--normal/hypertrophylater--atrophy-epithe protuding into muscle coat-->Aschoff-Rokitansky sinusCholesterolosis-accum chol in macrophage in mucosa-strawberry GBAdenomyomatosis-cholecystitis glandularis proliferan-hypertrophic smooth m.-ingrowth of mucosal gl into m.(epi.sinus formation)Clinical-GS pain=constant pain--l-S hr-epigastrium,RUQ-radiate to rt upper back/btw scapular-night,after fatty meal-nlv, bloating-mild tender RUQduring pain(if no pain PE:normal)-impact stone result in hydrop GB:bile--absorb, GB--secrete mucus

Dx-u/s = std testTx-symtomatic GS=elective LC-DM c symp GS : cholecystectomy-pregnant c symp GS can safely LCduring 2nd trimester


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CBO stonelstone-brown pigment type-asso bile stasis/infection-biliary stricture,tumor,stoneSaharia criterial.previous cholecystectomy2.no biliary symptoms>2yr3.brown,soft stone4.no long cystic duct2stone-6% cholecystectomy-CBD stoneClinical-silent-obstruction: complete/incomplete-cholangitis-GS pancreatitis-intermittent jx : ball valveIxu/s-dilate CBD > Smm in pt c GS,jxMRIEndoscopic cholangiography-gold std dx+can therapeuticEUS-good as ERCP,can't TxTxl.dx pre-op-ERCPc EST-->LC2.dx intra-op LC-lap.CBD exploration (same d)-fail--open choledochotomy+ T tube-ERCP,EST(next d)3.dx post op-T tube-wait 4-6wk-Dormia basket-no T tube-ERCP+ES*CDD or Roux en Y CDJ-impact stone in ampulla+CBD dilate (> l.Scm)*Pt> 70 c CBD stone-endoscopic Tx*Transduodenal sphincterotomy-impact/recurrent/rnulti stone-CBD


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Gall Bladder & BD short note by S.Wichien (SNG KKU)

IHD stone-hepatolithiasis-recurrent pyogenic cholangitis-asian, RUQ pain-CHCA 2-10%-follow up ca 19-9Sxl.IHD stone-1st lt/rt branchNo stricture-low risk-LC+LCBDE or OCBDE-hi risk-ERCP2.hilar stricture/recurrence case-Hepaticojeju nostomy-dimater 2.5 cm

Choledochal cyst-congen dilate of biliary tree-rare-fernale> male 3-8x-1/2 present at adults-causes = unknown-risk CHCA 15%Anomaly of pancreaticobiliary d jxn-APBDJ-90%-PD join CBD > 1 cm prox to ampulla-may reflux pancreatic secrete to bile

2.IHD stone-2nd,3rd branchIt lobe-lt hepatectomyBilat lobe (Lt>rt)-lt hepatectomy-aware LFR-dilate rt duct+balloonBilat lobe (rtxlt)-rt hepatectomy-dilate It duct+balloonHi risk-PTC+dilate+remove stone

SIS-jx-cholangitis-1/2=classic symptom--pain,jx,mass5 types- Todani classificationType1-fusiform of EHBD=most common-cyst excision+Roux en Y HJ-if severe adhere PV/HA:open cyst+dissect remove mucosa+bypassType2-saccular of EHBD-cyst excision+ T tube or bypassType3-choledochocele-duodenotorny+cyst excision-identify ampulla of vater--sphincteroplastyType4a-multiple cyst (EHBD+IHBD)Type4b-multiple cyst (IHBD)-as T1-involve one lobe--hepatectomyTypeS-calori disease-involve one lobe-hepatectomy-involve both lobe-OL T*don't bypass but not cyst excision


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Gall Bladder & BD short note by S.Wichien (SNG KKU)EHBD injCause1.iatrogenic--major-LC--0.3-0.5%-OC--0.1-0.2%-mobilize duodenum in gastrec-dissect hepatic hilum in hepatec2.trauma--rare

Strasburg ClassificationA-cystic duct stump leak/d of LuschkaTx--ERCP+stent, percu.biliary stentB-occlusion aberrant RHDTx-not sxC-transect wo ligate aberrant RHDD-Iateral inj major bile ductE-circum inj major bile duct

Suspect BD inj during cholecystectomy-cholangiogram-check whole biliary syst fill contrastPresent25% dx in operation-intraop bile leak-abnormal cholangiogram>50% in 1st mo post op-recurrent cholangitis

TxDuring cholecystectomyl.Iateral inj 30%-Roux en Y HJ3.complete transect CBD- Roux en Y HJ4.isolated HD inj-3mm/drain~2 segment-Roux en Y HJ5.Distal CBD inj-rare-choledochoduodenostomy6.Cystic duct leak-percu drainage of intraabdo fluid+Endoscopic biliary stent

DxEarly p/o period-progress LFT-pain, feverIxUS,CT-collectionn(biloma) in GBarea-fluid in peritoneumHIDA scan-site of bile leakPTC-in dilate IHD-retain cath/stentERC-stent across strictureMRC

Early post op-often detect d 7-10-u/s assess collection-percu drainage-control leakage-locate leakage site:MRCP:ERCP+biliary stentLate post op-bile duct stricture--OJ


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Gall Bladder & BD short note by S.Wichien (SNG KKU)Bile duct strictureCause-operative inj-LC (most common)-fibrosis--chronic pancreatitis-CBD stone-acute cholangitis-mirizzi synd-sclerosing cholangitis-stricture of biliary-enteric anas

Sclerosing cholangitis-uncommon dz-inflam stricture--IHBD+EHBD-progressive dz-if from stone,ac.cholangitis,sx-->2sclerosing cirrhosis-10-20%--CHCA-male 2x than female-30-45 yr

SIS-cholangitis episode-may jx without infection

lsclerosing cholangitis-unknown cause-2/3 asso ulcerative colitis-other=Riedel thyroiditis,retro.fibrosis

IxU/S,CT,MRC--dilate proximal to stricturePTC--proximal partERC--distal part

Pathogenesis-autoimmune-chronic bact,viral infection-toxic rxn-genetic factorismuth classification

Tl-bifurcate >2cmT2-bifurcate


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Gall Bladder & BD short note by S.Wichien (SNG KKU)Ca gall bladder-rare, aggressive tumor-poor prog--overall syr = 5%-1% incidental in cholecystectomy-95% have GS--most import risk f-20yr risk of ca in pt c GS 3cm--risk lOx-polyp >lcm-procelain GB--20% is ca:should remove,even asymp:strongest risk factor-choledochal cyst-sclerosing cholangitis,-anomalous pancreaticobiliary jxn-carcinogen--azatoluene,nitrosamine

2.pre-op DxiTl-sampling 12b,12c-ve-cholecystectomy+ve-liver bed resection+NlDiT2-sampling 12b,12c,13-ve all-liver bed resection+ve12/-ve13-liver bed resection+NlD+ve13-extend liver resection+N1/2DiT3/4-sampling 12b,12c,13-ve all-liver bed resection+NlD+ve any-extend liver resection+N1/2D

Patho-adenoca--80-90%-papillary,nodular,tubular-lyrnpatic/venous/direct spreading-1st LN = cystic duct node (calot)-vein drain direct to liver seg 4,5

Nl-12a,b,c,h,pN2-8a,p 13a 17Ml-16

Clinical-abdo discomfort-ni, anorexia-jx-wt loss-ascitisT Staging & TxTla-Iamina propia-simple cholecystectomyTlb-muscular layerT2-not beyond serosa-radical cholecystectomy(cholecystectomy+liver margin (s.4b/s)+regional lymphadenectomy)T3-beyond serosa,liver,l organ-as Tlb/T2+rt hepatectomy+BD resection+Roux en Y biliary reconstructionT4-mPV,HA, 2 organs-if resect as T3 or palliative Tx

gall bladder

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