Gall Bladder Stone with the description of Anatomy of Gall bladder ,its physiology and pathogenesis etc.

2. ‫فیصل‬‫محمد‬
17-11-162 Gall Stone
GALL BLADDER STONE
‫ہ‬‫ر‬‫ا‬‫ر‬‫م‬ ‫حصاۃ‬
‫معاونین‬:‫اختر‬ ‫،دانش‬ ‫احمد‬ ‫نزیر،وسیم‬ ‫جنید‬
‫اسکالرس‬ ‫جی‬ ‫پی‬:‫بنگلور‬ ‫میڈیسن‬ ‫یونانی‬ ‫ف‬ٓ‫ا‬ ‫انسٹیٹیوٹ‬ ‫نیشنل‬

3. CONTENTS
Surgical Anatomy of Gall Bladder
Physiology
Gall Stone
‫نظر‬ ‫نقطہ‬ ‫یونانی‬
 Causes
 Pathogenesis
 Types of Stones
 Features
 Effects of Gall Stone
 Complications
 Miscellaneous
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4. • Pear-shaped sac, about 5–12 cm long
• Lying on the visceral surface of the right lobe of the liver in a fossa
between the right and quadrate lobes
• Divided into four anatomic areas:
Fundus
The corpus (body)
The Infundibulum
The Neck
4
Anatomy
Gall Stone

5. 17-11-16Gall Stone
•The two hepatic ducts from right and left lobes of the liver unite at the porta
hepatis to form the common hepatic duct which is joined by the cystic duct from
the gallbladder to form the common bile duct.
•The common bile duct enters the second part of the duodenum posteriorly.
•In about 70% of cases, it is joined by the main pancreatic duct to form the
combined opening in the duodenum (ampulla of Vater).
CONT……

6. • In 30% cases, the common bile duct and the pancreatic duct open separately
into the duodenum.
• The common bile duct in its duodenal portion is surrounded by longitudinal and
circular muscles derived from the duodenum forming sphincter of Oddi.
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CONT……

7. HISTOLOGY
Serous layer
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Mucosal layer
Smooth muscle layer
Perimuscular layer

8. Gallbladder drains through cystic duct into common hepatic duct to form common
bile duct.
It is supplied by cystic artery, a branch of right hepatic artery.
Calot’s triangle is formed by common hepatic duct to the left, cystic duct below,
and inferior surface of liver above. Cystic artery originating from right hepatic artery
passes behind the common hepatic artery, enters the Calot’s triangle to reach the
gallbladder. It contains lymph node of ‘Lund’ (Fred Bates Lund).
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CONT……

9. 5. Maintenance of Pressure in Biliary System
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FUNCTIONS OF GALLBLADDER
1. Storage of Bile
2. Concentration of Bile
3. Alteration of pH of Bile
4. Secretion of Mucin

10. PROPERTIES AND COMPOSITION OF BILE
SECRETION OF BILE
STORAGE OF BILE
Composition of bile
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11. Differences between liver bile and gallbladder bile
Types of entities Liver bile Gallbladder bile
pH 8 to 8.6 7 to 7.6
Specific gravity 1010 to 1011 1026 to 1032
Water content 97.6% 89%
Solids 2.4% 11%
Organic substances
Bile Salts 0.5 g/dL 6.0 g/dL
Bile Pigments 0.05 g/dL 0.3 g/dL
Cholesterol 0.1 g/dL 0.5 g/dL
Fatty Acids 0.2 g/dL 1.2 g/dL
Lecithin 0.05 g/dL 0.4 g/dL
Mucin Absent Present
Inorganic substances
Sodium 150 mEq/L 135 mEq/L
Calcium 4 mEq/L 22 mEq/L
Potassium 5 mEq/L 12 mEq/L
Chloride 100 mEq/L 10 mEq/L
Bicarbonate 30 mEq/L 10 mEq/L
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12. BILE SALTS
Bile salts are the sodium and potassium salts of bile acids, which are conjugated with
glycine or taurine.
FORMATION OF BILE SALTS

13. 1. Emulsification of Fats
2. Absorption of Fats
3. Choleretic Action
4. Cholagogue Action
5. Laxative Action
6. Prevention of Gallstone Formation
FUNCTIONS OF BILE SALTS
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14. Formation and circulation of bile pigments
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15. FILLING AND EMPTYING OF GALLBLADDER
2. Hormonal Factor
When a fatty chyme enters the intestine from stomach, the intestine secretes the
cholecystokinin, which causes contraction of the gallbladder.
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1. Neural Factor
Stimulation of parasympathetic nerve (vagus) causes contraction of gallbladder by
releasing acetylcholine. The vagal stimulation occurs during the cephalic phase and
gastric phase of gastric secretion.

16. GALL STONE
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17. GALLSTONES
Definitions: Gallstone is a solid crystal deposit that is formed by cholesterol, calcium ions
and bile pigments in the gallbladder or bile duct. Cholelithiasis is the presence of gallstones
in gallbladder
Causes for Gallstone Formation
1. Reduction in bile salts and/or lecithin
2. Excess of cholesterol
3. Disturbed cholesterol metabolism
4. Excess of calcium ions due to increased concentration of bile
5. Damage or infection of gallbladder epithelium. It alters the absorptive function of the
mucous membrane of the gallbladder. Sometimes, there is excessive absorption of water or
even bile salts, leading to increased concentration of cholesterol, bile pigments and calcium
ions
6. Obstruction of bile flow from the gallbladder.
17-11-16Gall Stone
‫نظر‬ ‫نقطہ‬ ‫یونانی‬
‫جزئی‬ ‫کمی‬ ‫مزاج‬ ‫سوء‬

19. Geography
Genetic factors(CYP7A1- cholesterol 7-hydroxylase)
Age
Sex
Drugs
Obesity
Diet
Gastrointestinal diseases
Factors in pigment gallstones
RISK FACTORS

20. PATHOGENESIS OF CHOLESTEROL, MIXED GALLSTONES AND BILIARY SLUDGE.
17-11-16Gall Stone
PATHOGENESIS. The mechanism of gallstone formation

21. Factors altering the cholesterol to bile salt ratio
Obesity
Drugs
– Oral contraceptive pills
– Clofi brate
– Cholestyramine
Ileal disease
Ileal resection
Altered enterohepatic circulation

22. III. Bile stasis: Occurs due to estrogen therapy, pregnancy, vagotomy and in patients who
are on long term intravenous fluids or TPN
IV. Increased bilirubin production due to any of the causes of haemolysis as in hereditary
spherocytosis, sickle cell anaemia, thalassaemia, malaria, cirrhosis. Here pigment
stones are common.
II. Infections and Infestations:
Bacteria like E. coli, Salmonella,Parasites like Clonarchis sinensis and Ascaris
lumbricoides are often associated.
Moynihan’s aphorism: “A gallstone is a tomb stone erected to the memory of the
organism within it.”
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23. 1. Cholesterol stones are 6% common, often solitary.
Types

24. 2. Mixed stones are 90% common. It contains cholesterol, calcium salts of phosphate
carbonate, palmitate, proteins, and are multiple faceted.

25. 3. Pigment stones are small, black or greenish black, multiple. Often they can be
sludge like.

26. Features of Gallstones.
Type Freq Com Gallbladder Changes Appearance
1. Pure 06% i) Cholesterol Cholesterolosis Solitary, oval, large, smooth,
yellow gallstones white; on C/S
radiating glistening crystals
ii) Bile pigment No change Multiple, small, jet-black,
mulberry shaped; on C/S soft black
iii) Calcium carbonate No change Multiple, small, grey-white,
faceted; C/S hard
2. Mixed 90% Cholesterol, bile pigment Chronic cholecystitis Multiple, multifaceted, variable size,
and calcium carbonate on C/S laminated alternating dark-
in varying combination pigment layer and pale-white layer
3. Combined4% Pure gallstone nucleus with Chronic cholecystitis Solitary, large, smooth; on C/S
Gallstones mixed gall stone shell, or central nucleus of pure gallstone
mixed gallstone nucleus with with mixed shell or vice versa
pure gall stone shell
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27. Saint’s triad
Gallstones
Diverticulosis of the colon
Hiatus hernia
Rarely centre of the stone contains radiolucent gas which is either triradiate
(Mercedes Benz sign) or biradiate (Seagull sign).
Black pigment stones are common in gallbladder. It is usually calcium bilirubinate, calcium
phosphate and bicarbonate stone with a matrix. It is common in haemolytic disorders.
They are usually multiple, small black and hard in consistency.
Only 10% of gallstones are radio-opaque, 90% are radiolucent.
Miscellanous

28. Brown pigment stones are formed in biliary tree as primary biliary stones. It is commonly due
to infection like Escherichia coli and bacteroides (98%) with bacterial nidus at the centre
(often Ascaris lumbricoides or Clonorchis sinensis infestation or foreign body or stents). They
secrete β glucuronidase to cause hydrolysis of soluble conjugated bilirubin to insoluble
calcium bilirubinate. It also contains calcium palmitate, calcium stearate and cholesterol. They
are brownish yellow, soft and mushy.

29. In the gallbladder
i. Silent asymptomatic stones occurs in 10% of males and 20% of females.
Effects of the Gallstones
ii. Biliary colic with periodicity, severe within hours after meal (commonest
presentation). Biliary colic is spasmodic pain often severe, in right upper quadrant
and epigastrium radiating to chest, upper back and shoulder. It is self-limiting, recurs
unpredictably, often precipitated by a fatty/heavy meal. Fever and increased WBC
count may be observed.
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30. iii. Acute cholecystitis.
iv. Chronic cholecystitis.
v. Empyema gallbladder.
vi. Perforation causing biliary peritonitis or pericholecystitic abscess.
vii. Mucocele of gallbladder.
viii. Carcinoma gallbladder.

31. complications of gallstones.

32. Gallstone Colic
It is sudden, severe colicky abdominal pain in right upper quadrant which radiates to back
and shoulder. 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. Tachycardia and
restlessness are common. Right hypochondrium is tender.
It is precipitated by supine position while sleeping at night. It lasts for few hours and is
episodic. It may precipitate acute cholecystitis or empyema gallbladder.
There is reflex pylorospasm causing vomiting.
Flatulent Dyspepsia
It is discomfort in the abdomen, belching, heartburn, fat intolerance, sensation of
fullness in the abdomen usually observed in fatty, fertile, flatulent female.

33. Silent gallstone
Asymptomatic stone in the gallbladder ,Usually it is cholesterol stone, often
single
It is accidentally discovered by U/S
It need not be treated unless:
– Patient is diabetic/immunosuppressed
– High chances of developing gallbladder carcinoma
– Stone more than 2.5 cm/multiple stones
– If gallbladder wall is thickened
– If there is high risk for carcinoma GB

34. ‫عالج‬:
‫میں‬‫حالت‬ ‫معمولی‬
‫میں‬‫صبح‬
۱‫کھالئ‬ ‫مالکر‬ ‫میں‬‫ام‬‫ر‬‫گ‬ ‫سات‬ ‫عونی‬‫ر‬‫ز‬ ‫ش‬‫ر‬‫جوا‬‫کر‬‫پیس‬‫یک‬‫ر‬‫با‬‫ام‬‫ر‬‫گ‬‫ایک‬‫ایک‬ ‫ہر‬ ‫ی‬ ‫سرماہ‬‫سنگ‬ ،‫الیہود‬ ‫حجر‬ ‫۔‬‫یں‬
‫انناس‬ ‫ق‬‫عر‬ ،‫ام‬‫ر‬‫گ‬ ‫تین‬‫ایک‬ ‫ہر‬ ‫ین‬‫ر‬‫خیا‬ ‫شیرہ‬ ،‫بادیان‬ ‫شیرہ‬ ،‫کاکنج‬ ‫شیرہ‬ ‫سے‬‫اوپر‬۱۵۰‫دینار‬ ‫شربت‬ ‫کر‬ ‫نکال‬ ‫میں‬ ‫ل‬ ‫م‬
۲۵‫مروق‬ ‫ترب‬‫سبز‬‫برگ‬‫ب‬
ٓ
‫ا‬ ‫کے‬ ‫کر‬ ‫حل‬ ‫میں‬ ‫ل‬‫م‬۵۰‫پالئیں‬ ‫کے‬ ‫کر‬ ‫شامل‬ ‫ل‬‫م‬
‫میں‬ ‫شام‬
۲‫انناس‬ ‫ق‬‫عر‬ ‫اہ‬‫ر‬‫ہم‬‫ام‬‫ر‬‫گ‬‫پانچ‬ ‫عقرب‬ ‫ن‬‫معجو‬ ‫۔‬۱۲۵‫ی‬‫بزور‬ ‫سکنجبین‬‫ر‬‫او‬ ‫ل‬ ‫م‬۲۵‫ائیں‬‫ر‬‫ک‬ ‫استعمال‬ ‫ل‬‫م‬
‫وقت‬‫تے‬ ‫سو‬
۳‫پالئیں‬ ‫ل‬ ‫م‬‫پچاس‬‫ن‬‫یتو‬‫ز‬ ‫روغن‬ ‫۔‬
‫عالج‬‫و‬‫عالج‬ ‫ل‬‫اصو‬:
۱‫لٹائیں‬ ‫میں‬‫کمرے‬‫دار‬ ‫ہوا‬‫ی‬ ‫کس‬،‫ائیں‬‫ر‬‫ک‬‫ام‬‫ر‬
ٓ
‫ا‬‫کو‬ ‫مریض‬‫وقت‬ ‫کے‬ ‫د‬‫ر‬‫د‬ ‫۔‬
۲‫کریں‬‫ٹکور‬ ‫سے‬ ‫جوشاندے‬ ‫کے‬‫ادویہ‬‫مسکن‬ ‫و‬‫محلل‬‫پہ‬ ‫مقام‬ ‫کے‬ ‫د‬‫ر‬‫د‬ ‫۔‬
۳‫ائیں‬‫ر‬‫ک‬ ‫استعمال‬ ‫کا‬‫ادویہ‬ ‫حصات‬ ‫مفتتات‬ ‫پر‬ ‫طور‬‫داخلی‬ ‫۔‬
۴‫پالئیں‬ ‫کے‬ ‫کر‬‫حل‬ ‫میں‬‫۔۔۔۔پانی‬‫لیٹر‬‫ملی‬ ‫ساٹھ‬ ‫ہ‬‫ر‬‫بخا‬‫لو‬
ٓ
‫ا‬ ‫زالل‬ ‫میں‬ ‫صورت‬ ‫کی‬ ‫۔قبض‬
۵‫ائیں‬‫ر‬‫ک‬‫پرہیز‬‫یکسر‬ ‫سے‬‫ں‬‫غذاؤ‬‫دار‬ ‫چربی‬‫پر‬ ‫طور‬ ‫ی‬ ‫،خصوص‬‫غذاء‬‫تقلیل‬ ‫۔‬

35. Diagnosis & Management of Gallstones
1. U/S abdomen
Ultrasound gallbladder showing echogenic lesion.

36. plain X-ray abdomen;
Plain X-ray showing (A) Mercedes Benz sign, (B) Multiple faceted stones
LFT; total WBC count.
Gall Stone

37. Laparoscopic cholecystectomy ideal.
Gall Stone

38. Open cholecystectomy is done through right subcostal Kocher’s
incision.
Gall Stone

39. Gall Stone
‫شکریہ‬