1. Gall Bladder Disease
Cara Campbell

2. Anatomy Pear-shaped sac Fundus, body and neck
8cm by 4cm, capable of considerable distention
Lined with mucus membrane, thrown into numerous folds (rugae)
As gallbladder fills with bile the folds flatten out
Sphincter of Oddi

3. Histology

4. Function Store and concentrate bile Bile emulsifies fats
Cholecystokinin (CCK)  gallbladder contract rhythmically  bile enters CBD  duodenum
Bile is concentrated by:
Reabsorption of water and electrolytes
Active transport of Na+ osmotic pressure  causing water and other electrolytes e.g. Cl- to be reabsorbed
Store and concentrate bile, deliver it to small intestine during a meal
Bile emulsifies fats
When food containing fat enters the digestive tract, it stimulates the secretion of cholecystokinin (CCK). In response to cholecystokinin, the gallbladder rhythmically contracts and releases its contents into the common bile duct, eventually draining into the duodenum
In the gallbladder bile is concentrated by removal of some water and electrolytes by active transport of Na+ ions across the epithelia of the gallbladder, which creates an osmotic pressure causing water and other electrolytes such as Cl- ions to be reabsorbed

5. Constituents of Bile
Primary bile acids: cholic and chenodeoxycholic acid
Secondary bile acids: deoxycholic and lithocolic acids
Lipids (Phospholipids and cholesterol)
Bilirubin
Waste products
Electrolytes
Proteins

6. Gallbladder diseases Gallstones Common bile duct stones
Biliary colic
Acute cholecystitis
Common bile duct stones
Ascending cholecystitis
Miscellaneous Conditions of the Biliary tract
Non- calculous conditions of gall bladder
Extra-hepatic biliary tract
Tumours of biliary tract
Gall bladder polyps
Primary cancer of gall bladder
Cholangiocarcinoma
Carcinoma of pancreas – bile duct obstruction

7. Gallbladder diseases Gallstones Common bile duct stones
Biliary colic
Acute cholecystitis
Common bile duct stones
Ascending cholecystitis
Miscellaneous Conditions of the Biliary tract
Non- calculous conditions of gall bladder
Extra-hepatic biliary tract
Tumours of biliary tract
Gall bladder polyps
Primary cancer of gall bladder
Cholangiocarcinoma
Carcinoma of pancreas – bile duct obstruction

8. Gallstones Increasing age Prevalence F>M Types:
Cholesterol gallstones (80%)
Cholesterol crystallisation from gallbladder bile
Cholesterol supersaturation of bile
Crystallisation-promoting factors within bile
Motility of the gallbladder
Bile pigment stones

9. Risk Factors Gallstones
5 F’s: Fat, forty, female, fertile, fair FH
Diet (high animal fat/low fibre)
Drugs (e.g. OCP)
Ileal disease or resection

10. Clinical Presentation of Gallstones
Majority are asymptomatic, found incidentally
Once symptomatic, recurrent complications
Biliary colic
Acute cholecystitis

11. Biliary colic
Biliary colic - pain associated with temporary obstruction of cystic or common bile duct
Severe pain, constant, crescendo
Epigastric/RUQ
Radiation over right shoulder and subclavicular region
Nausea and vomiting
After large meal, high fat
Mid-evening lasting early hours morning

12. Acute Cholecystitis
Initial event: obstruction gall bladder emptying (95% gallstones)
 increase in gall bladder glandular secretion  progressive distention compromise vascular supply
Inflammatory response
Infection
Clinical features
Similar to biliary colic + fever
After a few hours localised R UQP
Distended by pus (empyema)
Acute gangrenous cholecystitis  can perforate  generalised peritonitis
Initial event in acute cholecystitis is obstruction to gallbladder emptying (95% gallstones)
Results in increase in gall bladder glandular secretion, leading to progressive distention, may compromise vascular supply
Inflammatory response secondary to retained bile
Infection secondary to the above
Clinical features
Similar to biliary colic + fever
After a few hours localised upper right quadrant pain (parietal peritoneal involvement)
Distended by pus (empyema)
Acute gangrenous cholecystitis – can perforate – generalised peritonitis

13. Investigations
Biliary colic due to stone in neck of gallbladder or cystic duct
Unlikely to have significantly abnormal tests
Acute cholecystitis
Moderate leucocytosis
Raised inflammatory markers (ESR and CRP)
Serum bilirubin, alkaline phosphatase and aminotransferase levels
Marginally elevated in cholecystitis
More significant elevation in bile duct obstruction
Abnormal ultrasound scan
PPV 92%, NPP 95%

14. Differential diagnosis
Biliary colic
Irritable bowel syndrome (spasm of hepatic flexure)
Carcinoma of right side of colon
Atypical peptic ulcer disease
Renal colic
Pancreatitis
Acute cholecystitis (severe RUQ pain and fever)
Acute episodes of pancreatitis
Perforated peptic ulcer
Intrahepatic abscess
Basal pneumonia
Myocardial infarction

15. Management of Gallstones
Biliary colic
Cholecystectomy (laparoscopic approach)
Acute cholecystitis
Initial management is conservative
Nil by mouth
IV fluids
Opiate analgesia
IV antibiotics (local policy – broad-spec cephalosporins, fluroquinolones or piperacillin/tazobactam)
Cholecystectomy

16. Complications of cholecystectomy
Biliary leak (from cystic duct or gallbladder bed)
Injury to bile duct
Bile duct stricture
Secondary biliary liver injury
Overall mortality 0.2%
Post-cholecystectomy syndrome

17. Non-surgical techniques
Rarely used
Pure cholesterol stones can be solubilized by increasing bile salt content oral chenodeoxycholic acid and ursodeoxycholic acid, long term therapy, recurrence rates high
Statins
Extracorporeal shock wave lithotripsy

18. Gallbladder diseases Gallstones Common bile duct stones
Biliary colic
Acute cholecystitis
Common bile duct stones
Ascending cholecystitis
Miscellaneous Conditions of the Biliary tract
Non- calculous conditions of gall bladder
Exrta-hepatic biliary tract
Tumours of biliary tract
Gall bladder polyps
Primary cancer of gall bladder
Cholangiocarcinoma
Carcinoma of pancreas – bile duct obstruction

19. Common bile duct stones
Can lead to ascending cholangitis
Triad
Biliary colic
Fever
Jaundice
Investigations
FBC – normal
Elevated neutrophil count raised inflammatory markers (ESR and CRP)
Raised serum bilirubin – mild (high = complete bile duct obstruction)
Serum alkaline phosphatase and ɣ-glutamyl transpeptidase – raised
Aminotransferase – mildly raised (marked rises in complete bile duct obstruction)
Serum amylase – raised
Pro-thombin time prolonged (decreased absorption of vitamin K)
Imaging – ultrasound
ERCP Endoscopic retrograde cholangiopancreatography

20. Management Ascending cholangitis High morbidity and mortality
IV antibiotics
Urgent bile duct drainage (endoscopic retrograde approach)
CBD stones and gall bladder stones
Laparoscopic cholecystectomy + exploration of CBD
Endoscopic approach (immediately before/after cholecystectomy)

21. Complications of gallstones
Acute cholecystitis
Ascending cholangitis
Gallstone-related pancreatitis
Biliary enteric fistula (gallstone eroded through gall bladder wall, stone in small intestine – ileus/true obstruction)

22. Gallbladder diseases Gallstones Common bile duct stones
Biliary colic
Acute cholecystitis
Common bile duct stones
Ascending cholecystitis
Miscellaneous Conditions of the Biliary tract
Non- calculous conditions of gall bladder
Extra-hepatic biliary tract
Tumours of biliary tract
Gall bladder polyps
Primary cancer of gall bladder
Cholangiocarcinoma
Carcinoma of pancreas – bile duct obstruction

23. Miscellaneous Conditions of the Biliary tract
Non-calculous cholecystitis (chronic inflammation)
Cholesterolosis of gall bladder (cholesterol deposited in macrophages in lamina propria)
Adenomyomatosis of gall bladder (hyperplasia of mucosa, thickening of muscle wall and multiple intramural diverticular)
Chronic cholecystitis

24. Miscellaneous Conditions of the Biliary tract
Extra-hepatic biliary tract
Primary sclerosing cholangitis
Autoimmune cholangitis
Congenital malformation of bile duct
Benign bile duct strictures
Haemobilia

25. Gallbladder diseases Gallstones Common bile duct stones
Biliary colic
Acute cholecystitis
Common bile duct stones
Ascending cholecystitis
Miscellaneous Conditions of the Biliary tract
Non- calculous conditions of gall bladder
Extra-hepatic biliary tract
Tumours of biliary tract
Gall bladder polyps
Primary cancer of gall bladder
Cholangiocarcinoma
Carcinoma of pancreas – bile duct obstruction

26. Tumours of biliary tract
Gall bladder polyps
Majority non-neoplastic
Adenomas – benign neoplastic
Cholecystectomy – any polyp >1cm
Primary cancer of gall bladder
Adenocarcinoma
Cholangiocarcinoma
Carcinoma of pancreas – bile duct obstruction

27. Questions?