Gall bladder Disorders Gallbladder - PowerPoint Presentation

1. Gall bladder Disorders

2. Gallbladder AnatomyIt is a pear-shaped sac…..length about 7.5 to 12.5 cm …..with an average capacity of 30 to 50 ml (the gallbladder can distend markedly and contain up to 300 ml)located on the inferior surface of the liver attached to it by loose areolar tissue. Rich in blood vessels and lymphatic.The Gallbladder covered by peritoneum reflected from Glisson Capsule Less 10% complete covered by peritoneum (mesentery) The gallbladder is divided into four anatomic areas: the fundus: the corpus (body), the infundibulum, and the neck.Supplied by the cystic artery which arise from the right hepatic artery . Venues drainage : drain into the right branch of portal vein.Lymphatic drainage: drain into cystic lymph node.

3. a = right hepatic duct b = left hepatic ductc = common hepatic ductd = portal veine = hepatic arteryf = gastroduodenal arteryg = left gastric artery h = common bile ducti = fundus of the gallbladderj = body of gallbladderk = infundibuluml = cystic ductm = cystic artery n = superior pancreaticoduodenal artery.

4. Gallbladder Physiology Bile is mainly composed of water (97%), bile salts (1-2%), (1%) phospho-lipids, cholesterol, bile pigments, and electrolytes.Bile is alkaline and PH 5.7 – 8.6.The rate of bile secretion is 40 cc / hour.The normal adult consuming an average diet produces within the liver 500 to 1000 ml of bile a day.

5. Gallbladder FunctionBile storage.Bile concentration 5-10 times by active absorption of water and sodium decreasing the bile volume 80-90%.Secretion of mucin = 20 ml /day.

6. Diagnostic Studies

7. Limited value in the diagnoses GB disorder but helpful to rule out other differential diagnoses. Gallbladder stone can be seen by x-ray in 15-20%.Abdominal X- ray:

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9. Oral CholecystographyIt involves oral administration of a radiopaque compound that is absorbed, excreted by the liver, and passed into the gallbladder.largely been replaced by ultrasonography.

10. UltrasonographyAn ultrasound is the initial investigation of any patient suspected of disease of the biliary tree. It is noninvasive, painless, does not submit the patient to radiation, and can be performed on critically ill patients

11. Abdominal CT scans are inferior to ultrasonography in diagnosing gallstones.The major application of CT scans is to define the course and status of the extrahepatic biliary tree and adjacent structures. It is the test of choice in evaluating the patient with suspected malignancy of the gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of the pancreas. Use of CT scan is an integral part of the differential diagnosis of obstructive jaundice. Computed Tomography

12. Biliary scintigraphy provides a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information. The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis.The sensitivity and specificity for the diagnosis are about 95% each. Biliary leaks as a complication of surgery of the gallbladder or the biliary tree can be confirmed and frequently localized by biliary scintigraphy.Biliary Radionuclide Scanning (Hida Scan)

13. It has little role in the management of patients with uncomplicated gallstone disease.useful in patients with bile duct strictures and tumors, as it defines the anatomy of the biliary tree proximal to the affected segment. complications are bleeding, cholangitis, bile leak, and other catheter-related problems.Percutaneous Transhepatic CholangiographyNeedle

14. Magnetic Resonance ImagingIt has a sensitivity and specificity of 95 and 89%, respectively, at detecting choledocholithiasis. MRI with magnetic resonance cholangiopancreatography (MRCP) offers a single noninvasive test for the diagnosis of biliary tract and pancreatic disease

15. Endoscopic Retrograde Cholangiography and Endoscopic Ultrasound This test is rarely needed for uncomplicated gallstone disease, but for stones in the common bile duct, in particular, when associated with obstructive jaundice, cholangitis, or gallstone pancreatitis, ERC is the diagnostic and often therapeutic procedure of choice.Complications of diagnostic ERC include pancreatitis and cholangitis, and occur in up to 5% of patients.

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20. Gallstone DiseasePrevalence and Incidence :Gallstone disease is one of the most common problems affecting the digestive tract (Autopsy reports have shown a prevalence of gallstones from 11 to 36%.).The prevalence of gallstones is related to many factors:age, gender, and ethnic backgroundObesity, pregnancy, dietary factors,Crohn's disease, terminal ileal resection, gastric surgeryhereditary spherocytosis, sickle cell disease, and thalassemia

21. Types of gallstoneCholesterol stones ()Pigment stones ()Mixed ()EpidemiologyFat, Fair, Female, Fertile, Fourty inaccurate, but reminder of the typical patientF:M = 2:110% of British women in their 40s have gallstonesGenetic predisposition – ask about family historyGallstones

22. Composition of bileBilirubin (by-product of haem degradation)Cholesterol (kept soluble by bile salts and lecithin)Bile salts/acids (cholic acid/chenodeoxycholic acid): mostly reabsorbed in terminal ileum(entero-hepatic circulation).Lecithin (increases solubility of cholesterol)Inorganic salts (sodium bicarbonate to keep bile alkaline to neutralise gastric acid in duodenum)Water (makes up 97% of bile)Pathogenesis

23. Cholesterol Imbalance between bile salts/lecithin and cholesterol allows cholesterol to precipitate out of solution and form stones OR stasisPigmentOccur due to excess of circulating bile pigment (e.g. Heamolytic anaemia)MixedSame pathophysiology as cholesterol stonesOther FactorsStasis (e.g. Pregnancy)Ileal dysfunction (prevents re-absorption of bile salts)Obesity and hypercholesterolaemiaPathogenesis

24. Cholesterol Stones Pure cholesterol stones are uncommon and account for <10% of all stones. They usually occur as single large stones with smooth surfaces.Most other cholesterol stones contain variable amounts of bile pigments and calcium, but are always >70% cholesterol by weight. usually multiple, of variable size. Colors range from whitish yellow and green to black.Most cholesterol stones are radiolucent; <10% are radiopaque.the primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol.Supersaturation almost always is caused by cholesterol hypersecretion rather than by a reduced secretion of phospholipid or bile salts

25. Pigment Stones Pigment stones contain <20% cholesterol and are dark because of the presence of calcium bilirubinateblack and brown pigment stones have little in common and should be considered as separate entitiesBlack pigment stones are usually small, brittle, black, and sometimes speculated, formed by supersaturation of calcium bilirubinate, carbonate, and phosphate, most often secondary to hemolytic disorders, and in those with cirrhosis. Like cholesterol stones, they almost always form in the gallbladder.Brown stones : They may form either in the gallbladder or in the bile ducts, usually secondary to bacterial infection (such as Escherichia coli)caused by bile stasis. calcium bilirubinate and bacterial cell bodies compose the major part of the stone.

26. 80% Asymptomatic20% develop symptoms and complications (recurrent)Complications of Gallstones

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37. Biliary ColicAcute CholecystitisGallbladder EmpyemaGallbladder gangreneGallbladder perforationObstructive JaundiceAscending CholangitisPancreatitisGallstone Ileus (rare)Complications of Gallstones

38. Gallstone disease (and its related complications)Gastritis/duodenitisPeptic ulcer disease/perforated peptic ulcerAcute pancreatitisRight lower lobe pneumoniaMIWhen there is RUQ pain…… all patients should getBlood testsAXR/E-CXR (to exclude perforation/pneumonia)ECGDifferential Diagnosis of RUQ pain

39. Can differentiate between gallstone complications based on:HistoryExaminationBlood testsFBCLFTCRPClottingAmylaseWhich Gallstone Complication?

40. ComplicationHistoryExaminationBlood testsBiliary Colic- Intermittent RUQ/epigastric pain (minutes/hours) into back or right shoulder- N&V-Tender RUQ-No peritonism-Murphy’s –-Apyrexial, HR and BP (N)-WCC (N) CRP (N)- LFT (N)Acute Cholecystitis-Constant RUQ pain into back or right shoulder-N&V-FeverishTender RUQPeriotnism RUQ (guarding/rebound)Murphy’s +Pyrexia, HR (↑)WCC and CRP (↑)LFT (N or mildly (↑)Empyema-Constant RUQ pain into back or right shoulder-N&V-FeverishTender RUQ Peritonism RUQMurphy’s +Pyrexia, HR (↑), BP (↔ or ↓)More septic than acute cholecystitisWCC and CRP (↑)LFT (N or mildly (↑)Obstructive JaundiceYellow discolourationPale stool, dark urinepainless or assocaited with mild RUQ painJaundicedNon-tender or minimally tender RUQNo peritonismMurphy’s –Apyrexial, HR and BP (N)WCC and CRP (N)LFT: obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔)INR (↔ or ↑)Ascending CholangitisBecks triad-RUQ pain (constant)-Jaundice -Rigors-Jaundiced-Tender RUQ -Peritonism RUQSpiking high pyrexia (38-39)HR (↑), BP (↔ or ↓)Can develop septic shockWCC and CRP (↑)LFT : obstructive pattern bili (↑), ALP (↑), GGT (↑), ALT/AST (↔)INR (↔ or ↑)Acute PancreatitisSevere upper abdominal pain (constant) into backProfuse vomiting-Tender upper abdomen-Upper abdominal or generalised peritonism-Usually apyrexial, HR (↑), BP (↔ or ↓)-WCC and CRP (↑)-LFT: (N) if passed stone or obstructive pattern ifstone still in CBDAmylase (↑)INR/APTT (N) or (↑) if DICGallstone Ileus- 4 cardinal features of SBO-distended tympanic abdomen-hyperactive/tinkling bowel sounds

41. PathogenesisStone intermittently obstructing cystic duct (causing pain) and then dropping back into gallbladder (pain subsides)USS confirms presence of gallstonesTreatmentAnalgesiaFluid resuscitation if vomitingIf pain and vomiting subside does not need admittingBiliary Colic

42. Pathogenesis:Due to obstruction of cystic duct by gallstone:Cystic duct blockage by gallstoneObstruction to secretion of bile from gallbladderBile becomes concentratedChemical inflammation initiallySecondarily infected by organisms released by liver into bile streamUSS confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid)Complications of acute cholecystitisEmpyema of gallbaldderGangrene of gallbladder (rare)Perforation ofgallbaldder (rare)Acute Cholecystitis

43. TreatmentAdmit for monitoringAnalgesiaClear fluids initially, then build up oral intake as cholecystitis settlesIVFAntibiotics95% settle with above managementIf do not settle then for CT scanEmpyema  percutaneous drainageGangrene/perforation with generalised peritonitis emergency surgery

44. Pathogenesis: Stone obstructing CBD (bear in mind there are other causes for obstructive jaundice) – danger is progression to ascending cholangitis.USSWill confirm gallstones in the gallbladder CBD dilatation i.e. >8mm (not always!)May visualise stone in CBD (most often does not)MRCPIn cases where suspect stone in CBD but USS indeterminateE.g.1 obstructive LFTs but USS shows no biliary dilatation and no stone in CBDE.g. 2 normal LFTS but USS shows biliary dilatationObstructive Jaundice

45. ERCPIf confirmed stone in CBD on USS or MRCP proceed to ERCP which will confirm this (diagnostic) and allow extraction of stones and sphincterotomy (therepeutic)TreatmentMust unobstruct biliary tree with ERCP to prevent progression to ascending cholangitisWhilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis

46. Pathogenesis:Stone obstructing CBD with infection/pus proximal to the blockageTreatmentABCFluid resuscitation (clear fuids and IVF, catheter)AntibioticsPus must be drained* - this is done by decompressing the biliary treeUrgent ERCP Urgent PTC – if ERCP unavailable or unsuccesfulAscending Cholangitis

47. Acute PancreatitisPathogenesisObstruction of pancreatic outflowPancreatic enzymes activated within pancreasPancreatic auto-digestionUSS: to confirm gallstones as cause of pancreatitisUSS not good for visualising pancreasCT: gold standard for assessing pancreas. Performed if failing to settle with conservative management to look for complications such as pancreatic necrosisTreatmentAnalgesiaFluid resuscitationPancreatic rest – clear fluids initiallyIdentify underlying cause of pancreatitis95% settle with above conservative management5% who do no settle or deteriorate need CT scan to look for pancreatic necrosis

48. Gallstone ileusPathogenesis:Gallstone causing small bowel obstruction (usually obstructs in terminal ileum)Gallstone enters small bowel via cholecysto-duodenal fistula (not via CBD)AXR – dilated small bowel loopsMay see stone if radio-opaqueTreatmentNBM Fluid resuscitation + catheterNG tubeAnalgesiaSurgery (will not settle with conservative management) – enterotomy + removal of stone Diagnosis of gallstone ileus usually made at the time of surgery.

49. Chronic Cholecystitis About two thirds of patients with gallstone disease present with chronic cholecystitischaracterized by recurrent attacks of pain( biliary colic). develops when a stone obstructs the cystic ductvary from an apparently normal gallbladder with minor chronic inflammation in the mucosa, to a shrunken, nonfunctioning gallbladder with gross transmural fibrosis and adhesions to nearby structures.The mucosa is initially normal or hypertrophied, but later becomes atrophied, with the epithelium protruding into the muscle coat, leading to the formation of the so-called Aschoff-Rokitansky sinuses

50. Clinical Presentation Typical presentation:The chief symptom is pain (constant and increases in severity over the first half hour or so and typically lasts 1 to 5 hours ). located in the epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapulae…The pain is severe and comes on abruptly, typically during the night or after a fatty meal…The pain is episodic. The patient suffers discrete attacks of pain, between which they feel well.Physical examination may reveal mild right upper quadrant tenderness during an episode of pain. If the patient is pain free, the physical examination is usually unremarkableLaboratory values, such as WBC count and liver function tests, are usually normal in patients with uncomplicated gallstones. Atypical presentation ??

51. Asymptomatic gallstones do not require operationIndicationsA single complication of gallstones is an indication for cholecystectomy (this includes biliary colic)After a single complication risk of recurrent complications is high (and some of these can be life threatening e.g. cholangitis, pancreatitis)Whilst awaiting laparoscopic cholecystectomyLow fat dietDissolution therapy (ursodeoxycholic acid) generally uselessCholecystectomy

52. CholecystectomyAll performed laparoscopicallyAdvantages:Less post-op painShorter hospital stayQuicker return to normal activitiesDisadvantages:Learning curveInexperience at performing open cholecystectomies

53. TumorsCarcinoma of the Gallbladder :Incidence :the fifth most common GI malignancy in Western countriesaccounts for only 2 to 4% of all malignant GI tumors,two to three times more common in females than malespeak incidence is in the seventh decade of lifeIt is an aggressive tumor (The overall reported 5-year survival rate is about 5% ))

54. Etiology Gallstone is the most important risk factor for gallbladder carcinoma up to 95% of patients with carcinoma of the gallbladder have gallstones.Larger stones (>3 cm) are associated with a 10-fold increased risk of cancer.Polypoid lesions (( particularly in polyps >10 mm)))calcified "porcelain" gallbladder is associated with >20% incidence of gallbladder carcinomacholedochal cystsexposure to carcinogens (azotoluene, nitrosamines)

55. Pathology80 and 90% of the gallbladder tumors are adenocarcinomas while Squamous cell, adenosquamous, oat cell, and other anaplastic lesions occur rarelyspreads through the lymphatics, with venous drainage, and with direct invasion into the liverLymphatic flow from the gallbladder drains first to the cystic duct node (Calot's), then the pericholedochal and hilar nodes, and finally the peripancreatic, duodenal, periportal, celiac, and superior mesenteric artery nodes.The gallbladder veins drain directly into the adjacent liver, usually segments IV and V, where tumor invasion is commonWhen diagnosed :about 25% of gallbladder cancers are localized to the gallbladder wall35% have regional nodal involvement and/or extension into adjacent liverapproximately 40% have distant metastasis

56. Clinical Manifestations and DiagnosisSigns and symptoms of carcinoma of the gallbladder are generally indistinguishable from those associated with cholecystitis and cholelithiasis.More than one half of gallbladder cancers are not diagnosed before surgeryLaboratory findings are not diagnostic. Ultrasonography often reveals a thickened, irregular gallbladder wall or a mass replacing the gallbladder. Ultrasonography may visualize tumor invasion of the liver, lymphadenopathy, and a dilated biliary tree . The sensitivity of ultrasonography in detecting gallbladder cancer ranges from 70 to 100%A CT scan is an important tool for staging. identify a gallbladder mass or local invasion into adjacent organs. demonstrate vascular invasion. poor method for identifying nodal spreadMRCP has evolved into a single noninvasive imaging method that allows complete assessment of biliary, vascular, nodal, hepatic, and adjacent organ involvementIf diagnostic studies suggest that the tumor is unresectable, a CT scan or ultrasound-guided biopsy of the tumor can be obtained to provide a pathologic diagnosis.

57. TREATMENTSurgery remains the only curative option for gallbladder cancerno proven effective options for adjuvant radiation or chemotherapy for patients with gallbladder cancer.Tumors limited to the muscular layer of the gallbladder (T1) simple cholecystectomy is an adequate treatment for T1 lesions and results in a near 100% overall 5-year survival rateWhen the tumor invades the perimuscular connective tissue without extension beyond the serosa or into the liver (T2 tumors)… extended cholecystectomy should be performedincludes resection of liver segments IVB and V, and lymphadenectomyFor tumors that grow beyond the serosa or invade the liver or other organs (T3 and T4 tumors), there is a high likelihood of intraperitoneal and distant spread. If no peritoneal or nodal involvement is found, complete tumor excision with an extended right hepatectomy (segments IV, V, VI, VII, and VIII) must be performed for adequateAn aggressive approach in patients who will tolerate surgery has resulted in an increased survival for T3 and T4 lesions.

58. PrognosisThe 5-year survival rate of all patients with gallbladder cancer is <5%, with a median survival of 6 months.Patients with T1 disease.excellent prognosis (85 to 100% 5-year survival rate).T2 lesions treated with an extended cholecystectomy and lymphadenectomy compared with simple cholecystectomy is >70% vs. 25 to 40%, respectivelyPatients with advanced but resectable gallbladder cancer are reported to have 5-year survival rates of 20 to 50%.the median survival for patients with distant metastasis at the time of presentation is only 1 to 3 months.The prognosis for recurrent disease is very poorDeath occurs most commonly secondary to biliary sepsis or liver failure.

59. When should symptomatic gallbladder stones be suspected?The characteristic symptoms of gallbladder stones, i.e. episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction to analgesics, should be identified by medical history and physical examinationwhat is the treatment for symptomatic gallbladder stones?Cholecystectomy is the preferred option for treatment of symptomatic gallbladder stonesWhat are the appropriate investigations to diagnose acute cholecystitis?Acute cholecystitis should be suspected in a patient with fever, severe pain located in the right upper abdominal quadrant lasting for several hours, and right upper abdominal pain and tenderness on palpation (Murphy’s sign)

60. Should patients with asymptomatic gallstones be treated?Routine treatment is not recommended for patients with asymptomatic gallbladder stonesIs surgery indicated for gallbladder polyps? Cholecystectomy should be performed in patients with gallbladder polyps ≥1 cm without or with gallstones regardless of their symptoms Cholecystectomy should also be considered in patients with asymptomatic gallbladder stones and gallbladder polyps 6-10 mm and in case of growing polyps (Cholecystectomy may be recommended for asymptomatic patients with primary sclerosing cholangitis and gallbladder polyps irrespective of size Cholecystectomy is not indicated in patients with asymptomatic gallbladder stones and gallbladder polyps ≤5 mm

61. Is cholecystectomy indicated in patients with porcelain gallbladder?Asymptomatic patients with porcelain gallbladder may undergo cholecystectomyShould prophylactic cholecystectomy be offered to patients with hereditary spherocytosis or sickle cell disease?Cholecystectomy should be considered in patients with hereditary spherocytosis and sickle cell disease and concomitant asymptomatic gallstones at the time of splenectomy. In patients with sickle cell disease and asymptomatic gallstones, an additional reason for prophylactic cholecystectomy during other abdominal surgery is to avoid diagnostic uncertainty in case of sickle cell crisesHow should patients with acute cholecystitis be treated?Early laparoscopic cholecystectomy (preferably within 72 h of admission) should be performed by surgeons with adequate expertise in patients with acute cholecystitis

62. Thank youBest of luck