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GALL BLADDER. BY DR. HAYDER M. ABDULNABI MD, CABS. ANATOMY. PEAR-SHAPED, 7.5-12.5 CM NORMAL CAPACITY- 50 ML FUNDUS, BODY, NECK (TERMINATES IN A NARROW INFUNBIBULUM) ( HARTMANN ’ S POUCH- A DILATATION IN THE NECK DUE TO AN IMACTED STONE) - PowerPoint PPT Presentation

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  • GALL BLADDERBYDR.HAYDER M. ABDULNABIMD, CABS

  • ANATOMYPEAR-SHAPED, 7.5-12.5 CMNORMAL CAPACITY- 50 MLFUNDUS, BODY, NECK (TERMINATES IN A NARROW INFUNBIBULUM)( HARTMANNS POUCH- A DILATATION IN THE NECK DUE TO AN IMACTED STONE)CRISS-CROSS MUSCLE COAT (WELL DEVELOPED IN THE NECK)GLANDULAR MUCOUS MEMBRANE WITH CRYPTS OF LUSCHA

  • THE CYSTIC DUCT 2.5 CM (CONTAINS THE SPIRAL VALVE OF HEISTER)THE COMMON HEPATIC DUCT 2.5CM (UNION OF RT AND LT HEPATIC DUCTS)THE COMMON BILE DUCT 7.5CM (JUNCTION OF CHD AND THE CYSTIC DUCT), OF 4 PARTS

  • 1- SUPRADUODENAL 2.5CM (RUNS IN THE FREE EDGE OF LESSER OMENTUM2- RETRODUODENAL3- INFRADUODENAL4- INTRADUODENAL (PASSES OBLIQUELY THROUGH 2ND PART OF DUODENUM, SURROUNDED BY THE SPHINCTER OF ODDI, OPENS AT THE SUMMIT OF THE PAPILLA OF VATER

  • THE ARTERIAL SUPPLY OF THE GALL BLADDER THE CYSTIC ARTERY (BRANCH OF THE RT HEPATIC ARTERY), USUALLY BEHIND THE CBDACCESSORY CYSTIC ARTERY (OCCASIONAL)(BRANCH OF THE GASTRODUODENAL ARTERY)

  • LYMPHATICSSUBSEROSAL AND SUBMUCOSAL DRAIN INTO THE CYSTIC LYMPH NODE OF LUND (SENTINEL LN) THEN TO THE HILUM OF THE LIVER TO THE COELIAC LYMPH NODESSUBSEROSAL LYMPHATICS CONNECT WITH THE SUBCAPSULAR LYMPHATICS OF THE LIVER (FREQUENT SPREAD OF GALL BLADDER CA TO THE LIVER)

  • FUNCTIONS OF THE GALL BLADDERBILE IS COMPOSED OF 97% WATER, 1-2% BILE SALTS, 1% PIGMENTS, CHOLESTEROL AND FATTY ACIDSLIVER EXCRETION RATE IS 40 ML/HOUR1- RESERVOIR (FASTING CAUSE RESISTANCE INCREASE IN SPHINCTER OF ODDI) (FEEDING DECREASE THE RESISTANCE AND THE GALL BLADDER CONTRACTS BY THE ACTION OF CHOLECYSTOKININ RELEASED BY UPPER INTESTINAL MUCOSA IN RESPONSE TO FOOD PARTICULARLY FAT)

  • 2- CONCENTRATION OF BILE 5-10 TIMES ( BY ACTIVE ABSORBTION OF WATER, SOD. CHLORIDE, AND BICARBONATE) WITH INCREASE IN THE PROPORTION OF BILE SALTS, PIGMENTS, CHOLESTEROL AND CALCIUM3- MUCIN SECRETION, 20ML/HOUR

  • INVESTIGATIONS OF THE BILIARY TRACT1- PLAIN RADIOGRAPH-- (RADIO-OPAQUE STONE 10%, PORCLAIN GALL BLADDER, LIMEY BILE, AIR)2- ORAL CHOLECYSTOGRAPHY-- (A CONTROL X-RAY IS TAKEN THE DAY BEFORE AND IOPANOIC ACID CONTRAST MEDIUM TABLETS IS TAKEN ORALLY AT NIGHT, THE NEXT DAY ERRECT AND SUPINE X-RAY IS TAKEN TO THE RT HYPOCHONDRIUM AND X-RAY REPEATED TO OBSERVE GALL BLADDER CONTRACTION(

  • RADIO-OPAQUE STONESPLAIN X- RAY

  • PORCLAIN GBPLAIN X-RAY

  • PLAIN X-RAYAIR

  • ORAL CHOLECYSTOGRAMSTONES

  • NONVISUALIZATION (NONFUNCTIONING) GALL BLADDER IS DUE TO-- FAILURE OF THE PATIENT TO TAKE THE TABLETS, VOMITING, MALABSORBTION, IMPAIRED LIVER FUNCTION, BLOCKED CYSTIC DUCT,SEVERE GALL BLADDER DISEASE (FAILURE OF CONCENTRATION)

  • 3- INTRAVENOUS CHOLANGIOGRAM USING INTRAVENOUS RADIO-OPAQUE MEDIUM TO SHOW THE BILE DUCTS, MAY BE USED WITH ORAL CHOLECYSTOGRAM OR TOMOGRAPHY (A METHOD TO PUT ONE GIVEN PLANE INTO SHARP FOCUS WHILE BLURRING OTHERS)

  • 4- ULTRASONOGRAPHY (NONINVASIVE) AND SHOWS BILIARY CALCULI, DILATION OF BILIARY TREE,CA HEAD PANCREAS, WALL THICKNESS, GALL BLADDER SIZE, HALLO SIGN5- RADIOISOTOP SCANNING USING RADIOACTIVE IODINE(131) OR Tc(99)6- COMPUTED TOMOGRAPHY IN OBESE OR PATIENTS WITH GASEOUS DISTENTION THAT MAKE ULTRASONOGRAPHY DIFFICULT

  • USSTONEGBACOSTIC SHADOW

  • ULTRASONOGRAPHYACOSTIC SHADOWSTONECBD

  • 7- ENDOSCOPIC RETROGRADE CHOLAGIOPANCREATOGRAPHY (ERCP) BY CANNULATION OF THE AMPULLA OF VATER USING FIBEROPTIC DUODENOSCOPE AND INJECTION OF CONTRAST MEDIUM ,TO TAKE SAMPLE FOR CULTURE AND BRUSHING FOR CYTOLOGY. ITS USE CAN BE EXTENDED TO DO PAPILLOTOMY TO EXTRACT STONES, PASSING CATHETER OR DORMIA BASKET, AND STENT PLACING THROUGH STRICTURES. IT MAY CAUSE ASCENDING BILIARY INFECTION, SO SHOULD BE DONE UNDER ANTIBIOTICS COVER

  • ERCPCATHETER IN THE AMPULLADUCT OF WIRSUNG

  • 8- PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY- INJECTION OF CONTRAST MEDIUM THROUGH A CHIBA OR OKUDA NEEDLE (15CM LONG , 0.7MM IN DIAMETER) INTO THE LIVER THROUGH THE 8TH INTERCOSTAL SPACE IN THE MIDAXILLARY LINE. IT CAN BE USED TO PUT A CATHETER FOR DRAINAGE OR STENT FOR ANTEGRADE DRAINAGE. BLEEDING TENDENCY IS A CONTRA INDICATION AND THE PROCDURE SHOULD BE DONE UNDER ANTIBIOTICS COVER

  • PER CUTANEOUS TRANSHEPATIC CHOLANGIOGRAMCHIBA NEEDLE

  • 9- PEROPERATIVE CHOLANGIOGRAPHY BY TAKING X-RAY DURING OPERATION AFTER INJECTING THE CONTRAST BY A POLYTHENE CATHETER INTRODUCED INTO THE CBD THROUGH AN OPENING IN THE CYSTIC DUCT TO DETECT ANY STONE IN THE CBD BEFORE EXPLORATION. FAILURE OF THE CONTRAST TO ENTER THE DUODENUM MAY BE ALSO DUE TO SPHINCTER SPASM AND HERE SUCCINYLCHOLINE IS GIVEN TO EXCLUDE THIS POSSIBILITY 20% OF CASES THE MEDIUM ENTER THE DUCT OF WIRSUNG AND IT IS NOT NECESSARILY PATHOLOGICAL

  • PER- LAPAROSCOPIC CHOLANGIOGRAPHYCATHETER

  • PER-OPERATIVE CHOLANGIOGRAMCBDDUODENUMCATHETER

  • 10- OPERATIVE BILIARY ENDOSCOPY (CHOLEDOCHOSCOPY)11- PEROPERATIVE POSTEXPLORATORY CHOLANGIOGRAPHY (THROUGH THE T- TUBE)12- POSTOPERATIVE CHOLANGIOGRAPHY (T-TUBE), 10-14 DAYS AFTER CHOLEDOCHOTOMY

  • PER-OPERATIVE CHOLANGIOGRAPHSTONE IN CBD

  • PER-OPERATIVE CHOLEDOCHOSCOPERt HEPATIC DUCTLt HEPATIC DUCT

  • T-TUBE CHOLANGIOGRAMT-TUBESTONE IN COMMON HEPATIC DUCT

  • CONGENITAL ANOMALIES OF THE GALL BLADDER AND BILE DUCTS1. ANOMALIES OF THE GALL BLADDER- ABSENCE PHRYGIAN CAP (HAT OF THE PEOPLE OF PHRYGIA IN ANCIENT ASIA MINOR) (FRENCH REVOLUTION LIBERTE CAP) FLOATING GALL BLADDERTORTION DOUBLE GALL BLADDER

  • 2. ANOMALIES OF THE DUCTS- ABSENCE ATRESIA CONGENITAL DILATATION OF INTRAHEPATIC DUCTS CHOLEDOCHAL CYST LOW INSERTION OF CYSTIC DUCT ACCESSORY CHOLECYSTOHEPATIC DUCT

  • 3. ANOMALIES OF THE ARTERIES- RT HEPATIC ARTERY AND OR CYSTIC ARTERY CROSS IN FRONT OF THE CHD HEPATIC ARTERY TAKE A TORTOUS COARSE IN FRONT OF THE ORIGIN OF THE CYSTIC DUCT RT HEPATIC ARTERY IS TORTOUS AND THE CYSTIC ARTERY IS SHORT (CATERPILLAR TURN) ACCESSORY CYSTIC ARTERY

  • GALL STONES(CHOLELITHIASIS)MIXED STONES- 90%, CHOLESTEROL IS THE MAJOR COMPONENT, Ca CARBONATE, Ca PHOSPHATE, Ca PALMITATE AND PROTEIN (USUALLY MULTIPLE AND FACETED)2. CHOLESTEROL STONES- (CHOLESTEROL SOLITAIRE)3. PIGMENT STONES- (SMALL, BLACK, MULTIPLE)

  • MIXED STONES

  • MIXED STONES

  • CHOLESTEROL STONES

  • PIGMENTSTONES

  • LIMEY BILE- OCCUR WHEN THERE IS GRADUAL OBSTRUCTION TO THE CYSTIC DUCT OR THE CBD (CHRONIC PANCREATITIS, CA PANCREAS)THE GALL BLADDER WILL BE OPAQUE IN A PLAIN X-RAY (FILLED BY Ca CARBONATE AND Ca PHOSPHATE) WHICH IS THE COMPONENTS OF TOOTH PASTE

  • CHOLESTEROL IS HELD IN SOLUTION BY THE DETRERGENT EFFECT OF BILE SALTS AND PHOSPHOLIPID (LECITHINE)TO FORM MICELLES.ANY CHANGE IN THE EQUILIBRIUM BETWEEN THESE THREE ELEMENTS WILL LEAD TO GALL STONE FORMATION

  • HYDROPLYLIC ENDHYDROPHOBIC END(CHOLESTEROL)BILE SALT MICELLE

  • PATHOGENESIS OF GALL STONE FORMATIONMETABOLIC- INCREASE CHOLESTEROL LEVEL IN BILE(SUPERSATURATED OR LITHOGENIC BILE), WITH AGE, FEMALE ( CONTRCEPTIVE PILLS), OBESITY, PATIENTS ON CLOFIBRATEBILE SALTS DECREASE BY INTERRUPTION OF ENTERO-HEPATIC CIRCULATION( ILEAL DISEASSE, RESECTION, BYPASS SURGERY, CHOLESTYRAMINE)ESTROGEN DECREASE CONCENTRATION OF BILE SALT IN THE BILE(CCP)

  • CHOLESTEROL SOLUBILITY STATUS

  • 2. INFECTION- NIDUS3. BILE STASIS- GALL BLADDER CONTRACTILITY DECREASE IN PREGNANCY, BY ESTROGEN(CCP), AFTER TRUNCAL VAGOTOMY, PATIENTS ON TPN ( LACK OF GOOD ORAL INTAKE) CAUSE DECREASE IN CHOLYCYSTOKININ SECRETION

  • 4. PIGMENT STONES OCCUR WITH HEMOLYSIS( HEREDITARY SPHEROCYTOSIS, SICKLE CELL ANEMIA, THALASSEMIA, MALARIA)WHERE BILIRUBIN PRODUCTION WILL INCREASE.PIGMENT STONES ALSO INCEASE WITH BENIGN AND MALIGNANT STRICTURES AND WITH PARASITE INFESTATION OF THE BILIARY DUCTS( ASCARIS LUMBRICOIDES, CHLONORCHIS SINENSIS)

  • INCIDENCE OF GALL STONESFAT, FERTILE, FLATULENT, FEMALE, FIFTY- IS THE USUAL SUFFERER OF GALL STONESIT CAN OCCUR AT ANY AGE AND IN BOTH SEXESTOW THIRD ARE ASYMPTOMATICSAINTS TRIAD- GALL STONES DIVERTICULOSIS HIATUS HERNIA

  • COMPLICATIONS OF GALL STONES1.IN THE GB- SILENT( NO INDICATION FOR OPERATION) CH CHOLECYSTITIS AC CHOLECYSTITIS GANGRENE PERFORATION EMPYEMA MUCOCELE CARCINOMA2. IN THE BILE DUCTS- OBSTRUCTIVE JAUNDICE CHOLANGITIS ACUTE PANCREATITIS3. IN THE INTESTINE- ACUTE INTESTINAL OBSTRUCTION (GALL STONE ILEUS)

  • CHRONIC CALCULOUS CHOLECYSTITISTHICK, FIBROTIC WALL, BACTERIA ISOLATED IN LESS THAN 30% OF CASES FROM THE BILE AND SUGGESTS A CHEMICAL IRRITANTS IN THE BILE RATHER THAN BACTERIAL AS A CAUSE IN THE OTHER CASES

  • CHRONIC CHOLECYSTITIS

  • SIGNS AND SYMPTOMSRt HYPOCHONDRIAL PAIN- DISCOMFORT TO EXCRUTIATING PAIN(BILIARY COLIC) RIADITES TO THE Rt SHOULDER PRESIPITATED BY FATTY MEAL ASSOCIATED BY NAUSEA AND VOMITING TENDERNESS IN THE Rt HYPOCHONDRIUM MURPHYS SIGN MAY BE POSITIVE(IF PAIN LASTS MORE THAN 12 HOURS, TEPERATURE INCREASE, AND WBC INCREASE, CONSIDER THE DIAGNOSIS OF AC CHOLECYSTITIS)

  • DIAGNOSISULTRASONOGRAPHY IS USUALLY THE ONLY INVESTIGATION REQUIRED

    TREATMENTANALGESICS INCLUDING OPIATES (SIMULTANEOUS INJECTION OF HYOSCINE BUTYLBROMIDE IS NEEDED TO ENCOUNTER THE EFFECT OF OPIATES ON THE SPHINCTER OF ODDI)ANTIEMETICSLOW FAT DIET UNTIL---