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GALL BLADDER DISEASES

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Introduction

  • Relevant anatomy and pyysiology
  • Congenital :absence of the gall bladder/cystic duct

-low insertion of the cystic duct

-biliary atresia

-choledochal cyst

-varaitions of the cystic artery,Moynihan’s hump

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  • Acquired

-Trauma/Injuries

-Inflammation: Cholecystitis,cholangitis,cholesterosis

-cholelithiasis: Gallstones/calculi

-Neoplasm

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Cholelithiasis

  • commoner in developed countries,
  • 10-15% of adults in the U.S.& Europe
  • Incidence rising in Nigeria 1.5m/year
  • thought to be a disease of affluence
  • disordered composition of bile is thenmain abn.in lithogenesis
  • 3 factors involved;infection,bile stasis & metabolic issues

-bacteris found in calculi are;streptococci,salmonelll

Moynihan’s aphorism(a gall stone is a tombstone erected to the memory of the organism witin it)

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  • stasis in biliary stream enables stone formation,esp.in pregnancy
  • normal ratio of bile salts to cholesterol is 30:1,if less it enables stone
  • 3 types of stone;

-cholesterol

-pigment,incr’d haemolysis & bilir.prod;strictures,c.sinensis,A.lumbri.

- mixed

  • Gas may be found in gall stones,giving tri or biradiate radiolucent

fissure inX-RAY called Mercedes benx or Seagull sign

  • Saint’s triad(gallstone,diverticolosis,of the colon & hiatus hernia

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Complications of gallstones

  • In the gall bladder;

-chr.cholecystitis

-acute cholecystitis;gangrene,perfo,empyema,mucocele,carcinoma

  • In the bile ducts,obst,jaundice,cholangitis,acute pancreatitis
  • In the intestine,acute intestinal obstruction(gallstone ileus)

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CLINICAL FEATURES

  • may be asymptomatic,in silent gallstones,incidental at laporotomy/Inv

- as in acute or chronis calculous cholecystitis

  • acute calculouscholecystitis,

-Rt.hypochond. pain,dull/colicky if impacted(95%) at Hartmann’s pouch

or ostructing the cystic duct.

-sudden onset

-from chr.one

-nausea and vomitng severe

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  • pyrexial ~38 C
  • tenderness,rigidity rt.hypochondrium
  • may be a rt.hypochondial mass(g/bladder+g/omentum)
  • +ve Boas’s sign(hyperasthesia b/w Rt.9th & 11th ribs posteriorly)

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Differential diagnosis

  • Acute appendicitis
  • Perf.D.U/G.U
  • Acute pancreatitis
  • Rt.pyelonephritis
  • Myocardial infaction
  • Rt.lower pneumonia

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Investigations

  • USS
  • Oral cholecystography
  • Intravenous cholangiography
  • Radioisitope scanning HIDA/PIPIDA
  • CT-Scan
  • ERCP(Endoscopic Retrograde CholangioPancreatogrphy)
  • PTC(Percutanuos transhepatic cholangiography)
  • POC(Per oral cholangiography)
  • MRCP(Magnetic Resonance CholangioPancreatography),a substitute for ercp&ptc

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Treatment

  • Non-operative approach,to be followed bt cholecystectomy

-N/G Tube,IVT,antibiotics,analgesics

-90% will have fever,pain % other symptoms subside,then cholecyetectomy is done 2-3 days later.

-this is contraindicated if theDX is uncertain or symptoms are getting worse,so cholecystectomy is done immediately.

-if facilities exist ,percut.cholecystostomy is a safe and dependable procedure and a cholecystectomy is done later to remove the g/bladder.

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  • chronic calculous cholecystitis

-Rt.hypochondrial discomfort

-may radiate to b/w the shoulders

-nausea,vomiting may be present

-flatulence,dyspepsia

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  • USS
  • Ora cholangiography
  • ? Per operative cholangiogram done to exclude duct stones,e.g CBD,usually in 10% of cholecystectomies.

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  • FBC
  • U/E/Cr.
  • LFTS-
  • PT,KCCT
  • GXM

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  • Aim;to remove the disease gall bladder when the patient is fit.
  • Analgesics for pains/discomfort,opiates +buscopanHBbromide
  • Anti-emetics,
  • Low fat diet b4 cholecystectomy +-CBD exploration
  • Dissolution of gall stones,takes time,it is adjunct to lithotripsy,bile acids;chenodeoxycholic acid,ursodeoxycholic acid are taken orally.

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ACALCULOUS CHOLECYSTITIS

  • Inflammation od the gall bladder in the absence of stones/calculi

-may occur in patients who had major surgery ,trauma or burns

-similar to calculous cholecystitis

-oral cholecystography is better for chr.one than USS

-radioisotope scanning is best for acute cholecystitis

  • Treatment is cholecystectomy.

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CHOLEDOCHOLITHIASIS

  • Stone in the bile ducts;intrahepatic or extrahepatic ducts.
  • Charcot’s triad:pain(RUQ),fever and jaundice
  • Reynold’s pentad:charcot’s+shock+altered mental status
  • Courvoisier’s law:In obstruction of the CBD,due to stone,distension of the gall bladder seldon occurs,the organ usually is shrivelled or shrunken.Obstruction from other causes distension is common
  • The gall bladder in most of these patients is fibrotic& non-distensible

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DDX

  • Ca.head of pancreas
  • Primary biliary cirrhosis
  • Hepatoma
  • Hepatitis,viral or drug induced

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Treatment

  • Treat liver failure;

high glucose intake 10% dextrose,adequate hydration,IVF,Vit.K injection 10mg i/m daily for 10 days b4 surgery in deranged clotting profile

  • Bloos transfusion if need be
  • Endoscopic;papillotomy
  • Percut.removal of stone through T-tube
  • Percut.biliary drainage,e,g stenting in the very illmpatient.
  • Choledochotomy:takes priority over cholecystectomy,for a duct stone.

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