GB

1. Gall bladder disease
Mahteme Bekele (MD)
Assistant professor of surgery
Emergency directorate director
Postgraduate program director
SPHMMC
2/1/2023 mahteme bekele

2. Objectives
• To identify
– Common diseases of the GB
– Common presenting symptoms of GB disease
– principles and options of management GB
disease
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RUQ Anatomy: GB Location
• GB lies inferior to liver
• Between the right and quadrate hepatic lobes
• Hollow viscus in the gallbladder fossa 7-10cm
• Consists of fundus, body, and neck
• Neck tapers to cystic duct

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RUQ Anatomy
Gallbladder
Left
liver
lobe
Hepatic
artery
Portal
vein
IVC
Cystic
duct
Right
liver lobe
Common
Bile Duct
Quadrate
liver lobe

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The Bile Duct System
• Liver makes bile 500-1000ml/day
• Out to common hepatic duct
• Goes to…
– Common bile duct to duodenal ampulla
– Cystic duct to gall bladder

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Gallbladder function
• Reservoir for bile ( contains 40–70 ml bile)
• Concentrates bile up to 5-10x
– water is absorbed
– bile salts and solutes become concentrated
• Secretion of mucous up to 20 ml/d
• Contract &release bile into duodenum

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Gallbladder Anomalies
• Agenesis
• Hypoplasia
• Hyperplasia
• Total reduplication
• Subtotal division of fundus
• Phrygian cap
• Septated gallbladder
• Floating gallbladder

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Pathologic Conditions of the GB
• Cholelithiasis
• Cholecystitis
• Sludge
• Gall bladder Cancer
• GB polyps
– Benign polyps
» Adenomyomatosis
» Adenoma
» Cholestrolistasis
» Inflammatory polyps
» Miscellaneous
– Malignant polyps
» Adenocarcinoma
» Miscellaneous

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Cholelithiasis
Incidences
Most common biliary pathology
Prevalence: 6-10 % men, 12-20 % women
 Fat, fertile, flatulent, female of fifty.
Majority of gallstones clinically silent
18-50% become symptomatic over 10-15yr

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Classification
Based on stone composition ,location& etiology.
• Composition
– Cholesterol stone
– Pigment stone
– Mixed stone
• Location
– GB
– Extra hepatic BD
– Intra hepatic BD
– Major elements – cholesterol, bile pigments, calcium.
– Others – Fe, P, CO3, mucus,debris

12. RISK FACTORS
• Age >60yrs
• Gender women b/n 20-60 2x risk
•Estrogens
•pregnancy, hormone replacement, pills
•Obesity esp. in women
•Rapid wt loss
• Fasting Diabetes
•SBS , TPN ---- increase PGS
•cirrhosis & hereditary blood disorders
•Vagotomy
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pathogenesis of Gallstone
Multifactorial
• Metabolic(Abnormal bile production)
• Bile stasis
• infectious

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Nucleating agents
•Mucus
•Glycoprotein
•Infection
Supersaturated bile
•Age
•Sex
•Genetics
•Obesity
•Diet
Absorption/EHC
•Deoxycholate
•SBS
•Fecal flora
•Ileal resection
•Cholestiramine
Impaired GB function
•Emptying
•Absorption
•Excretion

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Pathogenesis Cholesterol & mixed stone
occurs in three stages
1) Cholesterol saturation
♣mixed bile acids, lecithin &cholesterol…micelles
♣ any alteration …cholesterol precipitation
♣ due to ↑ed quantity or alteration of the vehicle
…critical step
♣ supersaturation can occur due to
secretion of hepatic bile with either high cholesterol
or low bile acids or lecithin …litogenic bile

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2) Nucleation
 cholesterol monohydrate crystals form & agglomerate
…macroscopic stones
 promoters or retarding agents
● heat labile GP in the bile as potential pronucleating
factors (e.g GB mucus)
 Stasis of bile in the GB
● ↓ GB motility & emptying
● ↑ed calcium
● ↑ PGS
● alteration in GB secretion &absorption
3) Stone Growth
● Due to cholesterol precipitation & agglomeration

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Pathogenesis of Pigmented Stones
Due to
altered solubilization of unconjugated bilirubin
with precipitation of ca bilirubinate & insoluble salts
2 types
1.Brown pigment stones
-common in Asia
-secondary to infection
-release of beta glucuronidase
2. Black pigment stones
-pts with haemolytic dd. & cirrhosis

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Clinical Presentation
I. Asymptomatic
Dx incidentally > 50% of pts with GS
25% of pts within 5 yr…symptomatic
II. Symptomatic or cxn. of GS
biliary Colic
-sudden onset (30-60min) after meal
-increased freq. & intensity with time
-6-10% risk of recurrent each year
-2% risk of comp.
-large solitary stones…acute cholecystitis
-multiple stones<4 cm…acute pancreatitis

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Complications of GS
• IN THE GALLBLADDER
due to mov’t of stones & infection
cholecystitits →acute or chronic
gangrene
perforation
-biliary peritonitis
-biliary-enteric fistula
empyema
mucocele (hydrops)
carcinoma

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Cxn…cont’d
• IN THE BILE DUCTS
obstructive jaundice
cholangitis
 Acute pancreatitis
• IN THE INTESTINE
acute intestinal obstruction (GS ileus)

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Cholecystitis
• Could be
acute or chronic inflammation
Calculous or acalculous
• Risk factors: obstruction and bile stasis
• Bacterial growth common but secondary

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CHRONIC CHOLECYSTITIS
 incompletely resolved AC
 contracted fibrotic GB
 dyspepsia …belching ,flatus ,abdominal bloating
,fullness epigastric burning & Nausea & Vomiting

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ACUTE CHOLECYSTITIS
►most common cxn. of GSD
► in 95%....GS impacted at Hartman’s pouch
… acute inflammation of GB
► 50% bacteria cultured
► middle aged & elderly
►Hx of episodic biliary colic pain Unremitting for
days

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Hx persistence RUQ pain > 4 hrs
+ Nausea & Vomiting
+/- Pyrexia
+/- chills &Rigors
P/E
Direct & rebound tenderness & guarding
In 50%
mass in RUQ … 20%
Leukocytosis
Murphy’s sign +ve

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DDx
 perforated PUD
 appendicitis
 acute pancreatitis
 hepatitis
 lobar pneumonia
 pyelonephritis
 AMI

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ACALCULAS CHOLECYSTITIS
 pts with major abdominal & thoracic surgery & TPN
 recovering from major trauma
 severe burns
Acute emphysematous cholecycistitis
 serious form of Ac.
 xized by gas in the lumen or wall of the GB
 in the elderly pts
 25% have DM
 CF as AC but pts are more toxic
 DX ….air in the gallblader or wall on plain abd. Film
 GS in 75% of pts

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INVESTIGATION AND DIAGNOSIS
1. History & P/E
Typical biliary colic
may be associated with
fatty meal intolerances
Nausea and vomiting
Any of the atypical symptoms
Non-specific atypical symptoms like
indigestion,
abdominal bloating
Belching
although commonly reported by patients with gallstones,
are less likely to be caused by cholelithiasis since they are least likely to
disappear after cholecystectomy

28. 2. Standard base line investigation
- CBC
-LFT
-Serum Amylase ….. Acute pancreatitis
- Blood culture
3. Plain radiography
- 10% of GS are radio opaque
-not routinely indicated
-in acutely ill pts to R/O perforated viscus
- Gas in the GB or BD
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4. ULTRASOUND
primary screening
procedure
 can show us….
 Calculi with acoustic
shadow
 thickened wall ,
 distension of GB
 localized
pericholecystic
collection
 dilated CBD

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5. Oral cholecystography (OCG)
- replaced by U/S
- used to assess GB function
6. IV cholangiography
-to see extrahepatic biliary tree
-effective in jaundiced pts.
7. CT & MRI
- to R/O pancreatic head tumour
8. Scintography … to Dx acute cholecystitis

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9. PTC & ERCP
- in pts with comp. acute biliary dd. & jaundice
- clotting studies before PTC
- prophylactic antibiotics
indicated in pts.
- known GBS with increased bilirubin >10 mg/dl
- Sx pts with previous cholecystectomy
- pts with biliary Sx & inconclusive evidence

32. Management of GB stones
• category 1-Gallstones on imaging studies but
without symptoms
• category 2- Typical biliary symptoms and
gallstones on imaging studies
• category 3-Atypical symptoms and gallstones
on imaging studies
• category 4 -Typical biliary symptoms but
without gallstones on imaging studies
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33. Category 1
• Asymptomatic
– SYMPTOMS DEVELOPMENT
– ~3% /year ….2/3rd remain asymptomatic in
20years
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Management of acute cholecystitis
A. Conservative Rx
i. relief of pain
NSIAD
 opiates & morphine
 i.v fluids if DHN
ii. Control of nausea & vomiting
 keep NPO
anti emetics
NG tube
iii. Control of fever
broad spectrum Abs( blood culture)
-cephalosporin's & aminoglycosides
most pts respond within 48 hrs
 elective cholecystectomy after 6-8 wks

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Mx of…cont’d
B. Definitive Rx
I. Removal of GB & stones after 6-8wks
♣open cholecystectomy
♣ Laparoscopic cholecysectomy
**Emergency cholecystectomy
- pts not settling within 48 hrs
- pts with DM to prevent gangrene
II. Removal of GS alone
♣ medically dissolution agents (CDCA’& UDCA )
♣ other procedures Lithotripsy (ESWL)

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Mx of stones in CBD
• 1o stones originate in the CBD
• 2o stones -- Most CBD stones originate in the GB
• cxn of CBD stone
Obst. Jaundice
Cholangitis fever
RUQ pain Charcot’s triad
Jaundice
Charcot’s triad
+
altered mental status Reynolds’s pentad
+
shock
Suppurative cholangitis=>liver abscess
Impaired LF =>Biliary cirrhosis

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• DDx of obstructive jaundice
►CBD stones
► Pancreatic head tumor
► Biliary stricture
► Periampulary tumors
► Drug induced jaundice,
► Hepatitis (viral)
• Investigations
LFT,U/S,ERCP,PTC ,MRI ,CT

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• choledochotomy
Indications
(1) palpable CBD stones
(2) If there is jaundice or
Hx of jaundice or
cholangitis
(3) dilated CBD
(4) abnormal LFT, in particular, the alkaline
phosphatase is raised