Gall bladder

Size = 7.5 x12.5 cmCapacity= 50 mlsCystic duct= 2.5cm which contains the spiral valve of

HeisterC.H.D =2.5 cmC.B.D= 7.5 cm 1-supraduodenal 2-retroduodenal 3-infradudenal 4-intraduodenal which open in ampulla's of

of Vater.

Composition of Bile:

1- 97% water

2- 1-2% bile salts

3- 1% pigments, fatty acids, cholesterol

Liver excretes bile at rate of 40 ml/hr

Functions of gall bladder:

1-Reservoir of bile

2-Cocentration of bile 5-10 times by active absorption of water, Na+, Cl-, Bicarbonate

3-Secration of mucin (20 ml per day)

Investigation of the biliary tree:

1-US: sones & size2-Plain Xray: calcification3-MRCP: anatomy & stones4-CT san: cancer & anatomy5-HIDA Scan: function6-ERCP: stones & strictures7-PTC:proximal obstruction

PTC

ERCP

Congenital abnormalities of Congenital abnormalities of GB & bile ducts:GB & bile ducts:

Congenital abnormalities of GB & bile ducts:

1-absence of GB.

2-phrygian cap 2-6%

3-Floatting GB

4-Double GB

5-Absence of cystic duct

6-Low insertion of cystic duct

7-accessory cholecystohepatic duc

8-Atresia

9-choledocal cyst

Biliary Atresia

Might be due to viral infection

Correctable 10%

Uncorrectable 90%

CF:

*1\3 jaundice at birth

*all jaundice by the end of 1st week

Differential diagnosis

1-alpha one antitrypsin deficiency2-choledocal cyst3-insspissated bile syndrome4-neonatal hepatitis

Diagnosis:

*liver function tests*radioactive isotope scan---failure of the

isotope from reaching the intestine*Laparoscopy\laparotomy---liver biopsy

Choledocal cyst

Due to specific weakness in a part or whole wall of CBD

*female > male

*at age of 6 months

CF

*attacks of obstructive jaundice

*Cholangitis \ abdominal singns

*fever

*upper abdominal swelling.

Diagnosis:

CF+ US +MRI

Treatment:

*radical excision if possible

*choledochocystojujenostomy.

Gall stones

Gall stones

Types of gallstones

1-Pure cholesterol (10%). Often solitary, large (> 2.5cm), round.

2-Pure pigment (bile salts; 10%). Pigment stones are of two types:*black (associated with haemolytic disease);

*brown (associated with chronic cholangitis and biliary parasites).

3-Mixed (80%). Most common; usually multiple

Causes

1-supersaturated bile:

*age

*sex

*genetics

*obesity

*diet

2-impaired gall bladder function:

*emptying

*absorption

*excretion

3-cholestrol nucleating factors:

*mucus

*glycoprotein

*infection

4-absorption\enterohepatic circulation of bile acids:

*deoxycholate

*bowel transit zone

*faecal flora

*ileal resection

*cholestyramine.

Other factors:

A-Metabolic

B-Infective

C-Stasis

Saint's triad

*gall stones

*diverticular disease

*hiatus hernia

Presentation & DX

*silent in 85%

*acute cholecystitis:pain ,radiation,fatty meals

*chronic cholecystitis:flatulent dyspepsia & heart burn which has to be differentiated from:(hiatus hernia, chronic pancreatitis & peptic ulcer)

DX

CF+US+X-ray

Treatment:

*NBM + IVF

*biliary pain :(analgesia,spasmolytic,antiemetic)

*antibiotic(broad spectrum)

Surgery:urgent(for complicated cases),early(next available list) & delayed

Complications & effects of gall stones

A-on GB:1-acute cholecystitis2-chronic cholecystitis3-empyema4-mucocele5-biliary colic6-CA7-gangerene8-perforation

B-on bile ducts:1-obstructive jaundice

2-cholangitis—liver abscess

3-pancreatitis

C-on the bowel:1-cholecystoenteric fistula

2-gall stone ileus.

Achalculous cholycystitis:

Needs oral cholecystogram for dx

Presence of cholesterol crystals in duodenal aspirate.high mortality eraly perforation & gangerene

Usually seen after:major trauma,burns ,in ICU or patient recovering from major surgery