gb hbt

1. Gallbladder and Biliary system
NEIL MENDOZA, MD, FPCS, FPALES
Department of Surgery

2. The Gallbladder
3. Functions of Bile
Contains bile acids for fat digestion and absorption
Emulsification of fat
Aids in absorption of digested fat
For excretion of wastes from the blood
Bilirubin
Excess cholesterol
4. Bile Flow
Hepatocyte
BileCanaliculi
Perilobularductules
Lobar ducts
R & L hepatic ducts
Common hepatic duct
Common bile duct
Gall bladderCystic duct
5. Bile Flow
6. Bile Flow
x
INTRA-HEPATIC DUCTS
EXTRA-HEPATIC DUCTS
7. Hepatic Bile vs. GB bile
8. Gallstone formation
Too much water extraction from the bile
Too much bile salt extraction from the bile
Inflammation of the gallbladder wall
Stasis
9. Regulation of Bile Flow
Presence of bile acids
More bile acids = more bile production
Prevention of atherosclerosis
Secretin
Affects 2nd stage of bile production
10. Entero-Hepatic Circulation
Liver Cholesterol
Cholic Acid + Chenodeoxycholic Acid
Conjugation with glycine or taurine
Glyco- or Tauro- bile acids
+ NaCl
Bile Salts
Ileum
SMV
PV
11. Gallbladder
pear-shaped sac
7 to 10 cm long
average capacity of 30 to 50 mL
When obstructed
up to 300 ml
Shared lymph and vascular drainage with liver
12. Gallbladder
The gallbladder is divided into four anatomic areas:
fundus
corpus (body)
infundibulum
neck
13. GALLBLADDER
Functions
Concentrate bile
Temporary storage of bile
14. GALLBLADDER
4 parts
Hartmanns pouch
Cystic duct
1-5cm long
3-7mm diameter
Spiral valves of Heister
Junction with CHD
Angular=70%
Spiral=30%
15. Triangle of Calot
3 margins
3 contents
16. Triangle of Calot
the area bound by the:
cystic duct
common hepatic duct
liver margin
17. Cystic artery
usually a branch of the right hepatic artery (>90% of the time)
course of the cystic artery may vary, but it nearly always is found within the hepatocystic triangle
it divides into anterior and posterior divisions
18. Cystic Artery Anomalies
Most variable structure
90% from RIGHT hepatic artery
88% single, 12% double
19. Gallbladder
mucus secreted into the gallbladder originates in the tubuloalveolar glands found in the mucosa lining the infundibulumand neckof the gallbladder, but are absent from the body and fundus
histologically differs from the rest of the gastrointestinal tract i.e.lacks a muscularis mucosa and submucosa
20. Common Bile Duct (CBD)
5-17cm long
3-8mm diameter
21. Physiology
Fasting
Postprandial
Bile production
Extrahepatic bile duct
22. PHYSIOLOGY
During fastingcyclic emptying
Amount of bile produced
GB reabsorbs 90% of bile water
Bile lithogenicity
Cholesterol, phospholipids, bile salts
Post-prandial
Bile ejection GB, canaliculi
CCKstimulants vs. inhibitors
Extrahepatic bile ductno smooth muscle
23. GB Disease: Clinical Presentation
Causes of Symptoms
Infection
Obstruction
Extramural
Intramural
Intraluminal
Obstruction + Infection
24. SYMPTOMS
Abdominal pain
biliary colic vs. cholecystitis
Jaundice
direct vs. indirect
Fever
Charcots triad vs. Reynolds pentad
Hypotension, Neurologic symptoms
Nausea and Vomiting
Weight loss, Anorexia
25. Abdominal Pain
Biliary colic
Functional disease
Negative Murphys sign
Negative laboratory exams
Cholecystitis
Positive Murphys sign
Systemic manifestation
Irreversible GB injury
26. DIFFERENTIAL DIAGNOSIS
Peptic ulcer
Hepatitis
Pancreatitis
Diverticulitis
27. DIAGNOSTIC STUDIES
Laboratory exams
Bilirubin ( B1, B2 )
SGPT, SGOT
ALP
5 aminopeptidase
GGT
Protime
Albumin
28. Obstructive Jaundice
29. Laboratory Exams
33. DIAGNOSTIC IMAGING
Abdominal x-ray
Ultrasound
CT scan
Cholangiography
ERCP
PTC
IOC
MRCP
Scintigraphy
Oral Cholecystogram
Abdominal x-ray
Ultrasound
CT scan
CHOLANGIOGRAPHY
39. CALCULOUS DISEASE
Types of stones
Cholesterol
Pigment
Mixed
Gallbladder sludge, microcalcification
40. Cholesterol Stones
41. Cholesterol Gallstones
Unifying hypothesis
Risk factors
Age > 40 years old
Female
Race
First degree relatives with gallstones
Obesity
Crohns disease
Rapid weight loss
Stasis
Exogenous estrogen
42. Pigment Gallstones
Predominant variety in the world except in the U.S.
High bilirubin content
Black or brown coloration
43. Types of Gallstones
44. CLINICAL SYNDROMES
Asymptomatic Gallstones
Acute Cholecystitis
Hydrops of the Gallbladder
Choledocholithiasis
Cholangitis
Gallstone ileus
Acalculouscholecystitis
Oriental Cholangio-hepatitis
Biliary colic, cholecystitis in pregnancy
Mirizzi syndrome
1. Asymptomatic Gallstones

10%Biliary colic

46. 1-3% each yearAcute cholecystitis 47. 0.5-1% mortality 48. TreatmentObserve 49. Indications for surgeryClinical symptoms
Porcelain gallbladder
Gallbladder polyps
2. Acute cholecystitis
Cystic duct obstruction
Pain characteristic
P.E.
Murphys sign
Laboratory exams
Leukocytosis
LFTs
Diagnosis
Ultrasound
Complications
Empyema of the gallbladder
Emphysematous gallbladder
Perforation, sepsis
Complications
Empyema of the gallbladder
Emphysematous gallbladder
Perforation, sepsis
Treatment
Avoid morphine and opioid analgesics
Cholecystectomy
Early vs. Late cholecystectomy
Open vs. Lap Chole
54. Laparoscopic vs. Open Cholecystectomy
Hydrops
4. Choledocholithiasis
Complications
Jaundice
Cholangitis
Pancreatitis
Sepsis
Sources
Primary vs. secondary CBD stones
Retained vs. recurrent CBD stones
Indicators
SENSITIVE
ALP, Bilirubin
SPECIFIC
CBD stone on USG100%
Cholangitis100%
Pre-op jaundice97%
Dilated CBD on US96%
Pancreatitis95%
Amylase95%
Bilirubin88%
ALP85%
Diagnosis
Ultrasound
Cholangiography
Intra-operative/IOC
Routine vs. selective
4 indications
ERCP
PTC
MRCP
Treatment
Size
Timing of discovery
5. Cholangitis
Charcots triad
Abdominal pain
Fever
Jaundice
Bacterial reflux via canaliculi
Treatment
Antibiotics, supportive measures
CBD decompression:Endoscopic vs. operative
6. Gallstone Ileus
Cholecysto-enteric fistula
Elderly female
Cholecystectomy not advised
63. Gallstone Ileus
7. Acalculouscholecystitis
Ischemia
Critically ill, fasting, septic patient, ICU
Higher gangrene, empyema, perforation than in AC
Cholecystectomy vs. cholecystostomy
8. Oriental Cholangiohepatitis
Intrahepatic, extrahepatic BD with pigment stones
Normal GB
Hongkong
Parasites in BD
Ascarislumbricoides, Clonorchissinensis
Segmental, hence, rare jaundice
CBD exploration, biliary bypass
9. Cholecystitis and Biliary Colic in Pregnancy
Ultrasound
Historically, operate during 2nd trimester
Currently, anytime during pregnancy
Adequate tocolysis
Open vs. laparoscopic cholecystectomy in pregnancy
10. Mirizzi Syndrome
Type I- external CHD compression
Cholecystectomy
Type II- GB-CHD fistula
Partial chole +biliary-enteric anastomosis
Long cystic duct
Painless jaundice, Cholangitis
68. TREATMENT
Goals
Remove biliary calculi
Prevent stone-related complications
Medical Treatment
Oral dissolution therapy
Contact dissolution therapy
ESWL
69. Medical Treatment
Oral dissolution therapy
Urso- vs. chenodeoxycholic acidfor 6-12 months
For small, non-calcified cholesterol stones
50-60% response if

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bile salt extraction

stage of bile production

common bile duct cbd5

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right hepatic artery88

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