1. THE GALLBLADDER

2. I. Introduction/General Information
A. Location:
1. Epigastric region
2. Right hypochondriac region
3. On inferior surface of liver
4. Between quadrate and right lobes
B. Pear-shaped, hollow structure

3. C. Fundus slants inferiorly, to the right
Introduction/General Information, con’t.
C. Fundus slants inferiorly, to the right
D. Attached to liver by loose (areolar) connective tissue
E. Peritoneum covers free surfaces

4. The Gall Bladder and Bile Ducts
Fundus

5. G. Body and neck directed toward porta hepatis
Introduction, continued …
F. Normal measurements:
7-10 cm long
~ 6 cm diameter
30 – 35 cc volume
G. Body and neck directed toward porta hepatis

6. Introduction, continued …
H. Neck is continuous with cystic duct
I. Cystic duct:
1. joins common hepatic duct
2. superior and posterior to pylorus of stomach

7. J. Common Bile Duct 1. 10-15 cm long 2. Courses through lesser omentum
Introduction, continued …
J. Common Bile Duct
cm long
2. Courses through lesser omentum
3. Deep to pyloric sphincter
4. Narrow tube, 1-2 mm diameter
5. Should be no more than 6 mm in diameter

8. 6. May be 8-10 mm in post- cholecystectomy patients
CBD, continued …
6. May be 8-10 mm in post- cholecystectomy patients
7. Normally has smooth walls
8. Joins with pancreatic duct
9. convergence is seen
a. anterior to portal vein
b. posterior to head of pancreas

9. K. Combined duct empties into duodenum @ ampulla of Vater
Introduction, continued …
K. Combined duct empties into duodenum @ ampulla of Vater
L. Sphincter of Oddi guards duct, regulates bile flow
Closed: bile goes into gallbladder
Open: bile goes into duodenum

10. II. Detailed Anatomy
A. Fundus of GB:
1. may be palpated
2. in angle between lateral border of right rectus abdominis and costal margin
3. At level of elbow
4. Most anterior visceral structure

11. 1. Visceral surface of liver
Detailed Anatomy, con’t.
B. Body of Gallbladder
1. Visceral surface of liver
2. Deep to transverse colon or hepatic flexure of colon
3. Descending portion of duodenum is medial

12. Detailed anatomy, continued …
G. Cystic Duct
cm long
2. Extends from neck of gallbladder to common hepatic duct
3. Joins with common hepatic duct inferior to porta hepatis
4. Spiral valve may extend into neck of gallbladder

13. Biliary tract, continued …
L. Blood supply to gallbladder:
1. Cystic artery
a. arises (~ 60% of the time) from right hepatic artery
b. passes posterior to hepatic duct, then divides

14. Gallbladder Diseases
Cholelithiasis & Cholecystitis
1. Cholecystitis = inflammation of GB
2. Cholelithisis = Stone(s) in GB

15. Bile
Bile
Bile salts (primary: cholic, chenodeoxycholic acids; secondary: deoxycholic, lithocholic acids)
Phospholipids (90% lecithin)
Cholesterol
Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and phospholipid

16. Types of Gallstones Mixed (80%) Pure cholesterol (10%) Pigmented (10%)
Black stones (contain Ca bilirubinate, cirrhosis and hemolysis)
Brown stones ( biliary tract infection)

17. Gallstone Pathogenesis
Pathogenesis of cholesterol gallstones involves: (1) cholesterol supersaturation in bile, (2) crystal nucleation, (3) gallbladder dysmotility, (4) gallbladder absorption
Black pigment stones: contain Ca++ salts, hemolytic conditions or cirrhosis, found in the gallbladder
Brown pigment stones: Asians, contain Ca++ palmitate, found in bile ducts, biliary dysmotility and bacterial infection

18. Gallstone Risk Factors
“Female, Fat, Forty, Fertile”
Oral contraceptives
Obesity
Rapid weight loss (gastric bypass pts)
Fatty diet DM
Prolonged fasting
TPN
Ileal resection
Hemolytic states
Cirrhosis
Bile duct stasis (biliary stricture, congenital cysts, pancreatitis, sclerosing cholangitis)
IBD
Vagotomy
Hyperlipidemia

19. Cholecystitis (Acute & Chronic)
ESSENTIAL FEATURES • Cholesterol stones form in 20% of women and 10% of men by age 60 • Cholesterol stone risk factors include: –Female gender –Age –Obesity –Estrogen exposure –Fatty diet –Rapid weight loss EPIDEMIOLOGY • Symptoms develop in about 3% of asymptomatic patients each year (20–30% over 20 years) • Acalculous cholecystitis affecting patients with acute, severe systemic illness

20. CLINICAL FINDINGS
SYMPTOMS AND SIGNS • Biliary colic but becoming unremitting and steady in epigastrium or right upper quadrant • Fever • Nausea • Vomiting • Right upper quadrant pain to palpation with peritoneal signs • Murphy sign • Anorexia

21. LABORATORY FINDINGS • Leukocytosis IMAGING FINDINGS • Right upper quadrant US showing gallstones, gallbladder wall thickening (> 4 mm), or pericholecystic fluid (no stones if acalculous cholecystitis) • HIDA scan showing failure of filling of gallbladder (> 95% sensitive) • CT showing gallbladder wall thickening (> 4 mm), pericholecystic fluid (for patients with suspected acalculous cholecystitis) as sensitive as US

22. DIAGNOSTIC CONSIDERATIONS
• Other causes of acute abdominal pain
Gallbladder: cholecystitis, choledocholithiasis, cholangitis
Duodenal ulcer
Hepatitis
Appendicitis (atypical presentation)
Pancreatitis
RULE OUT
• Choledocholithiasis
• Pancreatitis

23. WORK-UP
• History and physical exam • CBC • Amylase and lipase • Liver function tests • ALP, GGT • Right upper quadrant US • HIDA scan for difficult cases • CT if abdominal US not technically possible (patients with suspected acalculous cholecystitis, large wounds etc)

24. HIDA scan (Hepatobiliary Imino-Diacetic Acid scan) - radionuclide IV, extracted from blood, excreted into bile
Uptake by liver, GB, CBD, duodenum w/in 1hr = normal
Slow uptake = hepatic parenchymal disease
Filling of GB/CBD w/delayed or absent filling of intestine = obstruction of ampulla
Non-visualization of GB w/ filling of the CBD and duodenum = cystic duct obstruction and acute cholecystitis (95% sensitivity & specificity)

25. TREATMENT AND MANAGEMENT
MEDICAL • All patients require IV fluids and antibiotics • Management then can include either early cholecystectomy (generally preferred) or cholecystectomy after about 6 weeks SURGERY • Laparoscopic cholecystectomy • Open cholecystectomy • Cholecystostomy tube (if cholecystectomy too hazardous) Indications • Suspected acute cholecystitis • Suspected acalculous cholecystitis • Failure to resolve cholecystitis on antibiotics

26. Complications
• Bile duct injury or leak • Empyema –Suppurative cholecystitis occurs with frank pus in the gallbladder, high fever, chills and systemic toxicity –Percutaneous drainage or cholecystectomy is necessary • Pericholecystic abscess –Localized perforation at the gallbladder can result in a pericholecystic abscess –Treatment requires drainage with or without initial cholecystectomy • Free perforation –Rare but causes generalized peritonitis –This occurs when a gangrenous portion of the wall necroses prior to local adhesion formation –The diagnosis is rarely made before urgent laparotomy –Treatment is cholecystectomy • Cholecystoenteric fistula –Perforation at the gallbladder into an adjacent viscous generally resolves the acute episode –Symptomatic fistula and/or patients with continued gallstone symptoms should have cholecystectomy and closure at the fistula

27. a. Intraluminal echogenic projections
Gallbladder Diseases, continued …
Polyps of GB
a. Intraluminal echogenic projections
b. do not change position with patient
c. Must be differentiated from septations, mucosal folds
1. septations extend across lumen
2. folds change configuration upon inspiration

28. Cholelithiasis
ESSENTIAL FEATURES • Divided into symptomatic and asymptomatic • Caused by cholesterol (most common), black pigment, or brown pigment stones • Cholesterol stones form in 20% of women and 10% of men by age 60 • Cholesterol stone risk factors include: –Female gender –Age –Obesity –Estrogen exposure –Fatty diet –Rapid weight loss • Black pigment stone risk factors include: –Hemolytic disorders –Living in Asia • Brown pigment stone risk factors include: –Biliary stasis –Biliary infections EPIDEMIOLOGY • 20 million affected in United States • Symptoms develop in about 3% of asymptomatic patients each year (20–30% over 20 years) • Each year, complicated gallstone disease affects 3–5% of patients who are symptomatic

29. CLINICAL FINDINGS
SYMPTOMS AND SIGNS • Asymptomatic • Biliary colic –Right upper quadrant or epigastric –Episodic, often after meals or at night, lasting as long as 2–4 hours • Nausea • Vomiting • Diarrhea • Mild right upper quadrant tenderness to palpation

30. LABORATORY FINDINGS • Normal liver function tests, normal amylase and lipase, normal WBC count IMAGING FINDINGS • Right upper quadrant US showing acoustically dense stones in gallbladder with acoustic shadowing without evidence of gallbladder wall thickening or pericholecystic fluid (> 90% sensitive for gallstones)

31. DIAGNOSTIC CONSIDERATIONS • Other causes of abdominal pain RULE OUT • Cholecystitis • Choledocholithiasis • Pancreatitis

32. WORK-UP
• History and physical exam • CBC • Liver function tests • Amylase and lipase • Right upper quadrant US

33. TREATMENT AND MANAGEMENT
SURGERY • Laparoscopic cholecystectomy • Open cholecystectomy Indications • Symptomatic cholelithiasis • Porcelain gallbladder (25% risk of carcinoma) Contraindications • First or third trimester of pregnancy (relative) • Previous upper abdominal surgeries (laparoscopic) Complications • Bile duct injury or leak

34. Cholelithiasis, Rare Complications
ESSENTIAL FEATURES Gallstone Ileus • Small bowel obstruction secondary to 1 or more large gallstones entering via cholecystoduodenal fistula Mirizzi Syndrome • Biliary stricture secondary to direct compression by chronically impacted cystic duct gallstone or chronic inflammation secondary to chronically inflamed gallbladder EPIDEMIOLOGY • Both gallstone ileus and Mirizzi syndrome are rare complications mainly affecting patients older than 60 years

35. LABORATORY FINDINGS
Gallstone Ileus • Hypokalemia • Prerenal azotemia • Hypernatremia • Leukocytosis Mirizzi Syndrome • Hyperbilirubinemia • Elevated alkaline phosphatase

36. IMAGING FINDINGS
Gallstone Ileus • Abdominal x-ray –Air-fluid levels –Dilated loops of small bowel –Possible pneumobilia • US –Cholelithiasis and pneumobilia • Hypaque swallow –Fistula between duodenum and gallbladder Mirizzi Syndrome –Biliary dilatation (> 6 mm) –Cholelithiasis –Possible thickened wall of gallbladder • ERCP or percutaneous transhepatic cholangiogram (PTC) –Stricture of common bile duct

37. WORK-UP
Gallstone Ileus • History and physical exam • CBC • Electrolytes • Blood urea nitrogen, creatinine • Plain abdominal x-ray • Right upper quadrant US • Small bowel contrast study if partial small bowel obstruction Mirizzi Syndrome • Liver function tests

38. TREATMENT AND MANAGEMENT
SURGERY Gallstone Ileus • Removal of retained small bowel gallstone(s) via enterostomy or partial resection if bowel damaged • Cholecystectomy and resection of fistula and duodenal closure at same operation or as staged procedure Mirizzi Syndrome • Cholecystectomy and resection and/or bypass of stricture via hepaticojejunostomy Contraindications • Clinical status of patient during laparotomy for gallstone ileus

39. Complications
Gallstone Ileus • Missed enteral gallstone and recurrent obstruction • Duodenal leak • Bile duct injury or leak Mirizzi Syndrome • Anastomotic leak or stricture • Cholangitis

40. Choledocholithiasis & Gallstone Pancreatitis
ESSENTIAL FEATURES • Cholesterol stone risk factors include: –Female gender –Age –Obesity –Estrogen exposure –Fatty diet –Rapid weight loss • Complicated gallstone disease affects < 0.5% annually of patients who are asymptomatic EPIDEMIOLOGY • Average age generally 10 years older than those affected by cholelithiasis (eg, 40–50 years of age)

41. CLINICAL FINDINGS
SYMPTOMS AND SIGNS • Right upper quadrant pain • Painless jaundice • Both pain and jaundice • Fever • Asymptomatic • Nausea • Vomiting • Anorexia

42. LABORATORY FINDINGS • Conjugated hyperbilirubinemia (for choledocholithiasis) • Elevated alkaline phosphatase (for choledocholithiasis) • Leukocytosis (for pancreatitis or cholangitis) IMAGING FINDINGS • Right upper quadrant US showing presence of gallstones, dilated common bile duct (CBD) (> 6 mm) and CBD stone in only 20–30% of patients with choledocholithiasis • ERCP showing dilated CBD and presence of single or multiple CBD stones in patients with choledocholithiasis • ERCP showing impacted ampullary gallstone in < 10 % of patients with gallstone pancreatitis

43. DIAGNOSTIC CONSIDERATIONS • Presence of signs or symptoms suggestive of cholangitis RULE OUT • Biliary stricture

44. WORK-UP
• History and physical exam • CBC • Liver function tests • Amylase and lipase • Right upper quadrant US • ERCP or laparoscopic cholangiogram

45. TREATMENT AND MANAGEMENT
SURGERY • ERCP with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy (preferred when cholangitis present or if pancreatitis does not resolve) • Laparoscopic cholecystectomy with CBD exploration • Laparoscopic cholecystectomy and cholangiogram followed by ERCP and stone extraction (preferred stone extraction technique is center specific for stones noted on screening cholangiogram following resolution of gallstone pancreatitis) • Percutaneous transhepatic cholangiography and stone extraction if ERCP unsuccessful and cholangitis present Indications • Choledocholithiasis noted to be symptomatic or asymptomatic • Gallstone pancreatitis MEDICATIONS • Antibiotics to cover GI flora for cases of cholangitis Complications • Pancreatitis (for ERCP) • Bile duct injury or leak Prognosis • Gallstone pancreatitis resolves in > 90% of cases Prevention • Treatment of symptomatic cholelithiasis

46. Choledochal Cyst
ESSENTIAL FEATURES • Type I cysts (fusiform dilation of common bile duct [CBD]) account for 85–90% • Type II (true diverticula of CBD) 1–2% of cases • Type III (choledochocele–-dilation of distal/intramural portion of CBD) < 2% of cases • Type IV (multiple cysts involving intrahepatic and extrahepatic ducts) as high as 15% of cases in some series • Type V (cystic malformation of intrahepatic ducts) rare • 3–5% incidence of carcinoma EPIDEMIOLOGY • Onset of symptoms usually in infancy or childhood

47. CLINICAL FINDINGS
SYMPTOMS AND SIGNS • Jaundice • Fever • Pain • Palpable right upper quadrant mass • Hepatomegaly • Bleeding varices • Asymptomatic

48. LABORATORY FINDINGS • Hyperbilirubinemia • Elevated alkaline phosphatase • Leukocytosis • Elevated amylase and lipase IMAGING FINDINGS • US showing characteristic cystic dilation of biliary tree corresponding to type as well as proximal dilation in presence of obstruction • ERCP or magnetic resonance cholangiopancreatography (MRCP) showing cystic dilation corresponding to type and proximal obstruction in presence of obstruction

49. WORK-UP
• History and physical exam • Liver function tests • CBC • Amylase and lipase • Abdominal US • ERCP or MRCP (adults) • HIDA scan or MRCP (children)

50. TREATMENT AND MANAGEMENT
SURGERY • Cyst excision and biliary reconstruction (types I–III) • Types IV and V individualized and may require partial hepatectomy if unilobar involvement TREATMENT MONITORING • Surveillance for carcinoma since patients still at increased risk for remainder of biliary tree Complications • Biliary stricture or leak • Cholangitis

51. Cholangiocarcinoma
ESSENTIAL FEATURES • Arises from biliary epithelium • Risk factors –Primary sclerosing cholangitis –Choledochal cysts –Clonorchis infection EPIDEMIOLOGY • < 4500 patients per year • Average age, 50–70 years • Evenly distributed among men and women

52. CLINICAL FINDINGS
SYMPTOMS AND SIGNS • Painless jaundice • Right upper quadrant pain • Pruritus • Anorexia • Malaise • Weight loss • Cholangitis • Asymptomatic

53. LABORATORY and IMAGING FINDINGS
LABORATORY FINDINGS • Hyperbilirubinemia • Elevated alkaline phosphatase • Elevated CA 19-9 IMAGING FINDINGS • US showing dilated extrahepatic and intrahepatic biliary ducts (depending on level of tumor) • CT or MRI with biliary dilatation and occasional visible hepatic tumor • Percutaneous transhepatic cholangiography (PTC) or magnetic resonance cholangiopancreatography (MRCP) visualizing proximal and distal extent of tumor –PTC provides opportunity for brushings for cytologic studies of tumor • Mesenteric angiography for question of portal vasculature involvement

54. DIAGNOSTIC CONSIDERATIONS • History of pancreatitis (possible benign stricture) • History of ulcerative colitis (possible primary sclerosing cholangitis) • Choledocholithiasis RULE OUT • Extrahepatic disease or bilobar involvement

55. WORK-UP
• History and physical exam • Liver function tests • CA 19-9 • US to screen for anatomic causes of hyperbilirubinemia • Abdominal CT • PTC or MRCP (PTC if brushings needed) • Angiography if portal vessel involvement suspected

56. TREATMENT AND MANAGEMENT
SURGERY • Biliary resection followed by biliary-enteric resection • Extended right or left lobectomy if proximal disease noted (isolated to 1 side) above secondary radicals or if unilateral portal vein or hepatic artery involvement • Pancreaticoduodenectomy (Whipple) for distal common bile duct (CBD) tumors • Biliary-enteric bypass for PTC-placed wall stent for palliation Indications • Resectable cholangiocarcinoma or diagnosis of benign stricture can be difficult to distinguish • Presence of choledochal cyst Contraindications • Bilobar involvement or second order biliary radicals bilaterally • Extrahepatic disease • Main portal vein, bilateral portal vein, or bilateral hepatic artery involvement

57. Complications • Anastomotic leak or stricture • Cholangitis • Recurrent disease • Liver failure • Hemorrhage Prognosis • 10–30% 5-year survival with curative resection of proximal biliary tumor • 30–50% 5-year survival with distal CBD tumor

58. Gallbladder Cancer

60. Epidemiology 5th most common GI malignancy Women > men
High incidence in S America (Chile)
pt’s undergoing cholecystectomy for symptomatic gallstones

61. Risk Factors Gallstones Gallbladder Polyps
Chronic Salmonella infection
Abnormal Pancreaticobiliary duct junction
* Porcelain gallbladder
* Age

62. Presentation/Diagnostic Imaging
Presentation is non-specific
Diagnositic Imaging
Sono CT
MR/MRCP
EUS

66. Histology / Pathology * Progression to Ca may take up to 15 yrs
Adenocarcinoma 80-90%
Anaplastic 7%
Squamus 6%
Lymphoma, Sarcoma

67. Staging

70. Surgical Management Only 10-30% resectable @ time of diagnosis
Three Presentations:
GB CA discovered during or after lap/open chole for assumed benign dz
GB CA suspected after diagnostic evaluation
GB CA advanced stage at presentation

71. Surgical Options Simple cholecystectomy Radical cholecystectomy
Radical chole + anatomic liver resection
Radical chole + Whipple

72. What to do during elective lap chole if GB Ca is suspected intraoperatively ?
cases found to have GB CA in lap chole
Convert to OPEN
Resect PORTS
No place for laparoscopic resection

73. Management of locally unresectable (major vascular encasement)
NO DEBULKING
Chemoradiotherapy
No identified impact on survival & remains investigational
Systemic chemotherapy – no optimal regimen defined (5-FU based)