Galbadder disease _ نوري حنون

Question 1

The gall bladder Anatomy

Answer 1

Pear shape (7.5 – 12 cm in length )

Capacity > 50 ml

Question 2

gall bladder consist of

Answer 2

Fundus , body , neck & infundibulum

Question 3

duct are …

Answer 3

-cystic duct ( 2.5 cm , 0,5 cm )

join common hepatic duct ( 2.5 cm )

to form CBD 7.5 cm

Question 4

Blood supply of the gallbadder …

Answer 4

cystic artery from Rt. Hepatic artery

Question 5

what the congental anomalies of the galbadder artery ?

Answer 5

Caterpillar turn

means Tortuous Rt. Hepatic artery in front of origin of cystic duct with short cystic Ar.

Question 6

Lymphatics …

Answer 6

two ways ;
1- To cystic L.node of lund →coeliac L. N.

2- Directly to liver

Question 7

Bile consist of …

Answer 7

97% water

→2% bile salt

→1% bile acid and cholesterol.

Question 8

Bile production from the liver

Answer 8

40 ml / hour = 1000 ml /day .

Question 9

Gall bladder function

Answer 9

1- Reservoir & storage.
2- Concentration of bile 5-10 times .
3- secretion of mucin ; 20 ml / day .

Question 10

Investigations of biliary tract by …

Answer 10

-Plain Xray :
Radio opaque stone 10 – 20 %.
Porcelain gall bladder .
Limey bile .
Gas in biliary tree.

2) Oral cholecystography & iv. Cholangiography.
Out of use .
Historical interest.

(both x ray and chlecystography both not used )

*3) Ultrasonography :
Prime test .
Standard test .
Quick , non-invassive test .

4) *ERCP. & endoscopic ultrasonography .

5) *PTC .
Percutaneous transhepatic cholangiography(not used really)

6)* MRCP (standard, no contrast).

so the most important is the US MRCP ERCP and CT scan for tumor and LN

7) Radio isotope scanning
-99mTC
-labelled HIDA (hepatobiliary iminodiacetic acid (HIDA)) ,
-IODIDA .
Iv. given , excreted in bile, gall bladder visualised
30 minute if delayed to 1 hour suggest acute cholangitis or contracted gall bladder ( chronic ) .

8) CT. Scan :
To detect liver and pancreatic lesion .
Cancer extent and staging .
L. Node enlargement .

9) Per operative cholangiography .كلللش رفيع

10) Per operative choledochoscopy :
Flexible fibreoptic endoscope to localize and extract stone

Question 11

what’s the Radio isotope scanning ?

Answer 11

-99mTC
-labelled HIDA (hepatobiliary iminodiacetic acid (HIDA)) ,
-IODIDA .
Iv. given , excreted in bile, gall bladder visualised
30 minute if delayed to 1 hour suggest acute cholangitis or contracted gall bladder ( chronic ) .

Question 12

CT. Scan benefet in the gallblader?

Answer 12

To detect liver and pancreatic lesion .
Cancer extent and staging .
L. Node enlargement .

Question 13

Ultrasonography benefet in the gallblader?

Answer 13

it’s the standard test

Question 14

Congenital abnormalities of GB ?

Answer 14

1- Abscence of G.B.

2- Phryngian cap 2 – 6 % , phrygian cap like hats of people of phrygia (asia Minor). Suptum in G. bladder either complete or incomplete .
يعني بدل ما تكون كيس واحد راح نشوفها كانما مقسومه الى نصفين

3- Intra hepatic G.B.

4- Floating G.B. → torsion .

5- Double G.B

Question 15

Congenital abnormalities of the bile duct ?

Answer 15

Cystic duct anomalies : Intra hepatic ;

Accessory duct
They are small ducts that distinctly enter the gallbladder bed

Low insertion .
Low medial insertion of the cystic duct occurs when it joins the extrahepatic bile duct from the medial aspect at or near the ampulla of Vater

Short or absent.

Question 16

Extra hepatic biliary Atresia means

Answer 16

Define as partial or total absence of bile duct between porta hepatis and the duodenum

Question 17

Extra hepatic biliary Atresia incidence ..

Answer 17

1/ 14,000 live births

Question 18

Extra hepatic biliary Atresia complication andout cme if not fixed

Answer 18

Occlusion will lead to inflamation of the duct → destruction of the duct → fibrosis → obliteration طمس
so as result of olibaration newborn will having :

• Jaundice

-Biliary cirrhosis
is a disease caused by damage to bile ducts in the liver. These small channels carry the digestive fluid, or bile, from the liver to the small intestine. … It can lead to permanent scarring and cirrhosis

• Portal hypertension .
• Liver failure

Question 19

Extra hepatic biliary Atresia types

Answer 19

1 occlusion of common bile duct

2 occlusion of common bile duct and hepatic

3 occlusion of common bile duct, hepatic
and Rt and Lt heparic duct

Question 20

Clinical features of Extra hepatic biliary Atresia

Answer 20

1- Jaundice at birth – progressive – 
2- Pale muconium.
3- Dark urine .
4- Steatorrhoea leading to Osteomalacia( biliary rickets ).
---------------------
5- Clubbing of fingers .
6- Portal hypertension .
7- Another anomalies in 20% .

Question 21

DDx of the Extra hepatic biliary Atresia?

Answer 21

1- Neonatal jaundice .
2-Neonatal hepatitis.

2- Choledochal cyst .
3- Inspissated bile syndrome .

Question 22

Mangmanet of the Extra hepatic biliary Atresia?

Answer 22

• Early surgery Roux-en-Y

- or liver transplant.

Question 23

the complication of surgery of Extra hepatic biliary Atresia?

Answer 23

1- Cholangitis in 40% .

2- Portal hypertension 50% .

Question 24

Choledochal cyst means ..

Answer 24

Congenital cystic dilatation of biliary tract

DILATED DUCT

Question 25

Clinical features Choledochal cyst ?

Answer 25

1- Jaundice .

2- Rt. hypochondrial cystic mass .

3- Cholangitis & pancreatitis

Question 26

Dx of Choledochal cyst ?

Answer 26

1- ultrasound diagnostic test .
2- MRCP

قاعده
(CT for paranchymia whlile MRCP best for the DUCT )

Question 27

note

Answer 27

Choledochal cyst Premalignant → cholangiocarcinoma so we do the surgery

while in Extra hepatic biliary Atresia there will be danger to having liver faliure

Question 28

mangment of the Choledochal cyst ?

Answer 28

Surgical excesion & Roux-en-Y

Question 29

types of the galllstone ..

Answer 29

1- cholestrol
2- mixed
3- pigmented brown and black

all the stone in GB except the brown in the bile duct

Question 30

content of the cholestrol stone is

Answer 30

(almost pure cholesterol)

Question 31

content of the mixed stone is

Answer 31

Mostly cholesterol (51-99% of stone contents) +

others as

• calcium salts,
• bile acids
• bilirubin pigments
• phospholipid

Question 32

content of the black stone is

Answer 32

Mostly Bilirubin pigments+
others as

• Ca phosphate
• Ca carbonate+
• 30% cholestrol

Question 33

content of the brown stone is

Answer 33

Mainly Ca bilirubinate+

others as

• Ca palmitate
• Ca stearate
• 30% cholestrol

Question 34

feature of the cholestrol stone

Answer 34

Large ,solitary, white or pale

Question 35

feature of the mixed stone

Answer 35

Small, hard, multiple, multifaceted, green or yellow

Question 36

feature of the black stone

Answer 36

Small, black, irregular& multiple

Question 37

feature of the brown stone

Answer 37

Large, brown & single

Question 38

common possible Aetiology of the cholestrol and mixed ?

Answer 38

Most common Cases in which chol increase or bile acid dec in bile

• obesity,
• high caloric diet,
• contraceptive pills,
• ileal resection
• abnormal emptying of gall bladder

Question 39

common possible Aetiology of the black

Answer 39

1-SCA

2- H spherocytosis

3-cirrhosis

Question 40

common possible Aetiology of the brown

Answer 40

Associated with bile stasis & infected bile due to FB in bile duct like stent or parasitic infestations like Chlonorichis sinensis or Ascaris lumbricoidis

Question 41

In US and Europe most common stones are

Answer 41

80% cholesterol or mixed

around 10% of them is pure Cholestrol stone
70% of them is mixed stone

both types of pigment stones represent around 20% mostly in immigrant people from Asia and Africa

Question 42

In Asia most common type of stone is …

Answer 42

80% of stones are pigment stones (black more than brown

Question 43

what’re the causes of gallstones

Answer 43

1- supersaturated bile 
-----------------------------------
1- age
2- sex 
3-gentic 
4- obsity 
5-diet
5F(fatty , female , fertile , forty)

2- imparied gallbadder function 
-----------------------------------------------------
1- impared in empting 
2- imparied in absorbtion 
3- excretion 

3- cholestrol nucleating factor 
-------------------------------------------------
1- mucus 
2- glycoprotein 
3-infection 

+means the stone formation is composed from take up of cholestrol and then make it into multilaminar vesical that
which by process of nucleation and crystalization its will form the stone

1- deoxycholate
also known as cholanoic acid Increase of deoxycholate in supersaturated bile

2-bowel transit time
slow bowel transit time lead to due to, an increased proportion of deoxycholic acid (DCA)

3-fecal enteric flora
A study has just showed that the gut flora could play a part in the formation of kidney stones. Patients with a history of recurrent nephrolithiasis seem to have a lower content of oxalate-degrading digestive bacteria.

4- illiocecal recsetion
but there is a marked increase in the tendency to form uric acid stones, as well, particularly in patients with colon resection

5- cholestramine
lower high levels of cholesterol in the blood
does using cholestramine causing gallstone ?

Question 44

Effects & complications of stones in the gallbadder ? مهمه

Answer 44

1) Silent, asymptomatic (mostly)
these when we mange don’t do any surgery expect for DM and sicklar

2) Dyspepsia, Flatulence, Food intolerance (Fat)

3) Biliary colic
Biliary colic is a dull pain in the middle to upper right area of the abdomen. It occurs when a gallstone blocks the bile duct, the tube that normally drains bile from the gallbladder to the small intestine. The pain goes away if the stone passes into the small intestine and unblocks the duct , LFT is normal and the WBC normal and -murphy sign

while the most common presenting symptom of acute cholecystitis is upper abdominal pain. The following characteristics may be reported: … sever Pain may initially be colicky but almost always becomes constant. Nausea and vomiting are generally present, and fever may be noted. + marfan sign and the galbladder is dilated , thickened wall with fluid and liver function test is changes and WBCs are high

in choronic cholecyctitis the gallbadder wall is shrink and thickened with less pain with neusea and faltulace and dyspepsia no fever no pain no tendreness no murphy sign no WBC changes and no LFT changes

4) Cholecystitis (acute and chronic)

5) Fistula….leading to Mirizzi syndrom (less than 0.1%)
Mirizzi syndrome is defined as common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct

6) Mucocele.
gallbladder mucocele is the distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow, decreased gallbladder motility, and altered absorption of water from the gallbladder lumen are predisposing factors to biliary sludge. it’s not infected

 7) Empyema of gall bladder
      Gallbladder empyema (suppurative cholecystitis 1) is an uncommon complication of cholecystitis and refers to a situation where the gallbladder lumen is filled and distended by purulent material (pus).

8) Gangrene & perforation
9) Carcinoma of gall bladder.

Question 45

Effects & complications of stones on the bile duct ?

Answer 45

1- Jaundice

2- Acute Cholangitis

3- Acute pancreatitis

Question 46

Effects & complications of stones on the Intestine

Answer 46

intestinal obstruction ( gall stone ileus )

Question 47

feature of pt with Flatulant Dyspepsia ?

Answer 47

Dyspepsia; R hypochondrail Pain or epigastric pain (more often dull and constant) + flatulence+ intolerance of Fatty food

Question 48

feature of pt with Biliary colic ?

Answer 48

-10-20% of patients of gall stone,

Hx: Several episodes of pain which is sever (minutes-hours)+ nausea &vomiting for few weeks –then period of relief for few months as the stone dis-impacted back into gall bladder

Ex: negative Murphy’s sign + No fever

UlS: no signs of acute cholecystitis but there is stones

Blood invest.: no significant change in laboratory data (may be slight rise in liver enzyme and bilirubin)

+Biliary colic is a dull pain in the middle to upper right area of the abdomen. It occurs when a gallstone blocks the bile duct, the tube that normally drains bile from the gallbladder to the small intestine. The pain goes away if the stone passes into the small intestine and unblocks the duct , LFT is normal and the WBC normal and -murphy sign

Question 49

feature of pt with Acute cholecystitis

Answer 49

Hx: R hypo&/ or epigastric pain more sever

Ex: Tenderness+ Murphy’s sign positive+ low grade fever

UlS Scan: shows signs of acute cholecystitis: distended gall b.+ presence of stones+ thickened wall of gall bladder+ pericholecystic fluid collection

Blood invest.: leukocytosis +moderate elevation in LFT

Question 50

feature of pt with chronic cholecystitis

Answer 50

Hx: History of acute attack that has already been relieved+ pain less in severity and frequency + might be flatulent dyspepsia+ nausea and vomiting

Ex: No fever or tenderness or Murphy’s sign negative (shrinkage gall bladder)

U/S: shrinkage gall bladder+ presence of g. stone+ No sign of acute

Blood investing.: Often Normal

Question 51

feature of pt with Empyema of Gall Bladder ?

Answer 51

Same of acute cholecystitis + history of acute attack that has not relieved + more pain+ More tenderness+ more fever+ inc in pulse rate+ might be palpable mass in R hypochondrial region (gall bladder surrounded by omentum)

Question 52

feature of pt with Perforation

Answer 52

Sign and symptoms of peritonitis usuall localized.

include
- severe abdominal pain. 
-Fever,
- constipation, 
-bloody stool, 
rebound tenderness in the abdomen,
- abdominal rigidity and guarding, 
-bloating, 
-jaundice, 
-colic,
-migratory pain may also occur.

Question 53

ملاحظه

Answer 53

laparoscopic cholecystectomy had replaced open cholecystectomy as the first-choice of treatment for people with uncomplicated gallstones and acute cholecystitis. By 2014 laparoscopic cholecystectomy had become the gold standard for the treatment of symptomatic gallstones.