Gall Bladder and Biliary Tract Anatomy G B

Gall Bladder and Biliary Tract Anatomy: G. B. Parts: Fundus, Body, Neck, (infundibulum), Cystic Duct 4 cm 0. 5 cm- Capacity 20 -30 ml ___ 200 -300 ml Vessels and Nerves Artery: Cystic artery Rt. Hep. Artery Occasionally L. H in 15% , Rt. G. A ( right gastroepiploic artery) , S. M. A( superior mesenteric artery). 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 ( become dilated in patient with obstructive jaundice MORE THAN 6 mm indicate distal obstruction ) • Length 7. 5 cm diameter 6 mm Portions: ( of the CBD ) : • Supra duodenal • Retro duodenal • Pancreatic ( impeded in the BODY of the pancreas ) • Intra mural • Open in the POSTERIOMEDIAL aspect of 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 ( pseudodiverticula in the wall of the gallbladder , , not themselves considered abnormal but they can associated with cholecystitis , form because of increase pressure in the GB ang recurrent damage to its wall ) • 40% of normal G. B& all inflamed • Ducts of Luschka ( group of minute ducts communicate between the liver and the body of the GB ) After operation the patient maybe presented with ascites due to bile leak from these ducts • Accessories cystic ducts

Cont. BILIARY TRACT • Sphincter of Oddi ( Garde the lower end of the CBD and the duodenum ) • 4 -6 mm length • Resting pressure 13 mm Hg • 4 contractions/min • During contraction pressure 130 mm Hg • CCK + causes (relaxation of the sphincter and contraction of wall of the GB) • 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 more than that in the liver

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

Calculous disease G. B stones Types: pure cholesterol 10% Pure pigment (bile) 15% (either black ( hemolytic disease, liver cirrhosis )or brown ( infection or obstruction) ) Mixed 75% >> cholesterol dominant

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 ( increase)

Predisposing factors • • hereditary and ethnic Gender ( females more than males ) • Pregnancy (because of the effect of progesterone >> causing stasis of bile in the GB so causing GB stones ) • Obesity ( lipid converted to cholesterol ) • • • Diabetes ( neuropathy so decrease the contraction of the GB ) Hemolytic disorder ( increase bilirubin pigmented stones ) Cirrhosis Vagotomy ( no contraction ) TPN ( total parenteral nutrition ) >> no food >> no contraction >> stasis of bile >> stones ileum disorder like crohn disease >> decrease the absorption of bile salt short bowel syndrome congenital anomalies • • •

Mechanism of cholesterol stones Formation • Lithogenic bile • Bile salts • Chenodexy cholic acid. • Cholic acid • cholesterol • phospholipids lecithin Increase cholesterol , decrease bile salt and phospholipid >> increase the risk for GB stones Three components of bile , , any alteration of their values cause stones

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 ( pain due to stone impaction at the neck of the GB or the cystic duct ) • cholecystitis (acute or chronic associated with fatty dyspepsia) • Choledocholithiasis( gallbladder stones in the common bile duct ) • Pancreatitis ( if the stone impacted at the ampulla of vater ) There is rare case where the impaction of the stone at the ampulla of vater doesn’t cause pancreatitis ? Pancreatic divisum • Ca. gall bladder ( adenocarcinoma is the most common ) Rarely the irritation by the stones cause metaplasia >> dysplasia >> squamous cell carcinoma )

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 Manifestation of • Lab. Leucocytosis infection ( E. coli) Bilirubin normal or increased in less than 20%, , either due o edema causing pressure in the CBD or stones • 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 ( pain in the RUQ , radiating to the back , refer to the shoulder , , post prandial) nausea , fever, anorexia , marphy sign positive • Radiography • Oral cholecystogram ( radio-active iodine ) • U/S ( most of them diagnose by us ) >> only in few cases with distended abdomen ( fat or gases) its difficult The US findings : 1 - black shadowing of the GB 2 - thickening of the wall more than 3 mm 3 - pericystic fluid edema around the GB ( halo sign ) • Hepatobiliary scantigraphy HIDA >> important in acalculous GB stones 5%

Acute cholecystitis cont. Management • Early supporitive measures • I. V. fluid, Analgesics, antibiotics >> act on gram negative bacteria E. coli • Early cholecystectomy 3 – 5 days • Elective or delayed cholecystectomy 4 – 6 weeks

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

Indication of cholecystectomy for asymptomatic GB stones • 1 - large stones more than 5 cm • 2 - calcification in the wall of the GB • 3 - porcelain GB ( malignancy ) • 4 - typhoid carrier >> because the GB harbor T. bacilli • 5 - extremes of age

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” >> bilirubin , alkaline phosphatase , ALT , AST • U/S • +/- C. T. • MRCP • “ magnetic resonance cholangia pancreato graph” if stones appear the treatment is >> E. R. C. P. – P. T. C “ percutaneous transhepatic cholangiography 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

Acalculous cholecystitis • Less than 5% • Common in children and old people • ( severely ill like the ICU patients ) • Not caused by stones • Mainly due to ischemia • More serious than calculus >> because of risk of early perforation and peritonitis