Gallbladder diseases Flashcards
Which artery supplies the gallbladder? and what is the gallbladder’s capacity?
CYSTIC ARTERY branch of right hepatic artery
30-45cc
How long is the common bile duct?
10-15cm
should not be more than 6mm in diameter
Where does the common bile duct join the major pancreatic duct?
the wall of the second part of the duodenum -> AMPULLA OF VATER
intraduodenal part of CBD has sphincter of ODDI to regulate bile flow
Where does the spiral valve of Heister exist?
in the neck of the gallbladder continuous with the cystic duct -> makes catheterization difficult
What is the lymphatic drainage of the gallbladder?
- cystic lymph node of LUND by the junction of the cystic & common hepatic ducts ——> CELIAC NODES -> porta hepatis
Which hormone is responsible for stimulation of gallbladder contraction?
CHOLECYSTOKININ (CCK)
- fatty food stimulates the duodenal mucosa to secrete it
What are the benefits of x-ray use in case gallbladder disease?
- could detect only radio-opaque stones (10-15%) —> mercedes benz
- porcelain gallbladder -> calcified wall -> premalignant
- emphysematous cholecystitis -> gas within wall
- biliary fistula -> gas within biliary system after sphincterotomy or anastomosis
how can we differentiate between a renal & gallbladder stone in an x-ray?
LATERAL X-RAY
- renal -> in spine
- gallbladder -> anterior to spine
What are the functions of the gallbladder?
- storage of bile until CCK is secreted -> contracts
- concentration of bile -> absorption of water, sodium chloride, & bicarbonate by mucous membrane
- secretion of mucus -> in complete obstruction of cystic duct could lead to mucocele
What is the first-line of radiological investigations used in biliary disease?
ultrasound abdomen shows
- > visualizes mobile, hyperechoic, intraluminal mass with acoustic shadow
- > cholelithiasis
- > gallbladder wall thickening
- > pericholecystic fluid
- Murphy’s sign
What was used in adjunction with ultrasound when a patient had symptoms of cholelithiasis with a negative ultrasound?
ORAL CHOLECYSTOGRAM (OCG)
- more useful in smaller stones & counting the number of stones present
- patient should be on a fat free diet for 3 days -> take 6 tablets of TELEPAQUE the previous night -> x-ray abdomen in erect position -> fatty meal is given -> another x-ray taken to see change in size of gallbladder
What are the contraindications of oral cholecystogram (OCG)?
- patient with serum bilirubin >3mg
- acute cholecystitis (because cystic duct is contracted)
- vomiting —-> use IV CHOLANGIOGRAM instead (inject biligram)
What are the advantages of sonography?
- no ionizing radiation
- detection of small calculi
- no contrast medium
- less patient preparation
When is CT used in case of gallbladder disease?
- extent of primary tumor
- relationship to other organs & blood vessels
- in obese patients
- if ultrasound is not definitive
What is the benefit of Magnetic Resonance CholangioPancreatography (MRCP)?
- non-invasive & as diagnostic as PTC & ERCP
- demonstrates ductal obstruction, strictures, & intraductal abnormalities
What is the benefit of Tc99-labelled iminodiacetic acid (HIDA)?
diagnoses ACUTE CHOLECYSTITIS & other biliary disorders (biliary atresia)
- non-visualization of gallbladder -> acute cholecystitis
- delayed or reduced visualization -> chronic cholecystitis
- biliary scintigraphy diagnoses bile leaks & iatrogenic biliary obstruction
- evaluation of biliary dyskynesia or sphincter of Oddi dysfunction -> post-cholecystectomy syndrome
When is peroperative cholangiography used?
- during a cholecystectomy -> catheter is placed in the cystic duct & contrast is injected directly into the biliary tree
- defines the anatomy of the biliary tree
- excludes the presence of stones within the bile ducts
- when cystic duct feels dilated more than normal
- if u feel a stone slipping into ducts after clipping the gallbladder
- make sure the OR table is fit for x-ray or not
What method of investigation is used to cannulate the sphincter of Oddi, and inject dye to visualize the biliary & pancreatic tree?
Endoscopic Retrograde Cholangio-pancreatography (ERCP)
What are the diagnostic indications for ERCP?
- congenital anomalies
- stones
- stricture in biliary tree
- choledochal cyst
- chronic pancreatitis -> chain of lakes
- malignancy -> irregular filling defect
- biopsy from tumors
- sampling or biliary & pancreatic juices for cytology
What are the therapeutic uses of ERCP?
- extraction of stone
- stenting of tumor in CBD or pancreas
- dilatation of biliary strictures
- endoscopic sphincterotomy
What are the complications of ERCP?
- pancreatitis
- duodenal injury
- cholangitis
- bleeding
What are the rules of use of Percutaneous Transhepatic Cholangiography (PTC)?
- normal coagulation
- dilated biliary radicles (in long standing obstruction)
What are the indications for PTC?
- in severe obstructive jaundice -> under antibiotics & control of bleeding tendencies
- if ERCP is inappropriate of failed
- to drain biliary obstruction
- used for stenting through obstruction in hepatic ducts or CBD
Where is the Chiba or Okuda needle inserted while preforming PTC?
right 8th intercostal space in mid-axillary line -> aspirate bile -> inject water-soluble iodine to visualize biliary radicles
What are the complications of PTC?
- bleeding
- biliary leak
- biliary peritonitis
- septicemia
if a doctor is concerned about residual stones or strictures following a cholecystectomy, what should he preform?
T-tube or delayed cholangiography
- extends to the outside of the body
What are the investigations that should be done in case of choledocholithiasis?
1- sonography -> enlargement or narrowing of biliary ducts due to presence of stones
2- ERCP
3- operative cholangiography
What are the investigations that should be done in case of cholelithiasis?
1- ultrasound
2- scintigraphy (HIDA) -> failure of accumulation inside gallbladder
What are the investigations that should be done in case of neoplams?
1- ultrasound
2- CT
What are the investigations that should be done in case of biliary stenosis?
1- operative cholangiogram
2- ERCP
What is the pathogenesis of gallstones?
- metabolic abnormalities -> increased cholesterol to bile salt ratio (1:25), or ileal abnormality or resection, DM, obesity
- infections & infestations
- bile stasis -> estrogen therapy, VAGOTOMY, pregnancy, long term TPN
- increased bilirubin -> haemolysis (thalassaemia & sickle cell anemia)
What are the symptoms of gallstones?
Biliary Pain
- after meals
- RUQ
- referred to right shoulder & back
- recurrent
- Murphy’s sign
Reflex retrosternal pain as angina
Fatty dyspepsia
What are the effects of gallstones on the gallbladder?
- silent stones
- acute cholecystitis
- chronic cholecystitis
- obstruction of cystic duct -> mucocele
- > empyema gallbladder
- > perforation -> biliary peritonitis -> pericholecystitic abscess - carcinoma gallbladder
What are the complications of gallstones?
- obstructive jaundice
- cholangitis
- biliary cirrhosis
- pancreatitis
What are the effects of gallstones on the CBD?
- obstruction of CBD
- cholangitis & pancreatitis
- Mirizzi syndrome -> compression of CBD by stone from cystic duct or cholecysto-choledochal fistula
What is the effect of gallstones on the intestine?
- cholecystoduodenal fistula -> gallstone ileus -> intestinal obstruction
What is the effect of fistulation caused by a gallstone on the intestine?
- to CBD -> Mirizzi syndrome
- to duodenum -> gallstone ileus
- to colon -> pass down
What is the modified Mirizzi classification?
- type I -> extrinsic compression on CBD by impacted gallstone -> cholecystectomy
- type II -> cholecystobiliary fistula due to gallstone involving 1/3rd of CBD -> subtotal cholecystectomy, leave 5mm of gallbladder & put T tube
- type III -> cholecystobiliary fistula involving 2/3rds of CBD -> subtotal cholecystectomy, leave 1cm of gallbladder & bilioenteric anastomosis OR Roux-en-Y
- type IV -> cholecystobiliary fistula compromising the whole circumference of CBD -> subtotal cholecystectomy with Roux-en-Y hepaticojejunostomy
- type V -> any cholecystoenteric fistula -> Va: without gallstone ileus -> division & simple suture of fistula + cholecystectomy
- > Vb: with gallstone ileus -> treat gallstone ileus -> 3 months -> definitive surgery depending on type
What is Rigler’s triad?
signs in intestinal obstruction due to gallstone ileus
- pneumobilia
- signs of small bowel obstruction
- ectopic radio-opaque gallstone
What is Forchet sign?
contrast passes around radiolucent calculus -> SNAKE HEAD with clear halo of the calculus
What is Petren’s sign?
passage of contrast medium into biliary tract or bilioenteric fistula
What are the indications of cholecystectomy?
- complicated gallstones
- symptomatic gallstones
- asymptomatic GS in young age or immunocompromised
- acute/chronic acalcular with non functioning gallbladder after conservation for 1-2 years
When should the CBD be evaluated?
- dilated CBD
- history of jaundice in the past 6 months
- increased GGT
What are the borders of Calot’s triangle?
Superiorly -> cystic artery
Laterally -> cystic duct
Medially -> CHD & CBD
What are the borders of the hepatocystic triangle?
Superiorly -> inferior border of liver
Laterally -> cystic ducts & neck of gallbladder
Medially -> CHD
