GALL BLADDER Flashcards
Treatment of choice for symptomatic gallstones
Laparascopic cholecystectomy
measurement of a gallbladder
7 to 10 cm long
average capacity
30-50ml
Location of gallbaldder
anatomic fossa on the inferior surface of the licer
Cantle’s line
vertical plane running from the gallbladder fossa anteriorly to the inferior vena canca posteriorly divides left to right lobes
four anatomic areas
fundus, body, infundibulum, neck
mucosal lining of GB
single, highly redundant, simple, columnar epithelium contains cholesterol and fat globules
Epi lining supported by
LAMINA PROPRIA
Gallbladder differs histologicallt from the rest of Gi TRACTS
Lacks muscularis, mucosa and submucosa
Cystic arrert supplies GB usually a branch of the right hepatic artery
gallbladder lymphatrics drain into nodes
neck of the gallbladder
Visible lymph node (Lund’s or Mascagni’s node - overlies rge insertion of cystic artery into gb wall
Calot’s node
galllbaldder receives
parasympha, sympha, and semsory innervation via nerve fibers runnung largely via GASTRO HEPATIC LIGAMENT
Parasymphatetic cholinergic arise from where
HEPATIC BRANCH OF VAGUS NERVE
Vagal nerve branches also have PEPTIDE-CONTAINING NERVES
somatostatin, enkephalins, substance P, VIP
extrahepatic biliary tree consist of
right and left hepatic ducts, common bile ducrs, cystic duct and other common bile duct
common hepatic duct extends
1-4cm
segment of the cystic ducr immediately adjacent to the gallbladder neck bears a variable number of mucosal folds
SPIRAL VALVES OF HEISTER
Union of the cystic duct and the common hepatic ducr start of the common bile ducr.
7-11cm in length and 5-10 cm in diameter
Union of the cystic duct and the common hepatic ducr start of the common bile ducr.
7-11cm in length and 5-10 cm in diameter
Upper third (Supraduodenal portion)
passes downward in the free edge of the hepatoduodenal ligament, to the righ of the hepatic artery and anterior to the portal vein.
Middle third (retroduodenal portion)
bile ducr curves behind the first portion of the duodenum and diverges laterallt from the porral vein and hepatic arteries
lower third (pancreatic portion)
curve behind the head of the pancreas
sphincter of oddi
thick coat of circular smooth muscle, surroubds the common bile duct. Controls the flow of bile, and pancreatic juice and into duodenum.
The arterial supply to the bile ducts derived from
GASTRODUODENAL AND RIGHT HEPATIC ARTERIES, MAJOR TRUNKS LATERAL WALLS OF THE COMMON DUCT
Normal adult consuming an average diet
500-1000ml of bile a day
rudimentary
small, nonfunctional hypoplastic remnat
lIver produces bile continously and excetes it into the
BILE CANALICULI
BIle is composed of
water, mixed with bile salts, and acids, cholesterol. phospholipids (lecithin), proteins, and bilirubin.
80% of the secrered conjugated bile acids are reabsorbed in the
terminal ileum
GB, Bile ducts, sphicter of oddi
act together to store and regulate flow of bile.
Main fx of hepatic bille
store hepatic bile in order to deliver it in a coordinated fashion to the duodenum in response to meal.
MUCOSAL CELLS OF GB SECRETE AT LEAST 2 IMORTATNR PRODUCT
GLYCOPROTEIN AND HYDROGEN IONS
GLYCOPROTEINS SECRETES
Protect the mucosa from the corrosive action and facilitate passage of bile via cystic duct.
HYDROGEN IONS
decreasing the ph of stored bile. This acidification helps prevent the precipitation of ca salts, which can act as a nidus for STONE FORMATION
main stimuli to this coordinated effort of gb emptying
cholecystokinin cck#
CCK released
endogenouslt from enteroendocrine cells in the duodenum in response to meal
defects in the motor activity of the gb inhibit correct emotying are thought to play a role
Cholesterol nucleation and gallstone formation
Parasympathomimetic or cholinergic drugs contract the GB
nicotine and caffeine
Anticholinergic drugs for gallbladder relaxation
Atropine
Antral distenton of the stomach causes both
Gallbladder contraction and relaxation of the spinchter of oddi.
Initial test of choice in evaluating pt with suspected malignancy of the GB
ct scan
Preferred imaging modality for precise evaluation of biliary and pancreatic duct pathology
MRCP
another option for noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum that provides both ana and fx information. Technetium-labeled derivatives of imnodiacetIc acid are injected iV, taken up by the Kupffer cells in the liver, excreted in the bile.
HEPATOBILIARY SCINTIGRAPHY OR HIDA SCANNING
Advantage of ECRP
Direct visualization of the ampullary region, direct access to the distal common bile duct for cholangiography or cholescopy
can be used to identify choledocholithiasis. useful for eval of retroduodenall portion of bile ducr, which is difficukt to resr in transabdominal ulratsonography
ENDOSCOPIC US
biliary tree cant be assessed endoscopically, anterograde cholangiography can be performed by acessing i ntrahepatic bile ducr percistaneously with needle under fluroscopic guidance
Percutaneous transheparuc cholangiography
Ptc potental rrisks
mainly bleeding, cholangitis, leak an dother catheter related probs
Conditions predispose to the dev of gallstones
PREGNANCY
NON HDL HYPERLIPIDEMIA
CHROH’S DISEASE
CERTAIN BLOOD D/O HEREIDTARY SPHEROCYTOSIS, SC, THALASSEMIA
PORCELAIN GB
significant calcifcation
pre malignant condition
absolute indication for cholecystectom, even when asymp
Primary event in the formation of cholesterol stones
Supersaturation of bile with cholesterol
- non polar and soluble in water and bile
What is formed when cholesterol is secrered into bile and sourrounded by bile salts and phospholipids
VESICLE COMPLEX
Contains <20% cholestererol and are dark because of the presence of CA bilirubinare.
PIGMENTED STONES - usually brittle, small, dark and sometimes spiculared
- formed by supersat of Uncojugated bilirubin within the bile.
usually <1cm in diameter, brownish-yellowish, soft, and often mushy. form either in the gb or in the bile ducts secondary to bacterial infection and bile statsis. bacteria such as E.coli secrete b-ucoronidase that enzymaticallt cleaves conjugated bilirubin to produce insoluble uncojugated bilirubin. assoc with stasis secondary to parasite infection with Ascaris lumbricoides (roundworm) or Chlonorchis sinensis (liver in fluke)
BROWN STONES
chief symp associated with symptomatic cholelithiasis
PAIN Biliary colic - constant and increases in severity. firts half of hour last up to 1 hr - 5hr
Atypical presentations
in the back or left upper or right lower quadrant.
bloating and bleching may be present associated with attacks of paib,
when pain lasts greater than 24 hours without resolving
impacted stone in the cystic duct or acute cholecystitis
Impacted stone without cholecystitis
HYDROPS OF THE GB
diagnosis of syptomatic chole or chronic chole depends on the presence of
typical symptoms and demonstration of stones on DIAGNOSTIC IMAGING
Standard diagnistic test for gallstones as it is noninavsive and highly sensitive
abdominal ultrasound
best long term results for patient with symptomatic gallstones
SURGICAL CHOLECYSTECOTOMY
Impactiob of a larfe stone in rge neck og the gallbladder causing obstruction at the level of confluece of the cystic duct and common hepatic duct
MIRIZZI’S SYNDROME
acute chole is mediated initially by mucosal toxin ___ a product of lecithin, as well as bile salts and platelet activating factors
lysolecithin
CM of acute chole:
Begins as an attack of biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium that may radiate to the right back or interscapular area.
-febrile
, anorexia, nausea, vomiting.
creates focal peritinitis.
PE of acute chole
tenderness and guarding are usualyy present in right upper quadrant.
INspiratory arresr with deep palapatio in thw right subcostal area.
Murphy’s sign
