Gall Bladder and Biliary Tract Anatomy G B

Gall Bladder and Biliary Tract Anatomy: G. B. Parts: Fundus, Body, Neck, (infundibulum), Cystic Duct 0. 5 cm-4 cm Capacity 20 -30 ml ___ 200 -300 ml Vessels and Nerves Artery: Cystic artery Rt. Hep. Artery Occasionally L. H, Rt. G. A , S. M. A. Veins: drain = Rt portal Vein of liver Lymphatics: node of lund (neck) celiac portahapatis Nerves: Para symapathatic (Vagus) Sympathetic Celiac plexuses (7 -10 thoracic segments)

Extra hepatic Biliary system • C. H. D 1 - 2. 5 cm length diameter 4 mm • Cystic Duct 0. 5 -4 cm (Valves of Heister) • C. B. D. C. H. D. + cystic duct • Length 7. 5 cm diameter 6 mm Portions: • Supra duodenal • Retro duodenal • Pancreatic • Intra mural • Open 2 nd part of duodenum at ampula of water 10 cm from pylorus

Histology • • • Culumnar Epithelium No sub mucosa, No muscularis mucosa Rokitanzky Aschoff sinuses 40% of normal G. B& all inflamed Ducts of luschka Accessories cystic ducts

Cont. BILIARY TRACT • • • Sphincter of Oddi 4 -6 mm length Resting pressure 13 mm Hg 4 contractions/min During contraction pressure 130 mm Hg CCK + causes relaxation Parasympathetic Sympathetic Alpha 1 stimulate contraction Beta causes relaxation Opposite to function on G. B. Others V. A. P. somatostatin

Physiology of G. B. • • Storage & concentration of bile 70 -90% bile pass to G. B. Absorption of water Concentration of bile 2 -10 times

Main G. B. and biliary pathology • • • Calculous biliary disease Neo. Plastic disease Others : strictures, congenital, trauma

Calculous disease G. B stones Types: pure cholesterol 10% Pure pigment (bile) 15% (either black or brown) Mixed 75%

Calculous disease Hepatic Duct stones • Primary: Black (hemolysis, cirrhosis) Brown (infection, obstruction) • Secondary: migrate of G. B Residual after cholecystectomy • Incidence : 10% of population • Epidemiology : linear relation to age

Predisposing factors • • • hereditary and ethnic Gender Pregnancy Obesity Diabetes Hemolytic disorder Cirrhosis Vagotomy TPN ileum disorder short bowel syndrome congenital anomalies

Mechanism of cholesterol stones Formation • Lithogenic bile • Bile salts – Chenodexy cholic acid. – Cholic acid • cholesterol • phospholipids lecithin

Calculus Diseases Pigment Stones: • Brown: free unconjugated bilirubin (Infection) “bile ducts” • Black: Hemolysis, liver cirrhosis tarry “ gall bladder”

Cont. GALL STONES Pathology and clinical presentation • silent (Asymptomatic) • biliary colic • cholecystitis (acute or chronic) • Choledocholithiasis • Obstructive jaundice • pancreatitis • Ca. gall bladder

Cont. GALL STONES Biliary Colic • Different from other colics. Rapid increase in intensity of pain that lasts several hours followed by gradual decrease. • Post prandial

Cont. GALL STONES Acute cholecystitis • Start as biliary colic but lasts several days • Anorexia, nausea, vomiting • Murphy’s sign is positive • Fever, Tachycardia • Lab. Leucocytosis Bilirubin normal or increased • It is mainly a chemical process super added by a bacterial infection • Untreated : Resolution or Complications

Cholecystitis Complications: • Gangrene • Empyema • Perforation • Emphysematous cholecystitis • Cholangitis + jaundice • Hydrops (Mucocele gall bladder) No infection, filled with mucus.

Acute cholecystitis cont. Diagnosis • Clinical • Radiography • Oral cholecystogram • U/S • Hepatobiliary scantigraphy HIDA

Acute cholecystitis cont. Management • Early supporitive measures • I. V. fluid, Analgesics, antibiotics • Early cholecystectomy 3 – 5 days • Elective or delayed cholecystectomy 4 – 6 weeks

Gall bladder cont. Types of cholecystectomy Open chole. Lap chole. Other procedures Cholecystostomt Or P. C. aspiration

Cont. Gall bladder. Other modality of treatment Medical dissolution: systemic • Chenodeoxycholic acid • Urodeeoxycholic acid (9 – 12 months) Contact dissolution • Methyl tert-butyle ether(MTBE) Cholesterol stones Patent cystic duct Lithotripsy

Choledocholithiasis • Primary – due to stasis and infection • Secondary – from G. B. Incidence 10 – 12%

Gall Stones Cont. Presentation • Biliary colic • Jaundice • Cholangitis • Pancreatitis Investigation • L. F. T “Elevated” • U/S • +/- C. T. • MRCP – E. R. C. P. – P. T. C Management • Cholecystectomy

Carcinoma G. B. Incidence 3 – 4% of G. I. T. cancer • Female/Male 3/1 • 70 – 90% associated with gall stones • Increase in porcelain G. B. and Typhoid carrier Spread • Direct to liver • Through lymphatics • Blood

Cont. Ca. Gall bladder Presentation • R. U. Q. pain • Abdominal mass • Jaundice • Weight loss, dyspepsia, anorexia, etc… Diagnosis • U/S • C. T. • M. R. I.

Cont. Ca. Gall bladder Stages – – – Mucosa mucosa and muscular layer sub serosal all layers plus cystic lymph nodes distant Mets. Plus liver Treatment – Early stages: cholecystectomy +/- lymphadenectomy +/segmental liver resection – Late stage: palliation Bypass Stents Chemo and radio therapy

Carcinoma of bile ducts • Less common than G. B. cancer • Incidence: male/female 2/1 Associating factors • Gall stones • Infestation with cholonorchis sinensis • Typhoid • Congenital hepatic fibrosis • Choledochal cyst • Ulcerative colitis • Sclerosing cholangitis

Cont. Bile duct carcinoma Presenation • Jaundice • Mass • Cholangitis • Ascities • Anemia • Nausea • Vomiting • Weight loss • Pain

Cont. Bile duct carcinoma Diagnosis • Blood test ↑ LFT • Biochemistry – elevated liver enzymes • U/S + C. T. + M. R. I. • M. R. C. P. + E. R. C. P + P. T. C. Managment • Surgery – curative or palliation • Stents • Dilatation • Chemo & radio therapy