2 ANATOMY OF GALLBLADDER AND EXTRAHEPATIC BILIARY TREE BileHelps the body digest fatsMade in the liverStored in the gallbladder until the body needs itContains:WaterCholesterolBile pigmentsPhospholipidsBicarbonateAnions of the bile acidsConcentrations vary - different kinds of stones may be formed
3 What are gallstones? Small hard deposits that form in the gallbladder Process of gallstone formation is known as cholelithiasisrange in size from a few millimeters to several centimeters in diameter-Pigment stones, cholesterol stones, mixed stones
5 pathophysiologyWhen bile is concentrated in the gallbladder, it can become supersaturated with these substances, which then precipitate from solution as microscopic crystals. The crystals are trapped in gallbladder mucus, producing gallbladder sludge.Over time, the crystals grow, aggregate, and fuse to form macroscopic stones. Occlusion of the ducts by sludge and/or stones produces the complications of gallstone disease.
6 Signs/symptoms About 90% of gallstones cause no symptoms Pain in the RUQMost common and typical symptomMay last for a few minutes to several hoursMostly felt after eating a heavy and high-fat mealPain under right shoulder when lifting up armsFever, nausea and vomitingJaundice (obstruction of the bile duct passage)Acute pancreatitis (gallstone enters the duct leading to pancreas and blocks it)Also need to rule out:Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis
7 causesBile contains too much cholesterol—excess cholesterol may form into crystals and eventually into stonesBile contains too much bilirubin—certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood disorders.Your gallbladder doesn’t empty cholesterol—bile may become very concentrated and this contributes to the formation of gallstones.
8 management Management depends on the stage Treatment for asymptomatic gallstones—medical dissolution for gallstones is recommended--Months or years of treatment may be necessary before all stones dissolve-25% of patients develop symptoms within 10 yearsTreatment for symptomatic gallstones—cholecystectomy recommended, open versus laproscopic cholecystectomy, cholecystosomy, Endoscopic retrograde sphincterotomy,Contact dissolution therapyExperimental procedureInvolves injecting a drug directly into the gallbladder to dissolve cholesterol stones
9 complications Inflammation of the gallbladder—cholecystitis Blockage of the common bile duct—jaundice and bile duct infection can result.Blockage of the pancreatic duct—gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitisGallbladder cancer—rare
10 In the GB: In the bile ducts: In the gut: Biliary colic Acute and chronic cholecystitisEmpyemaMucocoeleCarcinomaIn the bile ducts:Obstructive jaundicePancreatitisCholangitisIn the gut:Gallstone ileus
11 diagnosis Physical exam includes—Murphy’s Sign Abdominal Radiography—exclude other causes of abd painUltrasoundMost sensitive and specific test for gallstonesComputerized tomography (CT) scanMay show gallstones or complications, such as infection and rupture of GB or bile ductsCholescintigraphy (HIDA scan)Used to diagnose abnormal contraction of gallbladder or obstruction of bile ductsEndoscopic retrograde cholangiopancreatography (ERCP)Used to locate and remove stones in bile ducts-Blood tests—include CBC, liver function panel, amylase, lipase
12 Case study46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now.No prior episodesMinimal RUQ tenderness, no Murphy’sWBC 8, LFT normalRUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluidDiagnosis: ?
13 diagnosis → denotes gallstones ► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone