This document provides information on gall bladder diseases, including: 1. The anatomy and physiology of the gallbladder and biliary system. 2. Common gallbladder diseases like cholelithiasis, biliary colic, acute and chronic cholecystitis, and indications for cholecystectomy. 3. Radiological investigations used to diagnose gallbladder diseases, including ultrasonography, MRCP, ERCP, and PTC. The gallbladder stores and concentrates bile produced by the liver. Gallstones are common and may cause biliary colic, acute cholecystitis, or migrate and obstruct the common bile duct. Ultrasonography is usually the first imaging test,

1. Gall bladder Diseases
Dr. Jwan Ali AlSofi

2. Contents:-
• Anatomy of gallbladder
• Physiology of gallbladder
• Radiological Investigations of gallbladder diseases
• CHOLELITHIASIS
• Biliary colick
• Acute cholecystitis
• Chronic cholecystitis
• Mucocoele & Empyema of the gall bladder
• Biliary duct diseases
• Acute cholangitis
• Intestinal obstruction (gallstone ileus)
• Indications for Cholecystectomy & its complications.

3. Anatomy of gall bladder
• The gall bladder lies on the underside of the liver in the
main liver scissura at the junction of the right and left
lobes of the liver.
• The relationship of the gall bladder to the liver varies
between being embedded within the liver substance to
being suspended by a mesentry.
• It is a pear-shaped structure, 7.5–12 cm long.
• The anatomical divisions are
1. fundus,
2. body
3. Neck that terminates in a narrow infundibulum (The
infundibulum undoubtedly represents the so-called
Hartmann's pouch, a term frequently used by surgeons
when they find a large stone jammed there).
• The common hepatic duct is formed by the union of the right
and left hepatic ducts.

4. The common bile duct –CBD- :-
• Normal diameter is ≤ 4 mm,
• Dilated if ≥ 8mm,
• 4-8 mm is considered equivocal
• Is formed by the junction of the cystic and
common hepatic ducts.
• It is divided into four parts:
1. Supraduodenal portion. running in the free
edge of the lesser omentum.
2. Retroduodenal portion.
3. Infraduodenal portion lies in a groove, but at
times in a tunnel, on the posterior surface of
the pancreas.
4. Intra duedenal portion ,passes obliquely
through duedenal wall & encircled by
sphinctor of oddi, and terminates by opening
on the summit of the ampulla of Vater.
Common hepatic duct
Intra duedenal portion
Infraduod
enal
portion
Retroduo
denal
portion
Supraduo
denal
portion

5. • Calot’s triangle, or the hepatobiliary triangle, was initially described by Calot as the
space bordered by:
1. the cystic duct inferiorly,
2. the common hepatic duct medially
3. the superior border of the cystic artery.
• This has been modified in contemporary literature to be the area bound:
1. superiorly by the inferior surface of the liver,
2. laterally by the cystic duct and the medial border of the gallbladder
3. medially by the common hepatic duct.
• It is an important surgical landmark as the cystic artery usually can be found within
its boundaries and should be identified by surgeons performing a cholecystectomy to
avoid damage to the extrahepatic biliary system

8. Surgical physiology
• Bile is produced by the liver and stored in the gallbladder, from which it is
released into the duodenum.
• As it leaves the liver it is composed of:
1. 97% water,
2. bile salts (cholic and chenodeoxycholic acids, deoxycholic and lithocholic
acids),
3. phospholipids,
4. cholesterol
5. bilirubin.
• The liver excretes bile at a rate estimated to be approximately 40 mL/hour.
• About 95% of bile salts are reabsorbed in the terminal ileum (enterohepatic
circulation).

9. 1. The gall bladder is a reservoir for bile.
 During fasting, resistance to flow through the sphincter of Oddi is high, and
bile excreted by the liver is diverted to the gall bladder.
 After feeding, the resistance to flow through the sphincter is reduced, the gall
bladder contracts and the bile enters the duodenum.
• These motor responses of the biliary tract are in part effected by cholecystokinin
2. Concentration of bile by active absorption of water, sodium chloride and
bicarbonate by the mucous membrane of the gall bladder.
• The hepatic bile which enters the gall bladder becomes concentrated 5–10
times, with a corresponding increase in the proportion of bile salts, bile
pigments, cholesterol and calcium.
3. Secretion of mucus – approximately 20 mL is produced per day.
• With complete obstruction of the cystic duct in an otherwise healthy gall
bladder, a mucocoele may develop as a result of ongoing mucus secretion by
the gall bladder mucosa.
FUNCTIONS OF THE GALL BLADDER

10. Radiological investigations
Plain x-rays:
1. plain x-ray of the gall bladder will show radiopaque gallstones in 10 % of patients
2. A plain x-ray may also show the rare cases of calcification of the gall bladder,
a so-called ‘porcelain’ gall bladder.:
o Traditionally, this has been considered an indication for cholecystectomy as
it was associated with a high incidence of gallbladder carcinoma.
o However, contemporary data suggest that this may not be the case, with the
true incidence of cancer being less than 5%. Therefore, decisions on whether
or not a cholecystectomy should be performed should be individualised
depending on the age of the patient, comorbidities and presence or absence
of symptoms.
3. Gas may be seen in the wall of the gall bladder (emphysematous cholecystitis)
 in such cases emergency cholecystectomy is indicated.
4. Gas in the biliary tree may be seen after endoscopic sphincterotomy or surgical
anastomosis.

12. Gas in gallbladder:-
• Causes:-
1. Perforation of the galbladder into the bowel
(galstone, inflammation; tumor trauma), usually
accompanied by air in the bile ducts
2. Emphysematous cholecystitis
• Is a severe form of acute cholecystitis
• Results from ischemia of the gallbladder wall associated
with proliferation of gas-forming bacteria, including
Clostridium perfringens, Escherichia coli, or other gut
flora.
• Diagnosed by presence of gas in the lumen or wall of
gallbladder
• The gas is not caused by fistulous communication with the
GIT tract or from instrumentation
• Treatment includes emergent cholecystectomy.
3. After surgery Or papillotomy (endoscopic
sphincterotomy)

13. Ultrasonography
• Transabdominal ultrasonography is the initial imaging modality of choice
as it is accurate, readily available, inexpensive and quick to perform.
• However, it is operator dependent and may be suboptimal due to
excessive body fat and intraluminal bowel gas.
• It can demonstrate biliary calculi, the size of the gall bladder, the
thickness of the gall bladder wall, the presence of inflammation
around the gall bladder, the size of the common bile duct and,
occasionally, the presence of stones within the biliary tree.
• For the patient who presents with obstructive jaundice,
ultrasonography is particularly helpful because:
1. it can identify intra- and extrahepatic biliary dilatation
2. often the level of obstruction.
3. the cause of the obstruction may also be determined, such as
gallstones in the gallbladder, common hepatic or CBD stones,
lesions within the wall of the common bile duct suggestive of a
cholangiocarcinoma or enlargement of the pancreatic head
indicative of a pancreatic carcinoma.

14. Cholescintigraphy:
• Technetium-99m (99mTc)-labelled derivatives of iminodiacetic acid (HIDA, IODIDA) when injected intravenously are
selectively taken up by the retroendothelial cells of the liver and excreted into the bile.
• It is useful in :
1. visualisation of the biliary tree and gallbladder
 acute cholecystitis  Non-visualisation of the gallbladder.
 chronic cholecystitis  the patient has a contracted gallbladder, the gallbladder visualisation may be
reduced or delayed.
 gallbladder dyskinesia  An abnormally low gallbladder ejection fraction; however, the diagnosis and
interpretation of cholescintigraphy in this context are controversial.
2. diagnosing bile leaks and iatrogenic biliary obstruction.

15. Magnetic resonance cholangiopancreatography (MRCP):
• Is non-invasive modality that provides excellent imaging of the gallbladder and biliary system
• Images can be obtained of the biliary tree demonstrating ductal obstruction, strictures or other intraductal
abnormalities.
• Images comparable to those obtained using ERCP or PTC can be achieved non-invasively without the potential
complications of either technique.

16. Endoscopic retrograde cholangiopancreatography (ERCP):
• This technique remains widely used as both a diagnostic and a therapeutic modality.
• While the widespread availability of ultrasound and MRCP has reduced its diagnostic use.
• ERCP has evolved into a mainly therapeutic rather than a diagnostic technique.
• Using a “side-viewing” endoscope the ampulla of Vater can be identified and cannulated.
1. Injection of water-soluble contrast directly into the bile duct provides excellent images of
the ductal anatomy and can identify causes of obstruction such as calculi or malignant
strictures .
2. ERCP still has an important role in the assessment of the patient with obstructive
jaundice. In this group of patients it is especially useful in determining the cause and level
of obstruction.
3. During ERCP, bile aspirates can be sent for cytological and microbiological examination,
and endoluminal brushings can be taken from strictures for cytological studies.
4. Therapeutic interventions such as stone removal or stent placement to relieve the
obstruction can be performed.

18. Percutaneous transhepatic cholangiography (PTC):
• This is an invasive technique in which the bile ducts are cannulated directly.
• Prior to the procedure:-
• It is only undertaken once a bleeding tendency has been excluded and the patient’s prothrombin time is normal.
• Antibiotics should be given prior to the procedure.
• Procedure:-
• Usually, under fluoroscopic control, a is introduced percutaneously into the liver substance.
• Under radiological control (either ultrasound or CT), a bile duct is cannulated.
• Successful entry is confirmed by contrast injection or aspiration of bile.
• Water-soluble contrast medium is injected to demonstrate the biliary system.
• Multiple images can be taken demonstrating areas of strictures or obstruction.
• Useful in:-
• Bile can be sent for cytology.
• placement of a catheter into the bile ducts to provide external biliary drainage
• insertion of indwelling stents.
• PTC OR ERCP:-
• In general, if a malignant stricture at the level of the confluence of the right and left hepatic ducts or higher is
suspected in a jaundiced patient, a PTC is preferred to ERCP as successful drainage is more likely.

21. GALLSTONES (CHOLELITHIASIS)
• Gallstones are the most common biliary pathology.
• It is estimated that gallstones affect 10–15 per cent of the population in
western societies.
• Approximately, 1–2 per cent of asymptomatic patients will develop symptoms
requiring surgery per year, making cholecystectomy one of the most common
operations performed by general surgeons.

22. Gall stone types
1- cholesterol
2-pigmented
3-mixed
• In the US and Europe, 80 % are cholesterol or mixed stones,
• in Asia, 80 % are pigment stones.
• Cholesterol or mixed stones contain 51–99 % pure cholesterol plus an
admixture of calcium salts, bile acids, bile pigments and phospholipids.
• Pigment stone is the name used for stones containing less than 30 %
cholesterol.

23. Gall stone types: Cholesterol
1. Cholesterol, which is insoluble in water, is secreted from the canalicular membrane in
phospholipid vesicles.
2. Whether cholesterol remains in solution depends on the concentration of phospholipids and
bile acids in bile, and the type of phospholipid and bile acid.
3. Micelles formed by the phospholipid hold cholesterol in a stable thermodynamic state.
4. When bile is supersaturated with cholesterol or bile acid concentrations are low, unstable
unilamellar phospholipid vesicles form, from which cholesterol crystals may nucleate, and
stones may form.
5. Nucleation of cholesterol monohydrate crystals from multilamellar vesicles is a crucial step in
gallstone formation.
 Obesity, high-caloric diets and certain medications (e.g. oral contraceptives) can increase
secretion of cholesterol and supersaturate the bile increasing the lithogenicity of bile.
 Resection of the terminal ileum, which diminishes the enterohepatic circulation, will deplete
the bile acid pool and result in cholesterol supersaturation.
• Abnormal emptying of the gall bladder function may aid the aggregation of nucleated
cholesterol crystals; hence, removing gallstones without removing the gall bladder
inevitability leads to gallstone recurrence.

25. Gall stone types: Black pigmented
• Black stones are largely composed of: an insoluble bilirubin pigment polymer + calcium phosphate +
calcium bicarbonate.
• Overall, 20–30 per cent of stones are black.
• The incidence rises with age.
• Black stones are associated with haemolysis, usually hereditary, spherocytosis or sickle cell disease.
• For reasons that are unclear, patients with cirrhosis have a higher instance of pigmented stones.
Gall stone types: Brown pigmented
• Brown pigment stones contain: calcium bilirubinate + calcium palmitate + calcium stearate + cholesterol.
• Brown stones are rare in the gall bladder.
1. They form in the bile duct and are related to bile stasis and infected bile.
• Stone formation is related to the deconjugation of bilirubin deglucuronide by bacterial β-
glucuronidase.
• Insoluble unconjugated bilirubinate precipitates.
2. Brown pigment stones are also associated with the presence of foreign bodies within the bile ducts,
such as endo-prosthesis (stents), or parasites, such as Clonorchis sinensis and Ascaris lumbricoides.

26. Gall stone : Clinical presentation
• Gallstones may remain asymptomatic, being detected incidentally as imaging
is performed for other symptoms.
• If symptoms occur, patients typically complain of right upper quadrant or
epigastric pain, which may radiate to the back.
• This may be described as colicky, but more often is dull and constant.
• Other symptoms include dyspepsia, flatulence, food intolerance, particularly
to fats, and some alteration in bowel frequency.
• Transient obstruction precipitates acute biliary pain (biliary colic) whereas
persistent obstruction can lead to (acute cholecystitis) or its subsequent
complications.
• Jaundice may result if the stone migrates from the gall bladder and obstructs
the common bile duct.
• Rarely, a gallstone can lead to bowel obstruction (gallstone ileus)

28. Diagnosis
• A diagnosis of gallstone disease is based on the history and phys,ical
examination with confirmatory radiological studies, such as
transabdominal ultrasonography.
• CT scan of abdomen.
• MRCP(magnetic resonance cholangio-pancreatography)
• CBP &WBC count
• LFT

29. Biliary colic
o Biliary colic is due to transient obstruction of the gallbladder from an impacted stone.
o is typically present in 10–25 per cent of patients.
o This is described as a severe right upper quadrant pain which ebbs and flows (wax and wane).
(This pain is due to sudden spasm of gallbladder wall when gallstone moves towards the neck of
the gallbladder or cystic duct and gets impacted).
o Pain may radiate to the chest/back.
o associated with nausea and vomiting. (There is reflex pylorospasm causing vomiting. )
o The pain is usually severe and may last for minutes or even several hours.
o Frequently, the pain starts during the night and wakes the patient.
o Minor episodes of the same discomfort may occur intermittently during the day.
o Dyspeptic symptoms may coexist and be worse after such an attack.
o Resolution occurs when the stone falls back into the gallbladder lumen or passes onwards into
the common bile duct. The patient then recovers rapidly.
o As pain resolves, patient improves and is able to eat and drink again, often only to suffer further
episodes.
o It is of interest that a patient may have several episodes of this nature over a period of a few
weeks and then no more trouble for some months.
o In some patients, the obstruction does not resolve and the patient develops acute cholecystitis.

31. Acute cholecystitis: Pathogenesis
1. This is usually produced by obstruction of the neck of the gallbladder or cystic duct by a stone.
2. The obstruction results in increased pressure within the lumen of the gallbladder.
3. This results in bile being forced across the mucosal membrane resulting in an acute chemical inflammatory
reaction.
4. The trauma caused by the gall stones stimulates the synthesis of prostaglandins I2 and E2, which mediate the
inflammatory response.
5. Secondary bacterial infection with enteric organisms (most commonly Escherichia coli, Klebsiella, and
Streptococcus faecalis) occur in about 20% of cases.
6. The persistently obstructed gallbladder becomes intensely inflamed and oedematous.
 Fortunately in the majority of cases, the process is limited by the stone slipping back into the body of the gall
bladder and the contents of the gall bladder escaping by way of the cystic duct. This achieves adequate
drainage of the gall bladder and enables the inflammation to resolve.
 If the obstruction fails to resolve the transmural pressure in the wall of the gallbladder can result in venous
ischaemia, an empyema of the gall bladder may result. The wall may become necrotic and perforate, with
development of localised peritonitis.
• Perforation may be contained by the liver or surrounding viscera leading to localised abscess formation or
may result in biliary peritonitis.
• The abscess may then perforate into the peritoneal cavity with a septic peritonitis – because the inflamed
gall bladder is usually localised by omentum which contains the perforation.
• Gangrene occurs most commonly at the fundus because the vascular supply often becomes compromised.

33. Acute cholecystitis: Presentation
• Acute cholecystitis is a more prolonged and severe illness. Symptoms do not resolve, but progress to continued pain.
• It usually begins with an attack of biliary colic, although its onset may be more gradual.
• The pain in acute cholecystitis is usually constant and continues for 12-24 hours or more, differentiating this from biliary colic
where pain is short-lasting.
• There is severe RHC pain radiating to the right subscapular region, and occasionally to the right shoulder
• May be associated with a tachycardia, pyrexia, nausea, vomiting and leucocytosis and moderately elevated LFT.
• Boas’s sign and Murphy’s sign are usually present:
o Right upper quadrant tenderness that is exacerbated during inspiration by the examiner’s right subcostal palpation
(Murphy’s sign). A positive Murphy’s sign suggests acute inflammation.
o Boas’s sign: In acute cholecystitis, pain radiates to the tip of the scapula and there is a tender area of skin just below the
scapula, which is hyperaesthetic.
• A mass may be palpable as the omentum walls off an inflamed gall bladder.
• The development of a tender mass, associated with rigors and marked pyrexia, signals empyema formation.
• Mild jaundice (serum concentrations of bilirubin <60 μmol/l) can develop during the acute attack.
o caused by inflammation and oedema around the biliary tract and direct pressure on the biliary tract from the distended
gall bladder.
• Concentrations of bilirubin >60 μmol/l suggest a diagnosis of:
1. choledocholithiasis (a gall stone in the common bile duct)
2. Mirrizzi's syndrome (obstruction by a stone impacted in Hartmann's pouch that compresses the common hepatic duct).
• The gallbladder may become gangrenous and perforate, giving rise to biliary peritonitis.

34. Clinical features of acute cholecystitis: diagnosis is made when features
from all three points of diagnostic triangle are present.
Ultrasonography evidence
of cholecystitis:-
• stones in the gallbladder,
• a thickened gallbladder
wall,
• pericholecystic fluid,
• sonographic Murphy sign
+.
↑ liver enzymes

37. Treatment of acute cholecystitis
 Non-operative treatment is based on four principles:
1. Nil per mouth (NPO) and IV administration until the pain resolves.
2. Administration of analgesics.
3. Administration of antibiotics. As the cystic duct is blocked in most instances, the concentration of
antibiotic in the serum is more important than its concentration in bile. A broad-spectrum antibiotic
effective against Gram-negative aerobes is most appropriate (e.g. cefazolin, cefuroxime or gentamicin).
4. Subsequent management.
• When the temperature, pulse and other physical signs show that the inflammation is subsiding, oral fluids
are reinstated followed by regular diet.
• Ultrasonography is performed to confirm the diagnosis.
• If jaundice is present, an MRCP is performed to exclude choledocholithiasis.
• If there is any concern regarding the diagnosis or presence of complications, such as perforation, a CT should
be performed.
• Cholecystectomy may be performed on the next available list, or the patient may be allowed home to return
.

38. Treatment of acute cholecystitis
• Conservative treatment must be abandoned if the pain and tenderness increase;
depending on the status of the patient:
1. either operative intervention and cholecystectomy should be performed
2. or if the patient has comorbid conditions, a percutaneous cholecystostomy can be performed by a
radiologist under ultrasound control. This will usually rapidly relieve symptoms, however an interval
cholecystectomy will be required once the patient’s condition has stabilised.
• The timing of surgery in acute cholecystitis remains controversial with many units favouring an early
intervention within the first week, whereas others suggest that a delayed approach is preferable. Early
cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay.
• Provided that the operation is undertaken within 5–7 days of the onset of the attack, the surgeon is
experienced and excellent operating facilities are available, good results are achieved.
• Nevertheless, the conversion rate in laparoscopic cholecystectomy is higher in acute than in elective
surgery.
• If an early operation is not indicated, one should wait approximately 6 weeks for the inflammation to
.

40. Chronic cholecystitis
• Chronic cholecystitis is the most common cause of symptomatic gallbladder disease.
• Repeated bouts of transient gallbladder obstruction (biliary colic) or acute cholecystitis culminate in
1. fibrosis,
2. contraction of the gallbladder
3. chronic inflammatory change
4. marked thickening of the wall.
• The gallbladder ceases to function.
• Chronic inflammatory change may be present in the absence of gallstones, as is the case in the gallbladders of
typhoid carriers.
• The incidence of carcinoma of the gallbladder is increased in patients with long- standing gallstones.
• The patient gives a history of recurrent flatulence, fatty food intolerance and RUQ pain. The pain is worse after
meals and is often associated with a feeling of distension and heartburn.
• There is little systemic upset and no pyrexia.
• DDX:- duodenal ulcer, hiatus hernia, myocardial ischaemia, chronic pancreatitis and gastrointestinal neoplasia.

41. Palpable, non-tender gall bladder
1. A palpable, non-tender gall bladder (Courvoisier’s sign) portends a more sinister
diagnosis. This usually results from a distal common duct obstruction secondary
to a peripancreatic malignancy.
2. a distal common duct obstruction secondary to a stone.
3. Rarely, a non-tender, palpable gall bladder results from complete obstruction of
the cystic duct with reabsorption of the intraluminal bile salts and secretion of
uninfected mucus secreted by the gall bladder epithelium leading to a
mucocoele of the gall bladder.

42. Courvoisier’s law
• Fibrosed gallbladders that contain stones cannot distend when pressure
increases in the obstructed biliary tree.
• Courvoisier’s law states that ‘in a jaundiced patient, in obstruction of the
common bile duct due to stone, the gallbladder is seldom palpable; the organ
usually is already shrivelled; in distension due to other causes, distension is
common by comparison’.
• Simply stated, if the gallbladder is palpable in the presence of jaundice, the
jaundice is unlikely to be due to stone and one should think of a malignant cause
of the lower extrahepatic biliary tree.
• Distended gallbladders are not always easy to feel but can be detected readily by
ultrasound.

43. Mucocele of the gall bladder
• When stone impacted at neck of the gall
bladder, causes obstruction of cystic duct.
• Bile reabsorption, mucus secretion,
results in mucocele .
• Palpable non tender Rt up abdominal
mass.
• Symptoms for mucocoele are the same as
those for chronic cholecystitis but a
nontender piriform swelling may be
palpable in the right hypochondrium.
• If (mucocele)superadded by infection
results in empyema with fever
,leukocytosis &tender RUQ.

44. Empyema of the gall bladder
• Empyema may be a sequel of
- acute cholecystitis
- or the result of a
mucocoele becoming
infected.
• The gall bladder is distended
with pus.
• The optimal treatment is
drainage and, later,
cholecystectomy..

45. Mirizzi syndrome
• Is Partial or complete obstruction of
common hepatic duct due to gallstone
impaction in cystic duct, infundibulum, or
Hartmann pouch of gallbladder (GB).
• Present as painless jaundice or cholangitis.
• Rx:-
• Type 1  cholecystectomy
• Type 2  partial cholecystectomy with
bilioenteric anastomosis.

46. Gall stone illeus
• Large gallstones present for a long time
 chronic inflammation of gall bladder
with adhesion to surrounding organs 
pressure necrosis with erosion through the
wall of the gallbladder into surrounding
structures creating a fistula – Commonly
involved structures include the common
hepatic or bile duct (Mirizzi’s syndrome
type 2), duodenum, abdominal wall or
colon.
• Those eroding into the duodenum can pass
into the small bowel, impacted at terminal
ileum, resulting in mechanical small bowel
obstruction known as gallstone ileus.

47. Stone in the common bile duct(CBD)
Types:-
1. Primary stones:-
• Formed per primam in the CBD
• Usually of the brown pigment type
• They are the product of two conditions that must be corrected in treating these stones:- Bile
duct stasis and Infection
2. Secondary stones:-
• Formed within the gall bladder and migrate down the cystic duct to CBD
• More common type
• Usually are cholesterol stones

48. Stone in the common bile duct(CBD)
Presentation:-
1. Biliary obstruction
• Biliary obstruction causes jaundice,dark color urine,clay color stool, itching.
2. Acute cholangitis
• If infection occurred results in acute cholangitis(charcots triad)=fever & rigor,
colicky pain & jaundice.
3. Acute pancreatitis
• Pressure in the pancreatic duct with activation of pancreatic enzymes result in
pancreatitis, clinical features depend on severity.
• There is little muscle in the wall of the bile duct, and pain is not a symptom unless
the stone impedes flow through the sphincter of Oddi.

49. Stone in the common bile duct(CBD)
Management:-
• It is essential to determine whether the jaundice is due to liver
disease, disease within the duct, such as sclerosing cholangitis, or
obstruction.
• To identify the nature of the obstruction:-
1. Ultrasound scanning,
2. liver function tests,
3. liver biopsy if the ducts are not dilated,
4. MRI or ERCP.

50. Stone in the common bile duct(CBD)
Preoperative management:-
• Full supportive measures are required with rehydration,
• attention to clotting,
• exclusion of diabetes
• starting the appropriate broad-spectrum antibiotics.
• As soon as resuscitation has taken place, relief of the obstruction is essential.
Definitive management:-
• 1st choice:- Endoscopic papillotomy is the preferred first technique with a sphincterotomy,
removal of the stones using a Dormia basket or the placement of a stent if stone removal
is not possible.
• 2nd step:- If this technique fails, percutaneous transhepatic cholangiography can be
performed to provide drainage and subsequent percutaneous choledochoscopy.
• 3rd step:- Surgery, in the form of choledochotomy, is now rarely used for this situation as
most patients can be managed by minimally invasive techniques.

51. • Ascending bacterial infection of the biliary tract is usually associated with obstruction.
• Presents with clinical jaundice, rigors and a tender hepatomegaly.
• The diagnosis is confirmed by:
1. Ultrasound:- finding of dilated bile ducts,
2. Liver function tests:- obstructive picture
3. Blood on culture:- isolation of an organism.
• The condition is a medical emergency, and delay in appropriate treatment results in organ
failure secondary to septicaemia.
• Once the diagnosis has been confirmed, the patient should be:
1. commenced on a first-line broad-spectrum antibiotic
2. rehydrated, with monitoring of urine output and central venous pressure
3. adequate oxygen delivery
4. arrangements should be made for Urgent biliary decompression urgent ERCP or PTBD.
• Biliary stone disease is a common predisposing factor, and the causative ductal stones may
be removed at the time of endoscopic cholangiography by endoscopic sphincterotomy.
Ascending cholangitis

53. Acalculous cholecystitis
• Acute and chronic inflammation of the gall bladder can occur in the absence of stones
and give rise to a clinical picture similar to calculous cholecystitis.
• Some patients have non-specific inflammation of the gall bladder, whereas others have
one of the cholecystoses .
• Acute acalculous cholecystitis is particularly seen in critically ill patients and those
recovering from major surgery, trauma and burns.
• The diagnosis is often missed and the mortality rate is high.

54. INDICATIONS FOR CHOLECYSTECTOMY
 Patients with asymptomatic gallstones  it is safe to observe
 Patients who develop symptoms or complications  cholecystectomy
 Patients with biliary colic or cholecystitis  cholecystectomy.
 Prophylactic cholecystectomy may be considered for:-
1. Diabetic patients,
2. Those with congenital haemolytic anaemia
3. Patients who are undergoing bariatric surgery for morbid obesity
4. Porcelain gallbladder
5. Gallbladder polyp if:- single polyp > 1 cm / multiple polyps of any size.
6. Gallstone > 3 cm
7. Choledocolithiasis
• Symptomatic gall stones : need operation(cholecystectomy)by open or laparascopy.
• Colicky pain & infection : needs admission,pain killer,broad spectrum antibiotics.
• Obseructive jaundice : manages by ERCP ,which is diagnostic & therapeutic.
.

55. INDICATIONS FOR CHOLEDOCHOTOMY
 In an environment in which neither the modern diagnostic armamentarium
described at the beginning of this lecture nor peroperative cholangiography is
available, it is well to remember the traditional indications for choledochotomy,
which are:
1. Palpable duct stones
2. Jaundice or a history of jaundice or cholangitis
3. Abnormal liver function tests, in particular a raised alkaline phosphatase.
• The aim of this surgery is to drain the common bile duct and remove the stones through a
longitudinal incision in the duct.
• When the duct is clear of stones, a T-tube is inserted and the duct closed around it; the long
limb is brought out on the right side and the bile allowed to drain externally.
.

56. Reference
• Baily &Loves short practice of surgery