Gallbladder Done by Amr - PowerPoint Presentation

Slide1

Gallbladder

Done by

Amr

Alhusami

Introduction

the anatomy of the gallbladder

... The gallbladder is present in

the right upper quadrant of the abdomen, below the

visceral surface of the liver

. GB is a

pear-shaped muscular tube, with

fundus

, body and neck

. The

Biliary

Tree

consists of

right and left hepatic ducts

>

common hepatic duct

,

common hepatic duct with cystic duct

>

common bile duct

. The common bile duct "

CBD

"

descends behind the duodenum and pancreas and may be joined by main pancreatic duct before it enters the second part of duodenum

.

The Hartman’s pouch

(

Infundibulum

): is a dilation in the GB just before the origin of cystic duct (it is a pathological pouch not a physiological one).

Blood supply >>

Cystic artery (

branch of right hepatic artery).

Physiological aspect

The function of the GB

is

storage

and

concentration of bile between meals

. Bile composition:

1.

Water

(97.6%): this is after

reabsorption

.

2.

Electrolyte

s: most are absorbed in the GB.

3

. Bile salts

(like

cholic

acid and

chenodeoxycholic

acid).

4.

Phospholipids

(like lecithin): bile salts and phospholipids are used for excretion of cholesterol in a

micellar

from "since cholesterol alone is water insoluble" & digestion and absorption of lipids.

5.

Bilirubin

(conjugated)

. 6.

Fatty acids

: also secreted with cholesterol in

micells

.

Enterohepatic

circulation

:

95% of bile salts are reabsorbed in the terminal ileum,

pass back via the portal venous drainage to the liver, and from where they are once again secreted in the bile  surgical importance of this point is the resection of terminal ileum, so decrease in bile salts that causes GS formation.

Absence of bile causes

malabsorption

of fat and fat soluble vitamins (A, K, E, D).

Gallstones

Complications of GBS

:

A) Silent stones

:

asymptomatic

,

B) Complication in the GB

: 1.

Biliary

colic

. 2.

Acute

cholecystitis

. 3.

Chronic

cholecystitis

.. 4.

Carcinoma

.

C)

Complications in the bile duct:

1. Obstructive jaundice. 2. Ascending

cholangitis

& fever. 3. Acute pancreatitis. 4. GS

ileus

: this occurs when there is ulceration that make a fistula through the wall of the GB into the duodenum or colon, the large GS may pass per rectum or produce GS

ileus

– so it is a mechanical obstruction. Classic findings of

pneumobilia

"air in the gallbladder",

small bowel obstruction

, and

radiolucent gallstone on abdominal plain films

is known as

Rigler's

Triad

Acute

cholecystitis

: > Pathogenesis: obstruction of Hartmann's pouch or cystic duct by a stone. >Initially chemical irritation to mucosa > damage > inflammatory response in the wall of gall bladder.

> This will lead to edema and distention in the wall  increase in

intraluminal

pressure compromise blood flow.

> Decrease in blood flow with infection lead to gangrene that cause softness of the wall of gall bladder.

> Gangrene can cause perforation which will cause either abscess (because of localization of perforation) or chemical peritonitis which is very sever type of peritonitis.

 Unrelieved obstruction without superimposed infection will lead to

mucocele

(because of absorption of bile and continuous secretion of clear mucous).

 Unrelieved obstruction with superimposed infection and pus production will lead to

empyema

.

 Source of infection is either from the bile (20 – 30%) or ascending from the liver.



Duration of pain is more than 6 hours

.

History in acute

cholecystitis

: > The patient came with

sudden onset of severe pain in the right

hypochondrium

,

radiating to the back and referred to the tip of right scapula.

>

More than 6 hours duration

.  Associated symptoms: nausea, vomiting, pyrexia.  Because it is an inflammatory process and one of the cardinal signs of inflammation is

tenderness

,

movement and breathing causes movement of gallbladder stimulation pain

.

Examination in acute

cholecystitis

:

General:

patient is distressed of pain

,

tachycardia

,

high fever (> 38.5 c)

,

shallow breathing

because the in trying to minimize his movement as much as possible.

Abdomen

:

tenderness and guarding over right

hypochondrium

.

Murphy's sign

: cessation of breath at height of inspiration when the patient takes a deep breath because the inflamed gall bladder strikes the palpating hand