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GI 2 > Gall Bladder Physiology > Flashcards

Gall Bladder Physiology Flashcards

1
Q

Fuction of Gall Bladder

• The main function of the gallbladder is to_____and _____bile and deliver it into
the duodenum in response to meals
• The gallbladder bile ducts and sphincter of oddi act together to:

A

concentrate and store

store/regulate flow of bile

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2
Q

Location of Gall Bladder

A

• Location: Nestled in fossa beneath liver at separation of
right/left liver lobes: 7 to 10cm length

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3
Q

• Components of Gall Bladder
–_____: Rounded blind end; extends 1-2cm beyond liver
margin. Contains majority smooth muscle
–_____: Main storage area; contains most elastic tissue
–______: Funnel shaped, deep in fossa (Hartmann’s Pouch)
connect to cystic duct

A

Fundus

Corpus

Neck

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4
Q

• Connection of Gall Bladder

A 
R/L hepatic ducts join to form the common
bile duct (CBD) 7-11cm long; 5-10mm diameter
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5
Q

• Bile produced continuously by liver excretes into bile
canaliculi; 500-1000 ml daily
• Bile secretion increases with vagal stimulation; HCL,
digested proteins, fatty acids increase flow by
stimulating hormone______

A

secretin

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6
Q
  • Bile secretion decreases with _____ stimulation
  • Fasting state: ____bile stored in Gallbladder.
A

splanchnic

80%

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7
Q

________greatest absorptive power per unit
area of any body structure. Capacity: 30-50 ml; 300ml
when obstructed!

A

Gallbladder mucosa

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8
Q

What changes do we see in Bile composition in gall bladder storage?

A

Na+ and Bile acids increase

Bicarb and Cl- decresae

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9
Q

What do we see for motility responses of the Fasting gall bladder , between meals

A

Hepatic secreation pressure 25-30 mg and we see receptive relazation during gallbladder filling

the phincter of Oddi at 11-30 mmHg between meals

*see overal pressure differnce

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10
Q

Tonic contractions of the sphincter of oddi
(SO) create pressure gradient that directs flow into gallbladder

A

• Gallbladder filling:

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11
Q

Gallbladder emptying: Coordinated gallbladder contraction,
SO relaxation and meal intake gallbladder empties ______
contents in 30 to 40 minutes with eating; refills 60 to 90
minutes

A

50 to 70%

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12
Q

• Main stimuli to emptying of gall bladder: _________
released from duodenum in response to meals

A

Hormone cholecystokinin (CCK)

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13
Q

• SO motility: Basal contractile pressure; Response to____
Mitigating myenteric complexes

A

CCK;

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14
Q

Neurohormal control of the GB contraction and biliary secreation

A
  1. Nurtients in duodenum; release of CCK into the blood stream

–> CCK goes to Gall bladder to increase motility

–> CCK goes up vagal afferent to Doral vagal complex

–> vagal efferents relesase Ach to act on Gall bladder

Vagal efferents to act to release NO or VIP

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15
Q

• Primary bile acids (BA) entering enterohepatic circulation
synthesized from cholesterol in hepatocyte (Cholate,
Chenodeoxycholate) conjugated with _______
• Secreted across ______; Carried in bile to
gallbladder; Concentrated during digestion

A

taurine/glycine

canalicular membrane

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16
Q

• 95% BA actively absorbed from ______; 5% in colon, Bile
acid hydrolysis/dehydrogeneration performed by broad
spectrum of______ bacteria

A

terminal ileum

anaerobic

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17
Q

•______ reabsorbs BA from simisordal blood carried through
to liver through portal vein via series of transporters
• BA’s aid in digestion/absorption of fat in the intestine

A

Hepatocyte

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18
Q

• Nerves arise from vagus/sympathetic branches that
pass through____ plexus
• Preganglionic sympathetic level _____and____

A

celiac

T8 and T9

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19
Q

• Impulses from liver, gallbladder and bile ducts pass by
means of______ afferent fibers through
splanchnic nerves and mediate ______ pain
 Cannot differentiate specific biliary tract site by pain
pattern per se

A

sympathetic

“Biliary colic”

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20
Q

• Two types of gallstones:
–_____ stones: Most common in Western countries
–____ stone: Bilirubin deposition

A

Cholesterol

Pigment

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21
Q

• Cholesterol gallstones: Balance between normal ratio of
cholesterol to other biliary lipids is disrupted resulting in

A

Cholesterol hypersecretion: Hyposecretion BA’s or phospholipids
• Diminished BA pool of enterohepatic circulation
interrupted

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22
Q

• Supersaturation of cholesterol not necessarily sufficient for stone formation;______ must also occur, protein secretion may be nucleating agent

A

Nucleation

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23
Q

GB epidemiology:

A

women >50, white

men w/ stones increase with age and higher prevalance in American Indians

24
Q

Risk factors for Cholesterol Gallstones

A
  • Increasing age
  • Female sex
  • Pregnancy and parity
  • Exogenous estrogens
  • Race
  • Family history
  • Obesity
  • Rapid weight loss
  • Physical inactivity
  • Serum lipid levels
25
Q

How is strict dieting assoicated with gall stones?

A

overweight men/women on strict diet

some pts with gastric bypasss w/in 49 months surgery

women with weight loss of 9-22 lbs over 2 year are 44% more likely to devo stones

26
Q

Cirrhosis, chronic hemolysis, ileal crohn’s
disease at put pt at risk for;

A

black pigment stones

27
Q

What is biliary sludge

A

Biliary Sludge (Calcium bilirubinate and cholesterol
crystals embedded in mucus gel); Precursor to stone
formation? Associated with drugs like ceftriaxone,
octreotide, thiazide diuretics, parenteral nutrition

28
Q

What is the link between pregnancy and Cholelithiasis

A

• Incidence of biliary sludge (Precursor to gallstones)
and gallstones are 30% and 12% respectively during pregnancy and post partum
• 1 – 3% post partum woman: Cholecystectomy within first year
• Increased estrogen levels during pregnancy; Super saturated bile/sluggish GB motility
• Majority: Sludge/gallstones dissolve spontaneously after partition

29
Q

Inflammation of the gallbladder causing a syndrome
of prolonged (>4 to 6 hours) steady, right epigastric
pain with fever, leukocytosis associated with
gallstone obstruction of the cystic duct.

A

Acute Cholelithiasis

30
Q

what pts usually develop acute cholecystitis?

A

patients with a history of symptomatic gallstones

31
Q

Pt is ill looking, feverish and tachycardic; they are lying very still and have a + murphys sign. What do you suspect of lab tests? What other tests do you order?

A

Patient is ill-appearing, febrile, tachycardia: lies still (Parietal Peritoneal Inflammation) seen in acute cholecystitis

Liver function test usually normal

Order ultrasonography/cholescintigraphy to confirm

32
Q

How are ultrasonography and Cholescintigraphy (HIDA) used to dx acute cholecysitis

A

• Ultrasonography study: Detects stones; Gallbladder
wall thickening (> 4 to 5 mm) or edema. Sonographic
“Murphy’s Sign” Test sensitivity 88%; Specifity 80%
• Cholescintigraphy (HIDA scan): Technetium labeled
hepatic iminodiacetic acid (HIDA) injected IV, taken
up by hepatocyte, secreted into bile to determine
system patency – or not. Visualization in 30 to 60 minutes

33
Q

What do we do to tx pt with acute cholecystitis?

A
  • Surgical treatment Laparoscopic Cholecystectomy
  • Positive Advance
  • Risks/Benefits of operation
  • Individuals aged 15 to 24 years: Cholecystectomy
34
Q

Acute Cholangitis
• Clinical syndrome featured by ___, _____, _____ (Charcot’s Triad);

Results from stasis/infection in ______
• Severity ranges from mild to life-threatening

A

fever, jaundice and abdominal pain

biliary tract

35
Q

In acute Cholangitis, obstruction raises______ pressure, increases
permeability of _____, permits translocation of bacteria/toxins from portal circulation or ascending from the duodenum

A

intrabiliary

bile ductules

36
Q

Two most common causes of acute Cholangitis

A 
Most common causes of biliary obstruction are CBD
biliary calculi (28 to 70%) or benign stenosis (5 to 28%)
37
Q

Common pathogens associated with Cholangitis

A

gram-negative bacterium:

E. coli , Klebsiella, Enterobacteria
• Major gram-positive bacterium; Enterococcus
species 10 to 20%

38
Q

• Charcot’s triad occurs in only 50 to 70%
• Confusion/hypotension occur if suppurative
; Associated with significant morbidity
and mortality; Septic shock/multi-organ failure can occur

A

Acute Cholangitis

39
Q

Lab tests for cholangitis:

Cholestatic pattern of LFT abnormalities;

Elevation of ____ and ____ and ____
(GGT) and bilirubin; Blood cultures

A

WBC

GGT

Serum Alk Phos

40
Q

Three methods to Dx acute cholangitis

A

• Transabdominal ultrasonography to detect ductal dilation or stones; Small calculi difficult
• Magnetic resonance cholangiopancreatography (MRCP) helps with minute stones
• ERCP (Endoscopic retrograde cholangiopancreatography) is useful for diagnosis
and most importantly, drainage (sometimes immediately)

41
Q

tool is useful for diagnosis
and most importantly, drainage (sometimes immediately)

A

ERCP (Endoscopic retrograde
cholangiopancreatography)

42
Q

Obstructive stones in the distal CBD or at the
ampulla of vater may cause _____

A

acute pancreatitis

– may need to use ERCP to extract and train ducts in case of concurrent cholangitis

43
Q

Clinically identifiable to acute cholecystitis but not
associated with gallstones: Usually occurs in critically ill
patients. Accounts for 10% of acute cholecystitis. High
morbidity and mortality

A

Acalculous Cholecystitis

44
Q

Chronic progressive disorder of unknown etiology.
Characterized by inflammation, fibrosis, stricturing of
medium/large ducts in intrahepatic/extra-hepatic biliary tree

A

Primary Sclerosing Cholangitis (PSC)

45
Q

Lots of pts with Primary Sclerosing Cholangitis (PSC) have what underlying condition?

how long do they liver after transplant?

A

underlying ulcerative colitis

10-12 yrs

46
Q

What is on this image?

specifically what disease and where do you see sclerosis

A

Primary Sclerosing Cholangitis:
Periductal Sclerosis

47
Q

Biliary “colic” is a misnomer; The distress is typically
______in nature; Episodic

A

constant

48
Q

Where is biliary or GB pain located?

how is it different then cardiac pain?

A

Begins usually mid-epigastrium as dull, pressure-like.
Intense within 15 to 30 minutes: Severe, steady 3 to 5
hours. (Right shoulder/interscapular area)
• Unlike cardiac pain, the patient is “restless”, moves
about and re-positions in an effort to obtain relief

49
Q

referred pain from GB

A

Right shoulder, straight back adn RUQ

50
Q

The truth about biliary pain and meals

A

• Biliary pain often unrelated to meal time events;
may occur without clear precipitating events.
Nocturnal pain episodes (2 a.m. to 5 a.m.) are a classic feature

51
Q

Misconceptions on biliary pain

A

• GI symptoms such as dyspepsia, heartburn,
bloating and fatty food intolerance are not
suggestive of gallbladder disease per se
• Biliary pain not a chronic continuous process
• Biliary pain not associated with eliminations

52
Q

RUQ pain sight in gall bladder

A

• Chronic RUQ pain (often accentuated after meals) is
almost never caused by gallbladder disease
• Nonetheless: Physicians always suspect gallbladder
disease. Inevitable US study Stones = Postcholecystectomy Syndrome!!
• 22 patients with chronic RUQ pain >10 years. Balloon
inflations up/down GI tract. Pain reproduce in remote
site in ALL; reproduced in 2 sites in half of group
• Be suspicious of RUQ pain syndrome!!

53
Q

Challenge with gall bladder for physicians

A

The most important challenge to the physician
evaluating a patient with upper GI tract symptoms
in whom gallstones are detected is whether
cholelithiasis is the cause of symptoms or an
incidental finding!

54
Q

Group I: Pts with Ypical biliary symptoms/stones;

• Very likely to develop recurrent severe symptoms.
Risk of further symptoms/complications about ____
within 2 years after presentation
• Rₓ: _______

A

70%

Cholecystectomy

55
Q

Group II. Patients with Atypical
Symptoms/Stones;

A

• Worrisome group: Symptom relief post-op occurs
most likely in patients with biliary pain
• 2481 patients who had elective cholecsytectomy; Symptom persistence of gas/flatulence 40%
• Patients require comprehensive search for nonstone related causes; surgery with caution
• Post-cholecystectomy syndrome in the making

56
Q

III. Patients with Stones
and No Symptoms

A

• Gallstones are present in approximately 20% of
US adults!
• The vast majority of these people are never
bothered by this information
• Educate about gallstone symptom/disease
• No surgery

57
Q

IV. Pts with typical biliary sypmtpoms without stones;

detect these pts with what test?

A

Gall bladder ejection fraction (GBEF) to get best diagnosis;

shold be able to eject die w/in 30 mins

GI 2 (12 decks)

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