Gallbladder

& Biliary Tract

Dr. Rostamzadeh
Assistant Professor of General Surgery
 Anatomy (Gallbaldder)

• the gallbladder is located in the right upper quadrant(RUQ) of the

abdomen under the anatomic division of the right and left lobes of the
liver.

• Normally, it is a thin-walled, contractile, pear-shaped organ measuring 10

× 5 cm and consists of the fundus, body, and neck, which narrows joining
the cystic duct.

• The gallbladder contains approximately 50 mL of bile when distended

and is mostly covered by peritoneum, whereas the remainder is attached to
the liver.
 Anatomy (Biliary Tract)
• The right and left hepatic ducts join to form the common hepatic duct,
which is connected to the cystic duct to form the common bile duct (CBD)

• The cystic duct is lined by the spiral valves of Heister, which provide
some resistance to bile flow from the gallbladder
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• In the hepatoduodenal ligament, the CBD lies to the right side of the
patient, the proper hepatic artery to the left side, and the portal vein
posterior to both of these.

• The right hepatic artery gives off the cystic artery before traversing into
the right hepatic lobe
 Anatomy (Biliary Tract) continued
• The cystic artery lies in the triangle of Calot, which is the anatomic area
that is bound by the inferior margin of the liver superiorly, the common
hepatic duct medially, and the cystic duct laterally.

• The CBD passes through the head of the pancreas, usually joins the
pancreatic duct within 1 cm of the wall of the duodenum to form a
common channel, and then empties into the second portion of the
duodenum through the ampulla of Vater

• Bile flow into the duodenum is regulated in part by the sphincter of Oddi,
which encircles this common channel
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 Epidemiology
• The incidence of gallstones increases with age

• women are affected approximately three times more often than men

• Increase in the incidence of gallstones: Native Americans, Obesity, high-

dose estrogen oral contraceptives, cholesterol-lowering agents, rapid
weight loss, prolonged total parenteral nutrition, Crohn disease involving
the terminal ileum or resection of the terminal ileum, Patients with
hemolytic disorders and alcoholic cirrhosis.
 Gallstone types
• Mixed type (cholestrol):
• 75% of gallstones
• Most mixed stones do not contain enough calcium to make them radiopaque

• Pigment stones : are of two types, black and brown.

● Black pigment stones :
• 20% of all biliary stones
• generally found in the gallbladder.
• typically form in sterile gallbladder bile
• commonly associated with hemolytic diseases and cirrhosis
● brown stones:
• associated with infected bile.
• found primarily in the bile ducts and are soft.
● Pigment stones often contain enough calcium to render them radiopaque
.
 Gallstone types
• Gallbladder sludge
• is amorphous material that contains mucoprotein, cholesterol crystals, and
calcium bilirubinate.
• It is often associated with prolonged total parenteral nutrition, starvation,
or rapid weight loss.
• Gallbladder sludge may be a precursor of gallstones
 History
• The hallmark of gallstone disease is pain referred
to as biliary colic. The pain is usually steady,
fairly severe, and located in the RUQ or, less
commonly, in the epigastrium of the abdomen,
sometimes passing through to the back at the
same level.

• The pain is visceral, often described as dull or

aching, and may last from 1 to 4 hours.
• The pain is thought to be secondary to increased
pressure in the gallbladder that results from
 History continued
• Acute cholecystitis: These patients experience tenderness that is steady or
increasing in nature and is localized to the RUQ or epigastrium.
• The pain lasts longer than 3 to 4 hours and may continue for several days.
• It is mediated by somatic sensory nerves because the parietal peritoneum is
usually irritated.
• It may be accompanied by nausea, vomiting, and systemic manifestations of
an inflammatory process including fever, tachycardia, and, in moresevere
cases, hemodynamic instability.
 Clinical findings
• patient with biliary colic usually appears uncomfortable and restless, whereas a patient who
has pain associated with inflammation and acute cholecystitis tends to be still because the
pain is aggravated by movement.

•
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The pulse rate may be high secondary to pain, inflammation, or infection. Fever often
accompanies acute cholecystitis but not biliary colic, and high fever may be present with
gangrene of the gallbladder or if the patient has cholangitis. Low blood pressure signifies
severe dehydration or septic shock.

• The abdomen of patients with biliary colic is soft, but some tenderness may be found in the
RUQ. Once the pain subsides, the abdomen is non-tender between episodes of colic.
 Clinical findings cont.

• In acute cholecystitis, examination of the abdomen may show a positive Murphy

sign. A Murphy sign is the cessation of inspiration because of pain on deep
palpitation of the RUQ when the visceral peritoneum overlying the gallbladder is
inflamed

• A tender mass representing the inflamed gallbladder may also be palpable in the
RUQ of the abdomen in acute cholecystitis. The presence of a non-tender, palpable
gallbladder with jaundice suggests underlying malignant disease, such as
carcinoma of the pancreas and is known as Courvoisier sign
 Lab findings
• Liver function tests

• The serum level of unconjugated (indirect) bilirubin increases in hemolytic

disorders, whereas the conjugated (direct) fraction is elevated with extrahepatic
biliary obstruction or cholestasis

• Serum amylase and lipase may be slightly elevated in both acute cholecystitis and
acute cholangitis, but marked elevations suggest acute pancreatitis

• As a rule, the increase in ALP and GGT is greater than the increase in the levels of
AST and ALT in biliary obstruction
 Imaging Studies
• The initial study of choice for patients with
biliary disease is ultrasonography

• sensitivity and the specificity of this study are

approximately 95%.

• Ultrasonography can successfully detect stones as

small as 3 mm in diameter, and sometimes
smaller stones and debris like gallbladder sludge
may be seen
 Imaging Cont.
• Magnetic resonance cholangiography (MRC) refers to selected MR imaging of the biliary
and pancreatic ducts, which is helpful in demonstrating common duct stones and other-
biliary tract abnormalities.

• Radionuclide biliary scanning (hepatobiliary iminodiacetic acid [HIDA] scan: The normal
gallbladder begins to fill within 30 minutes. Visualization of the CBD and duodenum without
filling of the gallbladder after 4 hours indicates cystic duct obstruction, which supports the
diagnosis of acute cholecystitis

• The sensitivity and specificity of the HIDA scan for diagnosing acute cholecystitis are
95% to 97% and 90% to 97%, respectively.

• False-positive results may occur in patients who are receiving total parenteral nutrition
or those who have hepatitis.

• The HIDA scan is not useful for showing stones in either the gallbladder or the CBD
 Acute Cholecystitis
• The underlying pathology in acute cholecystitis is similar to that of biliary colic,
except that there is sustained obstruction of the cystic duct in this condition and it
is associated with inflammation and infection

• Left untreated, complications of empyema, gangrene, or perforation of the

gallbladder may result from progression of the disease process

• The differential diagnosis is long but should include acute hepatitis, acute
pancreatitis, perforated peptic ulcer, and acute appendicitis

• Laboratory studies demonstrate a leukocytosis and a left shift. Mild increases in

AST, ALT, and ALP are common. Patients may have a mild hyperbilirubinemia
(mostly direct), but a significant elevation in the serum bilirubin suggests a CBD
stone. On occasion, the patient will demonstrate a slight elevation of the serum
amylase.
 Acute Cholecystitis Cont.
• Ultrasonography is very helpful in making a definitive diagnosis

• findings of acute cholecystitis, such as a distended gallbladder, thickened

gallbladder wall (>3 to 4 mm), pericholecystic fluid collection, and
ultrasonographic Murphy sign. This sign is elicited by demonstrating the
presence of the most tender spot directly over the sonographically
localized gallbladder with the ultrasound probe.

• Upright views are necessary to exclude pneumoperitoneum fromanother

underlying cause of the acute abdomen
• Ct scan/HIDA
 Acute Cholecystitis Cont.
• The initial management of acute cholecystitis includes withholding oral intake,
administering intravenous fluids, and starting antibiotic therapy.
• The Most patients are best served by early cholecystectomy within a few days of
presenting.
• Patients with acute cholecystitis who are too ill to undergo cholecystectomy may
require cholecystostomy.
• Acute gangrenous cholecystitis :
• Patients with this condition tend to be older and generally have more serious
comorbid conditions
• Treatment includes stabilization of the medical condition, administration of
broad-spectrum antibiotics, and performance of emergency cholecystostomy or
cholecystectomy depending on the patient’s ability to tolerate surgery
 Acute Cholecystitis Cont.
• Acute emphysematous cholecystitis results from gas-forming bacteria
and is associated with a higher risk of gangrene and perforation
compared with nonemphysematous cholecystitis.

• It generally affects older individuals, and diabetes mellitus is present in

20% to 50% of these patients.

• The classic findings on plain radiographs include air within the wall or
lumen of the gallbladder, an air-fluid level within the lumen of the
gallbladder, or air in the pericholecystic tissues. Air in the bile ducts
may also be seen.

• Patients with acute emphysematous cholecystitis should receive

broad-spectrum antibiotics, including coverage for anaerobes. In
 .

Acute Cholecystitis Cont.

• Acute acalculous cholecystitis:
• may complicate the course of a patient who is being treated forother
conditions in a medical or surgical intensive care unit.

• Many patients are receiving total parenteral nutrition and mechanical

ventilatory support and are immunosuppressed

• the management is similar to that of patients with acute calculous cholecystitis

 Chronic Cholecystitis
• is the most common form of symptomatic cholelithiasis.

• results from repeated minor episodes of cystic duct obstruction with subsequent
inflammation and fibrosis of the gallbladder wall

• biliary colic is the most common symptom

• Because the condition is not associated with acute infection, fever and chills are
absent.

• Other associated symptoms include intolerance to fatty foods, flatulence, belching,

and indigestion

• Elective laparoscopic cholecystectomy is indicated in most patients with

symptomatic cholelithiasis. In patients with a history of multiple abdominal
surgeries, an open cholecystectomy is an option.
 Choledocholithiasis and Acute
Cholangitis
• Stones in the CBD or choledocholithiasis can be either primary or secondary.

• In the presence of concomitant infection, usually with E. coli or K. pneumoniae,

acute cholangitis will develop
• It is characterized by jaundice, RUQ abdominal pain, and fever associated
with chills (Charcot triad).
• may be hypotensive and demonstrate mental confusion in addition to
Charcot triad. These five features together constitute Reynold pentad.

• Abdominal examination may be unremarkable in a patient with choledocholithiasis

or may reveal tenderness in the RUQ if cholangitis is present
 Choledocholithiasis and Acute Cholangitis Cont.

• Other than choledocholithiasis, obstructive jaundice or cholangitis can be caused

by periampullary malignancy and stricture, most commonly iatrogenic after
cholecystectomy or secondary to chronic pancreatitis.

• Mirizzi syndrome, a condition in which a large stone in the gallbladder

compresses the common hepatic duct, can also lead to obstructive jaundice.

• A patient with choledocholithiasis without evidence of cholangitis should undergo

laparoscopic cholecystectomy and IOC, possibly followed by laparoscopic CBD
exploration if stones are seen. If the bile duct cannot be cleared of stones by
laparoscopic exploration, open bile duct exploration or postoperative ERCP
 Choledocholithiasis and Acute Cholangitis Cont.

• Acute suppurative cholangitis is a potential life-threatening condition and requires

urgent intervention. Initial management includes resuscitation with intravenous
fluids and antibiotics.

• The patient should be monitored closely in an intensive care unit

• Patients who do not respond to the initial therapy should have an urgent biliary
decompression through ERCP, percutaneous transhepatic tube placement, or open
surgery.

• The success rate with ERCP and sphincterotomy in removing stones from the CBD
is >90%, with a complication rate of approximately 5% to 10% (e.g., pancreatitis,
duodenal perforation, and bleeding
 Acute Biliary (Gallstone)
Pancreatitis
• Patients with acute pancreatitis present with acute
upper abdominal pain, often radiating to the back
with tenderness usually in the upper abdomen.

• Severe cases may present with peritoneal signs,

simulating other causes of an acute abdomen.
Nausea, vomiting, and a low-grade fever are
frequent, as are tachycardia and hypotension
secondary to hypovolemia
• Management of patients with acute biliary

Gallstone ileus
• accounts for <1% of all cases of intestinal
Obstruction

• Patients present with symptoms of bowel

obstruction and air in the biliary tree

• It occurs more commonly in women than in men

(3.5:1 ratio)

• Plain radiographs/ SONO

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 GALLBLADDER CANCER
• Gallstones are the most common risk factor

• Patients with gallbladder polyps 1.5 cm or greater

in diameter have a 46% to 70% prevalence of
cancer

• An anomalous junction of the pancreaticobiliary

duct has been noted in approximately 10% of
patients with gallbladder cancer.
• Another risk factor for gallbladder cancer is a

BILE DUCT MALIGNANCIES

• Extrahepatic is more common

• Bile duct cancer occurs with equal frequency in

both sexes, usually affecting individuals between
50 and 70 years of age

• RISK FACTOR: PSC (which is strongly

associated with ulcerative colitis/choledochal
cysts/ infection with the parasitic liver flukes
Opisthorchis viverrini or Clonorchis
THE END