Gallbladder and Bile Duct Case Study
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Simon Peter MollanedaGallbladder and Bile Duct Case Study
Uploaded by
Simon Peter MollanedaCalam, 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
