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Anatomy of biliary tree Physiology of bile and the bile circulation.

17-11-162Gall StoneGALL BLADDER STONE

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CONTENTSSurgical Anatomy of Gall BladderPhysiologyGall Stone CausesPathogenesisTypes of StonesFeaturesEffects of Gall StoneComplicationsMiscellaneous

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Pear-shaped sac, about 512 cm longLying on the visceral surface of the right lobe of the liver in a fossa between the right and quadrate lobes Divided into four anatomic areas: FundusThe corpus (body)The Infundibulum The Neck

4Anatomy

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The two hepatic ducts from right and left lobes of the liver unite at the porta hepatis to form the common hepatic duct which is joined by the cystic duct from the gallbladder to form the common bile duct.The common bile duct enters the second part of the duodenum posteriorly.

In about 70% of cases, it is joined by the main pancreatic duct to form the combined opening in the duodenum (ampulla of Vater).

CONT

In 30% cases, the common bile duct and the pancreatic duct open separately into the duodenum.

The common bile duct in its duodenal portion is surrounded by longitudinal and circular muscles derived from the duodenum forming sphincter of Oddi.

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CONT

HISTOLOGYSerous layer

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Mucosal layerSmooth muscle layerPerimuscular layer

Gallbladder drains through cystic duct into common hepatic duct to form common bile duct.

It is supplied by cystic artery, a branch of right hepatic artery.

Calots triangle is formed by common hepatic duct to the left, cystic duct below, and inferior surface of liver above. Cystic artery originating from right hepatic artery passes behind the common hepatic artery, enters the Calots triangle to reach the gallbladder. It contains lymph node of Lund (Fred Bates Lund).

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CONT

5. Maintenance of Pressure in Biliary System

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FUNCTIONS OF GALLBLADDERStorage of Bile2. Concentration of Bile3. Alteration of pH of Bile4. Secretion of Mucin

PROPERTIES AND COMPOSITION OF BILE

SECRETION OF BILE STORAGE OF BILE

Composition of bile

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Differences between liver bile and gallbladder bile

Types of entities Liver bile Gallbladder bilepH 8 to 8.6 7 to 7.6Specific gravity 1010 to 1011 1026 to 1032Water content 97.6% 89%Solids 2.4% 11%Organic substancesBile Salts 0.5 g/dL 6.0 g/dLBile Pigments 0.05 g/dL 0.3 g/dLCholesterol 0.1 g/dL 0.5 g/dLFatty Acids 0.2 g/dL 1.2 g/dLLecithin 0.05 g/dL 0.4 g/dLMucin Absent PresentInorganic substancesSodium 150 mEq/L 135 mEq/LCalcium 4 mEq/L 22 mEq/LPotassium 5 mEq/L 12 mEq/LChloride 100 mEq/L 10 mEq/LBicarbonate 30 mEq/L 10 mEq/L

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BILE SALTS Bile salts are the sodium and potassium salts of bile acids, which are conjugated with glycine or taurine. FORMATION OF BILE SALTS

Emulsification of Fats

Absorption of Fats

Choleretic Action

Cholagogue Action

Laxative Action

Prevention of Gallstone Formation

FUNCTIONS OF BILE SALTS

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Formation and circulation of bile pigments

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FILLING AND EMPTYING OF GALLBLADDER2. Hormonal FactorWhen a fatty chyme enters the intestine from stomach, the intestine secretes the cholecystokinin, which causes contraction of the gallbladder.

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1. Neural FactorStimulation of parasympathetic nerve (vagus) causes contraction of gallbladder by releasing acetylcholine. The vagal stimulation occurs during the cephalic phase and gastric phase of gastric secretion.

GALL STONE

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GALLSTONES

Definitions: Gallstone is a solid crystal deposit that is formed by cholesterol, calcium ions and bile pigments in the gallbladder or bile duct. Cholelithiasis is the presence of gallstones in gallbladderCausesfor Gallstone Formation

1. Reduction in bile salts and/or lecithin 2. Excess of cholesterol 3. Disturbed cholesterol metabolism 4. Excess of calcium ions due to increased concentration of bile5. Damage or infection of gallbladder epithelium. It alters the absorptive function of the mucous membrane of the gallbladder. Sometimes, there is excessive absorption of water or even bile salts, leading to increased concentration of cholesterol, bile pigments and calcium ions 6. Obstruction of bile flow from the gallbladder.

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Geography

Genetic factors(CYP7A1- cholesterol 7-hydroxylase)

Age

Sex

Drugs

Obesity

Diet

Gastrointestinal diseases

Factors in pigment gallstonesRISK FACTORS

PATHOGENESIS OF CHOLESTEROL, MIXED GALLSTONES AND BILIARY SLUDGE.

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PATHOGENESIS. The mechanism of gallstone formation

Initiation of cholesterol stones occurs by nucleation of cholesterol monohydrate crystals.Apolipoprotein .protein that bind lipid to form

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Factors altering the cholesterol to bile salt ratio

Obesity Drugs Oral contraceptive pills Clofi brate Cholestyramine Ileal disease Ileal resection Altered enterohepatic circulation

III. Bile stasis: Occurs due to estrogen therapy, pregnancy, vagotomy and in patients who are on long term intravenous fluids or TPN

IV. Increased bilirubin production due to any of the causes of haemolysis as in hereditary spherocytosis, sickle cell anaemia, thalassaemia, malaria, cirrhosis. Here pigmentstones are common.II. Infections and Infestations:Bacteria like E. coli, Salmonella,Parasites like Clonarchis sinensis and Ascaris lumbricoides are often associated.Moynihans aphorism: A gallstone is a tomb stone erected to the memory of the organism within it.

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1. Cholesterol stones are 6% common, often solitary.

Types

2. Mixed stones are 90% common. It contains cholesterol, calcium salts of phosphate carbonate, palmitate, proteins, and are multiple faceted.

3. Pigment stones are small, black or greenish black, multiple. Often they can be sludge like.

Features of Gallstones.Type Freq Com Gallbladder Changes AppearancePure 06% i) Cholesterol Cholesterolosis Solitary, oval, large, smooth, yellow gallstones white; on C/S radiating glistening crystals

ii) Bile pigment No change Multiple, small, jet-black, mulberry shaped; on C/S soft black

iii) Calcium carbonate No change Multiple, small, grey-white, faceted; C/S hard

2. Mixed 90% Cholesterol, bile pigment Chronic cholecystitisMultiple, multifaceted, variable size,and calcium carbonateon C/S laminated alternating dark- in varying combinationpigment layer and pale-white layer

3. Combined4%Pure gallstone nucleus with Chronic cholecystitis Solitary, large, smooth; on C/S Gallstonesmixed gall stone shell, orcentral nucleus of pure gallstonemixed gallstone nucleus withwith mixed shell or vice versapure gall stone shell

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Saints triad Gallstones Diverticulosis of the colon Hiatus hernia

Rarely centre of the stone contains radiolucent gas which is either triradiate (Mercedes Benz sign) or biradiate (Seagull sign).Black pigment stones are common in gallbladder. It is usually calcium bilirubinate, calcium phosphate and bicarbonate stone with a matrix. It is common in haemolytic disorders. They are usually multiple, small black and hard in consistency.Only 10% of gallstones are radio-opaque, 90% are radiolucent.

Miscellanous

Brown pigment stones are formed in biliary tree as primary biliary stones. It is commonly due to infection like Escherichia coli and bacteroides (98%) with bacterial nidus at the centre(often Ascaris lumbricoides or Clonorchis sinensis infestation or foreign body or stents). They secrete glucuronidase to cause hydrolysis of soluble conjugated bilirubin to insoluble calcium bilirubinate. It also contains calcium palmitate, calcium stearate and cholesterol. They are brownish yellow, soft and mushy.

In the gallbladderi. Silent asymptomatic stones occurs in 10% of males and 20% of females.Effects of the Gallstonesii. Biliary colic with periodicity, severe within hours after meal (commonest presentation). Biliary colic is spasmodic pain often severe, in right upper quadrant and epigastrium radiating to chest, upper back and shoulder. It is self-limiting, recurs unpredictably, often precipitated by a fatty/heavy meal. Fever and increased WBC count may be observed.

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iii. Acute cholecystitis.

iv. Chronic cholecystitis.

v. Empyema gallbladder.

vi. Perforation causing biliary peritonitis or pericholecystitic abscess.

vii. Mucocele of gallbladder.

viii. Carcinoma gallbladder.

complications of gallstones.

Gallstone Colic It is sudden, severe colicky abdominal pain in right upper quadrant which radiates to back and shoulder. This pain is due to sudden spasm of gallbladder wall when gallstone moves towards the neck of the gallbladder or cystic duct and gets impacted. Tachycardia and restlessness are common. Right hypochondrium is tender.

It is precipitated by supine position while sleeping at night. It lasts for few hours and is episodic. It may precipitate acute cholecystitis or empyema gallbladder.

There is reflex pylorospasm causing vomiting.

Flatulent Dyspepsia It is discomfort in the abdomen, belching, heartburn, fat intolerance, sensation of fullness in the abdomen usually observed in fatty, fertile, flatulent female.

Silent gallstone

Asymptomatic stone in the gallblad