Gallbladder

Question 1

What is the gallbladder and where does it lie?

Answer 1

• Pear-shaped, hollow, saclike organ (7.5-10 cm long)

- Lies in a shallow depression on the inferior surface of the liver attached by loose connective tissue

Question 2

What is the gallbladder responsible for?

Answer 2

Helping to digest fats and fatty foods in our diet by concentrating and storing bile

Question 3

How much bile can the gallbladder hold?

Answer 3

30-50 mL of bile (1/4- 1 1/4 L of bile produced every day)

Question 4

What can a blockage of the common bile duct cause?

Answer 4

Jaundice

Question 5

The cystic artery is a branch of which artery?

Answer 5

RT-hepatic artery (90% of the time)

Question 6

What is the gallbladder wall composed of?

Answer 6

Smooth muscle

Question 7

What is the gallbladder connected to the CBD by?

Answer 7

Cystic duct

Question 8

What is bile composed of?

Answer 8

Water
Electrolytes (Na, K, Ca, Cl, HCO3)
Fatty acids
Cholesterol
Bilirubin
Bile salts

Question 9

What happens to bile after it is stored in the gall bladder?

Answer 9

It is acidified in the gallbladder and then discharged into the intestines via the bile ducts

Question 10

What are the factors associated with increased risk of gallstone development?

Answer 10

• Obesity
• Pregnancy (in cholelithiasis increased abdominal pressure pushes the liver and gallbladder up)
• Crohn’s disease
• Terminal ileal resection
• Gastric surgery
• Sickle cell disease

Question 11

What is Murphy’s sign?

Answer 11

RUQ pain upon palpation which causes a cessation of breathing
-indicative of gallbladder disease

Question 12

What imaging would you use to evaluate RUQ pain?

Answer 12

1) Ultrasound
2) CT/HIDA
3) ERCP/MRCP

Question 13

What are the 3 stages of gallstone pathogenesis?

Answer 13

1) Cholesterol supersaturation in bile
2) Crystal nucleation
3) Stone growth

Question 14

What is symptomatic cholelithiasis?

Answer 14

Wax and waning postpandrial (after meals) epigastric/RUQ pain due to transient cystic duct obstruction by stone

• NO fever, NO elevated WBC or LFT
• Pain occurs due to a stone obstructing cystic duct -> wall tension -> pain resolves when stone passes (VISCERAL PAIN)

Question 15

What is acute cholecystitis?

Answer 15

Acute gallbladder inflammation due to cystic duct obstruction

• PERSISTENT RUQ pain (over 24 hours), +/- fever, elevated WBC and LFT
• (+) Murphy’s sign -> inspiratory arrest
• Sonography preferred as initial test

Question 16

What are complications associated with acute cholecystitis?

Answer 16

• Empyema of gall bladder (pus-filled GB)
• Emphysematous cholecystitis (common in men/diabetics; air in GB wall)
• Perforated gallbladder (10% of acute cholecysititis)

Question 17

What is chronic cholecystitis?

Answer 17

Recurrent bouts of colic/acute cholecystitis leading to chronic GB wall inflammation/fibrosis (GB wall thickening)

• No fever, NO elevated WBC
• 90% due to gallstones -> fluid around GB and GB distended

Question 18

What is acute acalculous cholecystitis?

Answer 18

GB inflammation due to biliary stasis (5% of the time- from lack of eternal stimulation by cholecystokinin) and not stones (95%)
-Seen in critically ill patients or prolonged TPN (total parenteral nutrition)

Question 19

What is choledocholithiasis?

Answer 19

Gallstone in the CBD

• Primary: stone originated there
• Secondary: came from the gallbladder

Question 20

What is cholangitis?

Answer 20

Infection of the bile ducts due to CBD obstruction secondary to stones

Question 21

What are signs of cholangitis?

Answer 21

In 70% cases, Charcot’s triad: RUQ pain, jaundice and fever

-Reynold’s Pentad: Charcot’s triad, septic shock and altered mental state

Question 22

What is acute calculous cystitis?

Answer 22

Persistent cystic duct obstruction - palpable, tender RUQ mass, pain persists > 24 hours

Question 23

What is Reynold’s pentad indicative of?

Answer 23

Obstructive ascending cholangitis