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GALL BLADDER DISEASES (Bile Duct Disorders (*Carcinoma of the GB
starts…
GALL BLADDER DISEASES
Bile Duct Disorders
Choledocholithiasis
- blockage of the biliary
duct by Gall Stones
Choledocholithiasis Proximal to
Hepatopancreatic Ampulla
- blockage of the bile ducts
Cholecystitis
- inflammation of the GB
- Adema and pressure build up in GB
--> risk of perforation and peritonitis
Acute
- 5-10% will have cholecystectomy
(GB removed)
Chronic
- does NOT require acute cholecystitis
- does NOT require duct obstruction
Signs and Symptoms
- RUQ pain
- irregular attacks after eating,
especially fatty foods
Histology
- Rokitansky-Aschoff Sinuses
- thickened GB wall
- fibrotic changes to the mucosa
due to chronic inflammation
Rokitansky-Aschoff Sinuses
- diverticula of the mucosa of the GB
-
-
Cholangitis
- infection of the GB by pathogens (bacteria or parasites)
--> usually Gram (-) bacteria
- usually secondary to cholecystitis
-
Signs and Symptoms
- fever
- chills
- URQ abdominal pain
- jaundice
Complications
- ascending cholangitis
--> infection ascends up to the liver
- sepsis
Choledocholithiasis Within
Hepatopancreatic Ampulla
- blockage of the bile ducts
Pancreatitis
- 2 main causes of acute pancreatitis
1 = choledocholithiasis
2 = alcoholism (unknown method)
-
Pathophys.
- usually adenomcarcinoma
--> since glandular cells
Risk Factors
- Gall Stones present 60-90%
- 70% female
--> recall that females more common
than men for Gall stones
Prognosis
- 1% survival for 5 years
--> GB is non-essential visceral organ
--> not diagnosed until
metastasized to essential organ
*Porcelain GB
- starts with Porcelin GB and leads to adenocarcinoma of the GB
*Porcelain GB on CT scan
- shows calcification and thickenning of the GB
-
-
*Terminology
- Chole = means GB --> think the "whole GB"
- lithi = means stone --> think "little stone"
- cyst = refers to the cystic duct --> the main duct to the Gb
- docho + lithiasis = means little stone in "common duct" = "docho"
- gitis = means bacterial infection
--> think of a stone starting in the GB and
--> moving down the biliar tree (cystic duct then common duct)
--> infection that ascends
Cholelithiasis (1/3 triad)
- Gall stones in the GB
- colicky RUQ pain that goes on and off
- worse when eating fatty foods since the GB is contracting
Cholecystitis (2/3 triad)
- Gall stones in the cystic duct
- CONSTANT - not colicky or transient pain
- positive Murphy's sign
--> patient breathes in
--> liver and GB become exposed under rib cage
--> RUQ pain when you push in there
- fever since inflammation
--> note there is no Jaundice in cholecystitis since the common bile duct is not blocked
Choledocholithiasis (2/3 triad)
- Gall stones in the common bile duct
- the duct is larger so there is less inflammation than in cholecystitis
--> less fever
- But the common bile duct is obstructed so there is bilirubin back up
--> jaundice
Cholangitis (AKA ascending Cholangitis) (3/3 triad)
- Choledocholithiasis that has lead to infection and inflammation of the entire biliary tree above
- Charcot's triad of symptoms
--> RUQ pain, fever, jaundice
--> think of Charcot's triad as the sum of the previous three main symptoms
- Note Charcot's Triad can move into Reynold's Pentad if not treated
Reynold's pentad
--> Charcot's + hypotension and altered mental status
--> moving into realm of shock
Normal Features
- single layer of columnar cells
-
*Cholelithiasis (Gall Stones in GB)
- hardening of the contents of bile into crystals
- affect 5-10% of total population
- of these 80% are asymptomatic
-
-
Signs and Symptoms
- Biliary Colic
- nausea
- vomiting (emesis)
- fever
- jaundice
--> if the biliary tree is obstructed
Biliary Colic
- RUQ abdominal pain
- since by the liver and diaphragm
--> c3,c4,c5
--> radiates to right neck, shoulder, jaw
- constant pain
--> lasts between 15 min. --> 4 hrs.
- usually due to stone in cystic duct
Causes
- hypomotility of the GB
- imbalance of bile salts and cholesterol
- loss of acidity of bile in the GB
--> allows the Ca2+ to crystallize
Terminology
- Chole = means GB --> think the "whole GB"
- lithi = means stone --> think "little stone"
- cyst = refers to the cystic duct --> the main duct to the Gb
- docho + lithiasis = means little stone in "common duct" = "docho"
- gitis = means bacterial infection
--> think of a stone starting in the GB and
--> moving down the biliar tree (cystic duct then common duct)
--> infection that ascends
Cholangitis (AKA ascending Cholangitis) (3/3 triad)
- Choledocholithiasis that has lead to infection and inflammation of the entire biliary tree above
- Charcot's triad of symptoms
--> RUQ pain, fever, jaundice
--> think of Charcot's triad as the sum of the previous three main symptoms
- Note Charcot's Triad can move into Reynold's Pentad if not treated
Reynold's pentad
--> Charcot's + hypotension and altered mental status
--> moving into realm of shock
Choledocholithiasis (2/3 triad)
- Gall stones in the common bile duct
- the duct is larger so there is less inflammation than in cholecystitis
--> less fever
- But the common bile duct is obstructed so there is bilirubin back up
--> jaundice
Cholecystitis (2/3 triad)
- Gall stones in the cystic duct
- CONSTANT - not colicky or transient pain
- positive Murphy's sign
--> patient breathes in
--> liver and GB become exposed under rib cage
--> RUQ pain when you push in there
- fever since inflammation
--> note there is no Jaundice in cholecystitis since the common bile duct is not blocked
Diagnosis of Cholecystitis
- transabdominal ultrasound is the gold standard
- when this not available, use radiotracer GB scan
- if the die goes past the GB and it is not seen, this means just the cystic duct is blocked
-
*Cholelithiasis (1/3 triad)
- Gall stones in the GB
- colicky RUQ pain that goes on and off
- worse when eating fatty foods since the GB is contracting
- affect 5-10% of total population (mostly women 5 Fs)
- of these 80% are asymptomatic
3 types of Gallstones
80-85% Mixed
- high inorganic calcium salts
--> calcium carbonate, calcium phosphate and calcium palmitate
--> radiographically visible on X-ray
- Commonly secondary to infection of the biliary tract
-
5-10% Pure Pigmented
- SOFT small and black
- > 90% unconjugated bilirubin
- hemolysis or bacterial infection
- glucuronidase reversing the process and unconjugating the bilirubin
--> ALL these increase unconjugated UCB
--> think this is unconjugated so thus can bind with Calcium
--> so it makes a Calcium Bilirubin salt which is brown or black = darker = Pigmented
-
-
10% Pure *Cholesterol
- HARD + light yellow --> green --> brown
- +/- dark, central spot
-
Rare Gallstone Complications
Gallstone *Illeus
- usually there has to be an abnormal connection between the GB and the small intestine for a large stone to enter the intestines
- can present as a mix of SBO and appendicitis
- see air in the GB and the stomach
-
Treatment for Cholelithiasis +/- others
- based on symptoms vs. non symptoms
- no symptoms = watch and wait
- symptoms with Gallstones present
--> transabdominal ultrasound
--> MRCP
--> ERCP
MRCP
- magnetic resonance Cholopancreatography
-
ERCP
- endoscopic retrograde Cholopancreatography
Notes:
- ERCP for cholelithiasis and possible obstriction is both diagnostic and treatment tool
--> may remove the Gallstone = cholithiectomy, stent biliary tree, or cholecystectomy
5 Fs of GB stones
- ntoe these mostly come in women from 2 things
--> pregnancy
--> OCPs
*Pregnancy and GB stones
- estrogen
--> increases the amount of cholesterol made in pregnant women
- progesterone
--> decreases GB motility
-
-
*Cholestasis (GB - not supplying bile salts)
- classic presentation = fatigue, pruritis (nonspecific to any rash), hepatomegaly, raised Alk Phosph
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