Calam, Gumapon, Reyes

CASE PRESENTATION
GENERAL DATA
CASE DISCUSSION
 GALLBLADDER

Anatomy
Parts (Fundus, Body, Infundibulum & Neck)
Blood supply : Cystic Artery w/in Triangle of Calot

Functions:
Storage of Bile
Concentration of Bile
GALLBLADDER

Fasting State:
80% of bile stored in GB
Motilin = gradual relaxation & emptying
Mucus Glycoproteins = prevents GB from lytic action of bile
= facilitate passage of bile thru cystic duct
Hydrogen Ions (acidification) = promotes calcium solubility =
prevents calcium precipitation
BILE DUCTS

Right & Left Hepatic Ducts

Common Hepatic Duct
Cystic Duct = Spiral Valves of
Heister
Common Bile Duct
Parts: Supraduodenal
Retroduodenal
Pancreatic
Ampulla of Vater
Ducts of Luschka
GALLBLADDER

After a Meal:
Cholecystokinin (CCK) = from duodenal mucosa
= facilitates GB emptying within 30 – 40 minutes

Defects in GB motor activity:

Cholesterol nucleation
Gallstone formation
GALLBLADDER

GB contraction
Parasympathetic Stimulation (Vagus Nerves)

GB relaxation
Sympathetic Stimulation
Chemical Stimulation (Atropine & VIP)
BILE PRODUCTION

Volume: 500 – 1,000 ml/day

Components:
Water Bile Acids
Proteins Electrolytes (Na, K, Ca, Cl)
Lipids Bile Pigments

pH = neutral/ slightly alkaline

ENTEROHEPATIC CIRCULATION

Bile Synthesized & Conjugated in the Liver

Cholesterol = main substrate
- primary Bile salts (Cholate & Chenodeoxycholate)

80% of Conjugated Bile = absorbed in terminal ileum

20% deconjugated by Gut bacteria – absorbed in colon

- secondary Bile salts (Deoxycholate & Lithocholate)

5% excreted in the stool as bile pigments

DIAGNOSTIC TESTS

Routine: Complete Blood Count

Liver Function Tests (SGPT, Alk Phos, Bilirubin,
Protime, Serum Albumin)
Leukocytosis = Cholecystitis
Hyperbilirubinemia, Increased Alk Phos & SGPT
= Cholangitis
DIAGNOSTIC TESTS

ULTRASOUND = 90% sensitivity/specificity for stones

Advantages:
Non-invasive Dynamic
Painless Evaluate adjacent organs
Radiation-free Can be done on critically ill
 DIAGNOSTIC TESTS

ULTRASOUND
Expected results:
Stones = dense with posterior acoustic shadowing moves
with change in position
Acute Cholecystitis = thickened GB wall w/ edema
Chronic Cholecystitis = contracted GB with thick wall
Dilated Bile Ducts = EHB Obstruction (stone vs. tumor)
DIAGNOSTIC TESTS

HIDA SCAN (Dimethyl Iminodiacetic Acid)

= test for acute cholecystitis

CT SCAN
= recommended for Tumors
= prerequisite for Obstructive Jaundice
 DIAGNOSTIC TESTS

PERC. TRANSHEPATIC CHOLANGIOGRAPHY (PTC)

= bile duct strictures & tumors
= prerequisite: Normal Protime

MAGNETIC RESONANCE IMAGING (MRI)

= CBD stones and tumors
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
= with contrast
= biliary & pancreatic disease
DIAGNOSTIC TESTS

ENDOSCOPIC RETROGRADE
CHOLANGIOPACREATOGRAPHY (ERCP)
= both diagnostic & therapeutic
= direct visualization of ampullary region
= sphincterotomy & stone extraction
= biopsy for tumors

ENDOSCOPIC ULTRASOUND
= evaluation of tumor resectability
= allows needle biopsy of pancreatic tumors
CHOLEDOCHOLITHIASIS
Primary Stones
= due to bile stasis
Causes:
biliary strictures
papillary stenosis
tumors

Secondary Stones
= 6-12% with gallbladder stones
 CHOLEDOCHOLITHIASIS

Manifestations:
- incidental finding
- Pain due to cholangitis
- Jaundice

Diagnosis:
Elevated serum bilirubin Ultrasound
Elevated alkaline phosphatase ERCP (Gold Standard)
Slight elevation of SGPT MRCP
CHOLEDOCHOLITHIASIS

Treatment:
ERC w/ sphincterotomy
Laparoscopic cholecystectomy
Open cholecystectomy with CBD exploration

Surgical Options:
Transduodenal Sphincteroplasty
Choledochoduodenostomy
Roux-en Y Choledochojejunostomy
T-tube Choledochostomy