Gall bladder

Size = 7.5 x12.5 cm Capacity= 50 mls Cystic duct= 2.5cm which contains the spiral valve of Heister C.H.D =2.5 cm C.B.D= 7.5 cm 1-supraduodenal 2-retroduodenal 3-infradudenal 4-intraduodenal which open in ampulla's of of Vater.

Composition of Bile: 1- 97% water 2- 1-2% bile salts 3- 1% pigments, fatty acids, cholesterol Liver excretes bile at rate of 40 ml/hr

Functions of gall bladder: 1-Reservoir of bile 2-Cocentration of bile 5-10 times by active absorption of water, Na+, Cl-, Bicarbonate 3-Secration of mucin (20 ml per day)

Investigation of the biliary tree: 1-US: sones & size 2-Plain Xray: calcification 3-MRCP: anatomy & stones 4-CT san: cancer & anatomy 5-HIDA Scan: function 6-ERCP: stones & strictures 7-PTC:proximal obstruction

PTC

ERCP

Congenital abnormalities of GB & bile ducts:

Congenital abnormalities of GB & bile ducts: 1-absence of GB. 2-phrygian cap 2-6% 3-Floatting GB 4-Double GB 5-Absence of cystic duct 6-Low insertion of cystic duct 7-accessory cholecystohepatic duc 8-Atresia 9-choledocal cyst

Biliary Atresia Might be due to viral infection Correctable 10% Uncorrectable  90% CF: *1\3 jaundice at birth *all jaundice by the end of 1st week

Differential diagnosis 1-alpha one antitrypsin deficiency 2-choledocal cyst 3-insspissated bile syndrome 4-neonatal hepatitis

Diagnosis: *liver function tests *radioactive isotope scan---failure of the isotope from reaching the intestine *Laparoscopy\laparotomy---liver biopsy

Choledocal cyst Due to specific weakness in a part or whole wall of CBD *female > male *at age of 6 months

CF *attacks of obstructive jaundice *Cholangitis \ abdominal singns *fever *upper abdominal swelling. Diagnosis: CF+ US +MRI Treatment: *radical excision if possible *choledochocystojujenostomy.

Gall stones

Gall stones Types of gallstones 1-Pure cholesterol (10%). Often solitary, large (> 2.5cm), round. 2-Pure pigment (bile salts; 10%). Pigment stones are of two types: *black (associated with haemolytic disease); *brown (associated with chronic cholangitis and biliary parasites). 3-Mixed (80%). Most common; usually multiple

Causes 1-supersaturated bile: *age *sex *genetics *obesity *diet

2-impaired gall bladder function: *emptying *absorption *excretion 3-cholestrol nucleating factors: *mucus *glycoprotein *infection

4-absorption\enterohepatic circulation of bile acids: *deoxycholate *bowel transit zone *faecal flora *ileal resection *cholestyramine.

Other factors: A-Metabolic B-Infective C-Stasis

Saint's triad *gall stones *diverticular disease *hiatus hernia

Presentation & DX *silent in 85% *acute cholecystitis:pain ,radiation,fatty meals *chronic cholecystitis:flatulent dyspepsia & heart burn which has to be differentiated from:(hiatus hernia, chronic pancreatitis & peptic ulcer)

DX CF+US+X-ray Treatment: *NBM + IVF *biliary pain :(analgesia,spasmolytic,antiemetic) *antibiotic(broad spectrum) Surgery:urgent(for complicated cases),early(next available list) & delayed

Complications & effects of gall stones A-on GB: 1-acute cholecystitis 2-chronic cholecystitis 3-empyema 4-mucocele 5-biliary colic 6-CA 7-gangerene 8-perforation

B-on bile ducts: C-on the bowel: 1-obstructive jaundice 2-cholangitis—liver abscess 3-pancreatitis C-on the bowel: 1-cholecystoenteric fistula 2-gall stone ileus.

Achalculous cholycystitis: Needs oral cholecystogram for dx Presence of cholesterol crystals in duodenal aspirate.high mortality eraly perforation & gangerene Usually seen after:major trauma,burns ,in ICU or patient recovering from major surgery