THE BILIARY TRACT

Gall Bladder

a storage organ for bile, with a capacity of 50 mL in adults .a storage organ for bile, with a capacity of 50 mL in adults .histology -mucosa -fibro-muscular layer -sub-serosal layer -peritoneal covering .cystic duct joins common hepatic duct> common bile duct courses head of pancreas>duodenum through Ampulla of Vater

CONGENITAL ANOMALIES .Agenesis .Duplicated .Bi-lobed .Aberrant location .Folded fundus

CHOLELITHIASIS. afflicts 10%-20% of adults CHOLELITHIASIS .afflicts 10%-20% of adults .types -cholesterol-containing stones, (80%) -bilirubin-containing stones, (20%) .risk factors -cholesterol stones .old age .female sex hormones .obesity & metabolic syndrome .rapid weight reduction .gallbladder stasis .inborn errors of bile acid metabolism .hyperlipidemia syndromes

-pigment stones. chronic hemolytic syndromes. biliary infection -pigment stones .chronic hemolytic syndromes .biliary infection .gastro-intestinal disorders (Crohn disease, ileal resection or bypass, cystic fibrosis)

pathogenesis -cholesterol stones .pathogenesis -cholesterol stones .super-saturation of bile with bilirubin & cholesterol -pigment stones .disorders associated with elevated levels of unconjugated bilirubin in bile -hemolytic syndromes -severe ileal dysfunction or bypass -bacterial contamination of biliary tree

morphology -cholesterol stones .morphology -cholesterol stones .pure-pale yellow, round to ovoid, (radiolucent) .mixed (calcium carbonate, phosphates, & bilirubin)-gray-white to black, (radio- opaque in 10%-20%) -pigment stones .black-sterile bile (radio-opaque in 50%- 75%) .brown-infected bile (all radiolucent)

Gall bladder, cholesterol stones

Gall bladder, pigment stones

.clinical features -silent -biliary colic -complication in gall bladder (empyema, perforation, fistulas, cholecystitis, carcinoma) -cholangitis & cholestasis -pancreatitis -intestinal obstruction

CHOLECYSTITIS .almost always occurs in association with gall stones .types -acute -chronic -active chronic

Acute Cholecystitis .calculous cholecystitis (obstruction of bladder neck or cystic duct) .acalculous cholecystitis (severely ill patients) -post-operative state -severe trauma -severe burns -multi-system organ failure -sepsis -prolonged intra-venous line -post-partum state

pathogenesis -calculous (chemical inflammation) -acalculous (ischemia) .pathogenesis -calculous (chemical inflammation) -acalculous (ischemia) .morphology -enlarged hemorrhagic gallbladder -lumen is filled with turbid bile that may contain pus & fibrin -empyema -gangrene

.clinical features -abdominal pain at right upper quadrant or epigastric region -most patients have no jaundice -in calculous cholecystitis, the attack may be sudden -in acalculous cholecystitis, symptoms are more insidious

Chronic Cholecystitis Chronic Cholecystitis .follows bouts of acute cholecystitis, or occurs de novo .gall stones are present in 90% of cases .pathogenesis -super-saturation of bile .morphology -gross, thickened wall, lumen contains clear, mucoid bile & usually stones -histology, inflammation -hydrops of gallbladder

Chronic cholecystitis

Chronic cholecystitis, Rokitansky-Aschoff sinus

.clinical features -recurrent attacks of abdominal pain at epigastric or right upper quadrant -nausea, vomiting, & intolerance for fatty foods .complications -bacterial infection>cholangitis -gallbladder perforation>local abscess -gallbladder rupture>peritonitis -biliary-enteric fistula -aggravation of a pre-existing medical illness -porcelain gall bladder>cancer

Extra-Hepatic Bile Ducts

CHOLEDOCHOLITHIASIS .stones either arise within gallbladder, or formed in ducts .clinical features -asymptomatic -obstruction>cholangitis -pancreatitis -hepatic abscess -secondary biliary cirrhosis -acute calculous cholecystitis

BILIARY ATRESIA .complete or partial obstruction of lumen of extra-hepatic biliary tree within first 3 months of life .presents as neonatal cholestasis .pathogenesis -fetal form, associated with other anomalies -perinatal form, normal biliary tree is destroyed after birth, due to .viral infection, or .genetic predisposition

Tumors Of Gall Bladder

BENIGN TUMORS AND TUMOR-LIKE LESIONS. Adenoma. Inflammatory polyp BENIGN TUMORS AND TUMOR-LIKE LESIONS .Adenoma .Inflammatory polyp .Adenomyosis

CARCINOMA OF THE GALLBLADDER. slightly more common in females CARCINOMA OF THE GALLBLADDER .slightly more common in females .most frequently in the 7th decade of life .only rarely is surgically resectable .mean 5-year survival rate is about 1% .predisposing factors -stones -infection .morphology -grossly (infiltrative, exophytic) -microscopically (adenocarcinoma) .clinically, rarely detected preoperatively

Gall bladder, adenocarcinoma

Gall bladder, adenocarcinoma