Gall bladder & Bile duct

Why is it important to know about it? Related cases are commonly encountered in Surgical words. Biliary stone linked Biliary colic Acute or Chr. Cholecystitis Mucocele/Empyema GB Acute Cholangitis Obstructive Jaundice Acute Pancreatitis

 Biliary growths

Carcinoma Gall-bladder Cholangiocarcinoma

Congenital anomalies Biliary atresia Choledochal cyst

Post-injury Biliary Shock / Peritonitis Stricture of CBD Others Acalculus Cholecystitis Sclerosing Cholangitis

Why anatomy is important here to Know

TO HAVE SAFE & EFFECTIVE BILIARY SURGERY. If inflamed mucosa present - Pain persists. If duct is injured -- Stricture, Jaundice. If blood vessels injured Bleeding, Liver malfunction.

 Gall-bladder - Length-, Capacity-, Parts-, Muscle fibres-, Mucosa-, Variations (Septum, double gall bladder, diverticulum, accessory cholecystohepatic duct ).

Cystic duct - Length-, breadth-, Valve of Heister,Spincture of Lutkins, Variations (Absent, Low insertion, High insertion).

 CBD - Length-, Parts ( Supra-duodenal, retro-duodenal, infra-duodenal), Variations (Extra-hepatic atresia, Choledochal cyst). Blood supply - Hepatic artery may have caterpillar turn in front of cystic duct. Cystic artery may arise from Rt. hepatic artery crossing in front of common hepatic duct . Accessory Cystic artery from gastroduodenal artery.

Function of Gall bladder

Storage and timely release of Bile. Concentration of bile 5-10 times. Secretion of mucus.

Investigation of Biliary tract disease

Plain X-ray abdomen-10% gall-stones radio-op. Porcelain G.B. a premalignant condition. USG of HBS &Pancreas It is the initial investigation with suspected G.B. disease ( Stone,dilated duct,wall-thickness, inflammation around G.B.). Bile duct disease ( Duct dilatation, Rarely Stone) Pancreas (May show Carcinoma).

 MRCP/ERCP- Specific for bile-duct anatomy & Pathology (Stone, dilatation, growth). Radio-isotope scan - For demonstration of obstruction to bile flow (Cholecystitis, Bilioenteric anastomosis etc.) PTC Useful in assessment of intrahepatic biliary channels & relief of obstruction by external drainage or stent. Per-operative Cholangiography/choledochoscopy Both are useful for per operative bile duct assessment.

Investigation in Jaundice patient

For exclusion of Pre-hepatic causesReticulocyte count Haptoglobin lebel Coombs test Blood film Liver Synthetic function Serum albumin Prothrombin time / INR. Liver cell damage Transaminases. -glutamyl transferase

 Bile duct Obstruction Alkaline Phosphatase USG of Hepato-biliary system & Pancreas MRCP ERCP CT for Pancreatic lesion PTC Intrahepatic Mass Cross-sectional imaging by USG & CT with needle biopsy.

Gall-Stones
According to clinical composition there are 3 types Cholesterol stonesConsists of Cholesterol, usually solitary, oval, may be multiple, Cut section shows crystals radiating from centre.

 Mixed stones Cholesterol is the major component. Others are Ca bilirubinate Ca carbonate Ca palmitate Ca phosphate & Protein Cut surface shows laminated light & dark zones of Cholesterol & Pigment.

 Pigment StonesConsists of calcium bilirubinate. Small, multiple, gritty, fragile

In Europe & USA 80% are Cholesterol & Mixed Stone In Asia 80% are Pigment Stones.

 Incidence A typical sufferer is a fat, fertile, flatulent, female of fifty. But it can occur in both sexes from childhood to centinarian. Commom in North India,Europe; Less in Africa. Causal factor Cholesterol,which is insoluble in water is secreted from biliary canaliculi in phospholipid vesicles. Solubility of Cholesterol depends on detergent action of the type & concentration of phospholipids & bile acid.

When bile is supersaturated with cholesterol or bile acid concetration is low,unstable unilamellar phospholipid vesicles form from which cholesterol crystal may nucleate, and stone may form. Supersaturation (with cholesterol) of phospholipid vesicles Nucleation (of Cholesterol crystals)
Aggregation of Crystals (into stone)

 Supersaturation. Due to metabolic factors. Cholesterol occur in aged obese females on fatty diet or genetic predisposition. Contraceptives & Clofibrate favours. Bile acid occurs in bile acid loss as occurs in decreased transit time, fecal enteric flora, ileal resection. Also with estrogen ( in HRT) & Cholestyramine. Nucleation. Factors include infection(dead bacteria),mucus, glycoprotein. Aggregation. Impaired GB function (Stasis).Occurs with Pregnancy, Estrogen, trunkal vagotomy, Parenteral nutrition.

 Pigment stones are of 2 types :Black - In Hemolytic anaemia Cirrhosis of Liver. Brown- Occurs in bile duct due to stasis, infection, F.B. within(e.g. AL, Stent). Deconjugation of bilirubin occur.

Effects & Complications of Gallstones

In G.B. Biliary colic Acute & Chronic Cholecystitis Mucocele & Empyema of G.B. Gangrene & Perforation. In Bile duct Obstructive Jaundice Acute Cholangitis Acute Pancreatitis In intestine Intestinal Obstruction(Gallstone ileus)