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The Gallbaldder and Biliary Disease - Coggle Diagram
The Gallbaldder and Biliary Disease
Anatomy
Anatomy
Extrahepatic bile ducts
Hium
Common hepatic duct
Common bile duct
Gall bladder
Intrahepatic bile ducts
Blood Supply
Cystic atery
Usually originates from right heptic artery ⭐
To the bile duct
Biliary sysetm supplied by
hepatic artery
Has
dual supply
unlike liver
Pringle's Manouvre
CHD and supraduodenal CBD line in the free edge of the lesser omentum
Bile duct - anterior right
Heaptic artery - anterior left
Portal vein - posterior
Foramen of window
Hepatocystic Triangle ⭐
Borders
Cystuc duct and gallbladder
Common hepatic duct
inferior border of the liver
Contents
Cystic artery
Calot's Triangle
Cystic duct
Cystic artery
Common hepatic duct
Physiology
⭐ Daily output of liver (bile) MCQ
Lier produces bile continuously
Average volum 500-100ml a day ⭐
Water and electrolyte concentration is almost same as plasma
Bile salts exreted
Function of Gallbladder
Store bile and regulate flow of bile
During fasting - sphincter of oddi contracted - bile stored and concentrated
Mucus secretion
Cholecystokinin (CCK) stimulates oddi relaxation, gallbladder contraction and released of stored concentrated bile in response to meals
Pathology
Gallstones and biliary colic
Cholecystitis
Mucocoele / Empyema
Mirizzi Syndrome
Gallbladdar Malignangy
Choledocholithiasis
Cholangitis
Secondary Biliary cirrhosis
Choledochal cysts
Biliary atresia
Gallstone pancreatitis
By location
Gallstones
Epidemiology
Extremely common
10-15% in west
Most asymptomatic > 80%
Types
Cholesterol
Pigmented
Mixed - most common
Causes?
Impaired gall bladder fucntioning
Supersaturated bile
Cholesterol nucleating factors
Absroption / enteropathic circulation of bile acids
Cholesterol and Mixed Stones
Form in the gallbladder from supersaturated bile
Most common in west
Rarely radio-opaque
Pure cholesterol are rare
Pigmented Stones
More common in asia
Black or broan
Black
Due to increased bilirubin - haemolysis or cirrhosis
60% radio-opaque
Brow
Chronic biliary obstruction, usually forms in ducts
Biliary Colic
Symptoms (Hx)
Sudden onset severe abdo pain
Minutesto hours
RUQ pain
Pain radiation to back / right shoulder
Signs (ExaM)
Often no findings
Mild RUQ tenderness
Investigations
Bloods
Normal
Imaging
Abdominal US
Posterior acoutic shadowing
Management
Analgesia +/- book for surgery
Cholecystitis
Types
Acute
Chonic
3,. Acute-on-chronic
Symptoms (Hx)
Persistent RUQ pain
Anorexia
N/V
Signs
Murphy's sign
RUQ tenderness
Tachycardiac
Investigations
Bloods
FBC
Mild Leukocytosis
Significantly high >20.000 suggest complication
CRP ↑
LFTs
Usually normal
If raised - consider cholangitis or choledocholithiasis
Imaging
US 1️⃣
95% sensitivy and specificity
Findings
Gallstones
Wall thickening
Pericholecystic fluid
Allows for sonographic Mrphy's Sign
HIDA
Extremely high sensitivity and specificity - limited access
Atypical cases
CT
BEst for looking for complications
MRI
IF concern for ? Stones
Managment
Acute
IV fluid and analgesia
Abx
Cover Gm -ve anaerobes and aerobes
Conservative
Indication
Asymptomatic stones
Risk of develping symptoms 3%
Surgery
All pt offered surgery if fit
Lap Cholecystectomy
Definitive treatment
Operate on acte Hot Gall Bladder - within 3-4 days
If presented late for elective surgery - delayed >6 w
Conversion rate 10-15% in acute setting vs 5% elective
Interventional Radiology
Cholecystostomy Tube
Types
Transcystic
Transhepatic
Indications
Complicated - perforation
Can be used as bridge to surgery - acute to elective
Definitive tx for unfit pts
Tube acan be removed after 6/52 if tubogram shows no obstruction
Endoscopy
Duodenocholecystostomy
EUS: HOt Axios Stent
New tech
Can bedefinitive tx for frail for pts
Causetive Organs ❓⭐
Ecoli
Kelbsiel
Proteus
Bacterios
Pseudomonus
Mucocoele, Empyema, Perforation
Persistent outflow obstruction
Bile stasis and mucus production
Gallbladder distension - mucocoele
VEous congestion and arterial compromise
Subclinical ischaemia and mucosal breakdown
Bacterial translocation
Purulent collection - empyema
Acute Acalculous Cholecystitis
Fax
Life threatening condition
Most common on critically ill pts (ICU / CCU)
Cystic artery is an end artery with no collaterals
Poor perfusion - ischaemia - 60% gangrene
Clinic picture masked by pt obtundation
Diagnosis
US
Treatment
Cholecystostomy / cholecystectomy depending on fit ess
Mirizzi Syndrome
Definition
Epidemiology
Higher association with malignancy
Classification
Managment
Bilioenteric anastomaosis
Carcinoma of Gallbladder
Epi
Rare
Least common malignangy of biliary
Pathophysiology
Choledocholithiasis
Definition
Investigations
Management
Ascending Cholangitis
DEfinition
Acute bacterial inflammation bile ducts
Causes
Any blockage of bile flow
Epi
High mortality 1-30%
Clinical Features
Charcot's Triad
Fever
Jaundice
Abdominal pain - RUQ
Present in 60-70%
Reynold's Pentad
Fever
Jaundice
RUQ pain
Hypotension
Confusion
Signs
Investigation
Bloods
LFTS
Raised bili / ALP / GGT
WCC / CRP ↑
Secondary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Gallstone Ileus
Epidemiology
Ifrequent
Elderly comorbid pts
Cause
Requires biliary enteric fistula
Cholecysto-duodenal - most common
Cholecysto-colonic
Cholecysto-enteric
Cholecysto-gastric
Investigations
Imaging
PFA
Classic PFA appearance
Rigler's triad
Pneumobilia
Dilated small bowel
Ectopic radioopaque gallstone
CT
Inpractive all get CT
Managment
Resus
Establish diagnosis
Surgery
One stage
Enterotomy prox to impacted stone, removal of stone
