1. THE GALLBLADDER AND THE BILIARY TREE BY MICHAEL BRILLANTES, MD, FPCS, FPSGS

2. ANATOMY Gallbladder Bile ducts Blood Supply Anomalies 1.Gallbladder- most common is an intrahepatic gallbladder 2.Bile Ducts- most common is a CBD and cystic duct that runs parallel 3.Blood Supply- most common is a right hepatic from the superior mesentric artery

4. PHYSIOLOGY Concentrates bile by absorption of water and sodium Stimulus for gallbladder emptying is cholecystokinin (CCK-PZ) secondary to fat in the GIT Truncal vagotomy promotes stasis Composition of bile: 1.Cholesterol- 5% 2.Bile Salts – 80% 3.Lecithin – 15%

5. PATHOLOGY GALLSTONES- approx. 10%of population Pathogenesis: 1.Cholesterol Stones Process: a. Cholesterol saturation – crystallization b. Nucleation- agglomeration of crystals

6. CLINICAL MANIFESTATIONS: 1.ASYMPTOMATIC- up to 50%, usually incidental findings No surgery needed for most EXCEPTIONS: 1.High risk patients undergoing a laparotomy for another problem 2.Good risk patients - Diagnosis: Ultrasound

9. 2. Biliary Colic- self- limited, usually 2-3 hours bec. Of stones obstructing the cystic duct dislodges Recurrent biliray colic- the most common reason for cholecystectomy 3. Acute Cholecystitis Impacted stone in the cystic duct Murphy’s sign: inspiratory arrest on deep palpation of the RUQ WBC count >20,000, consider gangrenous cholecystitis Diagnosis:a. Scintigraphy/HIDA scan b. Ultrasound

11. 4. Gallstone pancreatitis Caused by transient obstruction of the ampulla of Vater causing reflux of the bile and pancreatic enzymes into the pancreatic duct causing obstruction of pancreatic parenchyma Wait for clinical improvement of pancreatitis to subside before cholecystectomy is done; cholecystectomy is usually done within the same hospital stay if patient deteriorates while being observed and supported, exploration or ERCP should be done

12. Diagnosis- ultrasoundTreatment a. Open cholecystectomy c. Laparoscopic cholecystectomyd. Medical dissolution-inhibits HMG- COA e. Chenodeoxycholic acidf. Urosdeoxycholic acid g. Contact dissolution- methyl- terbutyl ether

13. View from laparoscopic cholecystectomy

14. View from open cholecystectomy

17. Complications a. Hydrops- accumulation of mucoid material within the gallbladder with no inflammation and infection b. Empyema- intramural abscess of the gallbladder Patient is toxic, w/ fever and leukocytosis Emergency cholecystectomy is needed c. Emphysematous cholecystitis Gas within the gallbladder wall with ischemi necrosis Cl. Welchii, E. coli, Klebsiella Seen primarily in diabetics Emergency cholecystectomy is needed

18. d. Perforation with gallstone ileus i.Free perforation ii.Sub acute perforation with abscess formation iii.Fistula formation e. Acalculous cholecystits- seen in critically ill patients Urgent cholecystectomy needed f. Hyperplastic Cholecystoses- symptomatic cholecystectomy Cholesterolosis- cholesterol deposits in the wall; “strawberry” gallbladder Adenomyosis- hyperplasia of the mucosa and the muscle layer

20. COMMON BILE DUCT STONES Types 1.Primary Stones Arising from the bile ducts; usually caused by organisms that contain beta- glucoronidase such as E. coli Beta- glucoronidase deconjugates bilirubin diglucorinade into bilirubin and glucuronic acid Bilirubin binds with calcium to form calcium bilirubinate stones

21. Endoscopic Retrograde CholangioPancreatography

22. Percutaneous Transhepatic Cholangiography

23. Magnetic Resonance Imaginng CholangioPancreatography

24. 2. For primary stones- cholecystectomy with: i.Sphincteroplasty ii.Choledochoduodenostomy iii.Choledochojejunostomy

25. Inflammatory and Other Benign Diseases: Cholangitis Charcot’s triad RUQ Pain Fever Jaundice Reynold’s Pentad- Charcot’s Triad with signs of sepsis Neurologic change Hypotension Secondary to bacterobilia and obstruction with increased pressure within the CBD Bacteriology: E. Coli and Klebsiella

26. Treatment: IV and Antibiotics Hydration Biliary Decompression If patient is toxic (unstable and hypotensive), then just do CBD drainage with a T- tube the close; definitive operation can be done if patient is stable

27. Choledochal Cyst Clinical manifestation similar to obstruction of the CBD which are seen until adulthood Recurrent bouts of cholangitis Types of cyst Type I- fusiform dilatation of extrahepatic biliary tract Type II- diverticulum of extrahepatic biliary duct Type III- Choledochocoele Type IV- Multiple intra and extrahepatic bile duct cysts Type V- Single or multiple intrahepatic bile duct cysts

28. Treatment Resection depending on the type (due to malignant potential) Reconstruction

29. Tumors: A. Gallbladder Pathology- usually adenocarcinoma Chronic presence of stones Calcified or porcelain gallbladder

30. Clinical Manifestation Similar to GB disease Jaundice in advanced stage Weight loss, anorexia, nausea Treatment Cholecystectomy with wedge resection of the liver and hyphadenectomy

31. B. Bile Ducts- Cholangiocarcinoma Pathology- adenocarcinomas Hilar or proximal- most common Mid-duct Distal Bile Duct Diffuse

32. Clinical Manifestation Acholic Stool Tea- colored urine Jaundice Pruritis

33. Diagnosis Ultrasound CT scan ERCP or PTC Treatment Resection with Biliary reconstruction Whipple’s procedure