1. Gallbladder anatomy

2. Bilirubin metabolism Haemoglobin is ingested by reticuloendothelial cells HaemGlobinAmino acids BiliverdinFe 3+ & CO Unconjugated bilirubin + 2 equivalents of glucuronic acid Conjugated bilirubin Urobilinogen StercobilinUrobilin Heme oxygenase Biliverdin reductase Glucuronyltransferase Reduced by gut bacteria Oxidised by gut bacteria +

3. Jaundice A yellow discolouration of the sclerae and skin A result of a raised serum bilirubin Detectable clinically when the bilirubin > 50 micromol/L

4. Type ExplanationInvestigationCauses Pre-hepaticIncreased breakdown of RBCNormal liver biochem Malaria, sickle cell leading to increased levels of (AST, ALT, alk phos) anaemia, thalassemia, unconjugated bilirubin.with raised serum normal in newborns. unconjugated bilirubin. Intra-hepaticHepatocellular swelling in Increase of AST andViral hepatitis, drugs, parenchymal liver disease orALT. Slightly increased alcoholic hepatitis, abnormalities at a cellular level.alk phos. Pale stools cirrhosis. Result of infection or exposureand dark urine. to harmful substances. Post-hepaticOccurs when the biliary Higher levels of Gall stones, pancreatic system is damaged, conjugated bilirubin,cancer, gallbladder inflamed, or obstructed.alk phos, and gammacancer, bile duct GT.cancer, pancreatitis (acute or chronic).

5. Case A 43-year-old female says that she has lost about 4kg over the last four months. Also she has noticed that her stools have become loose, and that she is opening her bowels more frequently than previously. Her stools have become pale, smelly, and difficult to flush down. She has had no significant illnesses in the past and no operations. On examination: 1. Swollen ankles and a regular pulse rate of 98 beats per minute. 2. Pale. 3. Unable to feel any abnormal masses but the patient tells you that her abdomen is bloated and that is feels a bit tender in places. 4. She has a few small bruises on her abdomen.

6. Question State three features from the history and examination that support this view and link each feature with the substance in her diet that is not being absorbed and accounts for the clinical feature.