GALL BLADDER Flashcards by CESS SOMORAY

Treatment of choice for symptomatic gallstones

Laparascopic cholecystectomy

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measurement of a gallbladder

7 to 10 cm long

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average capacity

30-50ml

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Location of gallbaldder

anatomic fossa on the inferior surface of the licer

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Cantle’s line

vertical plane running from the gallbladder fossa anteriorly to the inferior vena canca posteriorly divides left to right lobes

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four anatomic areas

fundus, body, infundibulum, neck

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mucosal lining of GB

single, highly redundant, simple, columnar epithelium contains cholesterol and fat globules

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Epi lining supported by

LAMINA PROPRIA

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Gallbladder differs histologicallt from the rest of Gi TRACTS

Lacks muscularis, mucosa and submucosa

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Cystic arrert supplies GB usually a branch of the right hepatic artery

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gallbladder lymphatrics drain into nodes

neck of the gallbladder

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Visible lymph node (Lund’s or Mascagni’s node - overlies rge insertion of cystic artery into gb wall

Calot’s node

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galllbaldder receives

parasympha, sympha, and semsory innervation via nerve fibers runnung largely via GASTRO HEPATIC LIGAMENT

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Parasymphatetic cholinergic arise from where

HEPATIC BRANCH OF VAGUS NERVE

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Vagal nerve branches also have PEPTIDE-CONTAINING NERVES

somatostatin, enkephalins, substance P, VIP

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extrahepatic biliary tree consist of

right and left hepatic ducts, common bile ducrs, cystic duct and other common bile duct

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common hepatic duct extends

1-4cm

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segment of the cystic ducr immediately adjacent to the gallbladder neck bears a variable number of mucosal folds

SPIRAL VALVES OF HEISTER

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Union of the cystic duct and the common hepatic ducr start of the common bile ducr.

7-11cm in length and 5-10 cm in diameter

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Union of the cystic duct and the common hepatic ducr start of the common bile ducr.

7-11cm in length and 5-10 cm in diameter

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Upper third (Supraduodenal portion)

passes downward in the free edge of the hepatoduodenal ligament, to the righ of the hepatic artery and anterior to the portal vein.

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Middle third (retroduodenal portion)

bile ducr curves behind the first portion of the duodenum and diverges laterallt from the porral vein and hepatic arteries

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lower third (pancreatic portion)

curve behind the head of the pancreas

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sphincter of oddi

thick coat of circular smooth muscle, surroubds the common bile duct. Controls the flow of bile, and pancreatic juice and into duodenum.

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The arterial supply to the bile ducts derived from

GASTRODUODENAL AND RIGHT HEPATIC ARTERIES, MAJOR TRUNKS LATERAL WALLS OF THE COMMON DUCT

Normal adult consuming an average diet

500-1000ml of bile a day

rudimentary

small, nonfunctional hypoplastic remnat

lIver produces bile continously and excetes it into the

BILE CANALICULI

BIle is composed of

water, mixed with bile salts, and acids, cholesterol. phospholipids (lecithin), proteins, and bilirubin.

80% of the secrered conjugated bile acids are reabsorbed in the

terminal ileum

GB, Bile ducts, sphicter of oddi

act together to store and regulate flow of bile.

Main fx of hepatic bille

store hepatic bile in order to deliver it in a coordinated fashion to the duodenum in response to meal.

MUCOSAL CELLS OF GB SECRETE AT LEAST 2 IMORTATNR PRODUCT

GLYCOPROTEIN AND HYDROGEN IONS

GLYCOPROTEINS SECRETES

Protect the mucosa from the corrosive action and facilitate passage of bile via cystic duct.

HYDROGEN IONS

decreasing the ph of stored bile. This acidification helps prevent the precipitation of ca salts, which can act as a nidus for STONE FORMATION

main stimuli to this coordinated effort of gb emptying

cholecystokinin cck#

CCK released

endogenouslt from enteroendocrine cells in the duodenum in response to meal

defects in the motor activity of the gb inhibit correct emotying are thought to play a role

Cholesterol nucleation and gallstone formation

Parasympathomimetic or cholinergic drugs contract the GB

nicotine and caffeine

Anticholinergic drugs for gallbladder relaxation

Atropine

Antral distenton of the stomach causes both

Gallbladder contraction and relaxation of the spinchter of oddi.

Initial test of choice in evaluating pt with suspected malignancy of the GB

ct scan

Preferred imaging modality for precise evaluation of biliary and pancreatic duct pathology

MRCP

another option for noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum that provides both ana and fx information. Technetium-labeled derivatives of imnodiacetIc acid are injected iV, taken up by the Kupffer cells in the liver, excreted in the bile.

HEPATOBILIARY SCINTIGRAPHY OR HIDA SCANNING

Advantage of ECRP

Direct visualization of the ampullary region, direct access to the distal common bile duct for cholangiography or cholescopy

can be used to identify choledocholithiasis. useful for eval of retroduodenall portion of bile ducr, which is difficukt to resr in transabdominal ulratsonography

ENDOSCOPIC US

biliary tree cant be assessed endoscopically, anterograde cholangiography can be performed by acessing i ntrahepatic bile ducr percistaneously with needle under fluroscopic guidance

Percutaneous transheparuc cholangiography

Ptc potental rrisks

mainly bleeding, cholangitis, leak an dother catheter related probs

Conditions predispose to the dev of gallstones

PREGNANCY NON HDL HYPERLIPIDEMIA CHROH'S DISEASE CERTAIN BLOOD D/O HEREIDTARY SPHEROCYTOSIS, SC, THALASSEMIA

PORCELAIN GB

significant calcifcation pre malignant condition absolute indication for cholecystectom, even when asymp

Primary event in the formation of cholesterol stones

Supersaturation of bile with cholesterol - non polar and soluble in water and bile

What is formed when cholesterol is secrered into bile and sourrounded by bile salts and phospholipids

VESICLE COMPLEX

Contains <20% cholestererol and are dark because of the presence of CA bilirubinare.

PIGMENTED STONES - usually brittle, small, dark and sometimes spiculared - formed by supersat of Uncojugated bilirubin within the bile.

usually <1cm in diameter, brownish-yellowish, soft, and often mushy. form either in the gb or in the bile ducts secondary to bacterial infection and bile statsis. bacteria such as E.coli secrete b-ucoronidase that enzymaticallt cleaves conjugated bilirubin to produce insoluble uncojugated bilirubin. assoc with stasis secondary to parasite infection with Ascaris lumbricoides (roundworm) or Chlonorchis sinensis (liver in fluke)

BROWN STONES

chief symp associated with symptomatic cholelithiasis

PAIN Biliary colic - constant and increases in severity. firts half of hour last up to 1 hr - 5hr

Atypical presentations

in the back or left upper or right lower quadrant. bloating and bleching may be present associated with attacks of paib,

when pain lasts greater than 24 hours without resolving

impacted stone in the cystic duct or acute cholecystitis

Impacted stone without cholecystitis

HYDROPS OF THE GB

diagnosis of syptomatic chole or chronic chole depends on the presence of

typical symptoms and demonstration of stones on DIAGNOSTIC IMAGING

Standard diagnistic test for gallstones as it is noninavsive and highly sensitive

abdominal ultrasound

best long term results for patient with symptomatic gallstones

SURGICAL CHOLECYSTECOTOMY

Impactiob of a larfe stone in rge neck og the gallbladder causing obstruction at the level of confluece of the cystic duct and common hepatic duct

MIRIZZI'S SYNDROME

acute chole is mediated initially by mucosal toxin ___ a product of lecithin, as well as bile salts and platelet activating factors

lysolecithin

CM of acute chole:

Begins as an attack of biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium that may radiate to the right back or interscapular area. -febrile , anorexia, nausea, vomiting. creates focal peritinitis.

PE of acute chole

tenderness and guarding are usualyy present in right upper quadrant.

INspiratory arresr with deep palapatio in thw right subcostal area.

Murphy's sign

GALL BLADDER Flashcards

(66 cards)