1. Gall bladder

2. 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.

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

5. 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)

6. 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

7. PTC

8. ERCP

9. Congenital abnormalities of GB & bile ducts:

10. 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

11. 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

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

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

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

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

17. Gall stones

18. 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

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

22. 2-impaired gall bladder function:
*emptying
*absorption
*excretion
3-cholestrol nucleating factors:
*mucus
*glycoprotein
*infection

23. 4-absorption\enterohepatic circulation of bile acids:
*deoxycholate
*bowel transit zone
*faecal flora
*ileal resection
*cholestyramine.

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

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

26. 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)

27. 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

30. 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

31. 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.

32. 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