Gall bladder pdf - صلاح الجنابي

Gall Bladder

Assist. Prof . Dr Salah aljanaby

General surgeon and laparoscopic surgeon

Babylon medical college

Lecture 3

Ultrasound

■

An ultrasound is the most common test used
for the diagnosis of biliary colic and acute
cholecystitis. It is 90-95% sensitive for
cholecystitis and 78-80% specific. For simple
cholelithiasis, it is 98% sensitive and specific.

Findings include gallstones or sludge and one
or more of the following conditions

■

Gallbladder wall thickening

(>2-4 mm) -

False-positive wall thickening found in
hypoalbuminemia, ascites, congestive
heart failure, and carcinoma

■

Gallbladder distention

(diameter >4 cm,

length >10 cm)

■

Pericholecystic fluid

from perforation or

exudate

■

Air in the gallbladder wall

(indicating

gangrenous cholecystitis)

■

Sonographic Murphy sign

(86-92%

sensitive, 35% specific), pain when the
probe is pushed directly on the
gallbladder (not related to breathing)

■

Some sonographers recommend the diagnosis of
cholecystitis if both a sonographic Murphy sign and
gallstones (without evidence of other pathology) are
present.

■

Additional findings in the presence or absence of
gallstones: Dilated common bile duct or dilated
intrahepatic ducts of the biliary tree indicate common
bile duct stones. In the absence of stones, a solitary
stone may be lodged in the common bile duct, a
location difficult to visualize sonographically.

■

Advantages of sonography include the following:

■

Images other structures (eg, aorta, pancreas, liver)

■

Identifies complications (eg, perforation, empyema,
abscess)

■

Rapidly performed at the bedside

■

No radiation (important in pregnancy)

■

Disadvantages of sonography include the following:

■

Operator dependent and patient dependent

■

Inability to image the cystic duct

■

Decreased sensitivity for common bile duct stones

■

Biliary scintigraphy (HIDA, diisopropyl iminodiacetic

acid [DISIDA]), nuclear medicine studies

■

Sonography or nuclear medicine testing is the test of

choice for cholecystitis. HIDA scans have sensitivity

(94%) and specificity (65-85%) for acute cholecystitis.

They are sensitive (65%) and specific (6%) for chronic

cholecystitis. Oral cholecystography is not practical for

the ED.

■

HIDA and DISIDA scans are functional studies of the

gallbladder. Technetium-labeled analogues of

iminodiacetic acid (IDA) or diisopropyl IDA-DISIDA are

administered intravenously (IV) and secreted by

hepatocytes into bile, enabling visualization of the liver

and biliary tree.

■

Normal scans are characterized by normal

visualization of gallbladder in 30 minutes.

■

With cystic duct obstruction (cholecystitis), the

HIDA scan shows nonvisualization (ie,

considered positive) of the gallbladder at 60

minutes and uptake in the intestine as the bile is

excreted directly into the duodenum.

■

Obstruction of the common bile duct causes

nonvisualization of the small intestine.

■

The

rim sign

is increased tracer adjacent to the

gallbladder at 60 minutes and suggests

gangrenous cholecystitis.

■

Advantages of HIDA/DISIDA scans include the

following:

■

Assessment of function

■

Normal-appearing gallbladder (by ultrasound); obstructed

cystic duct abnormal on DISIDA scan but not ultrasound.

■

Simultaneous assessment of bile ducts

■

Disadvantages of HIDA/DISIDA scans include the

following:

■

High bilirubin (>4.4 mg/dL) possibly decreases sensitivity

■

Recent eating or fasting for 24 hours also possibly affects

study

■

No imaging of other structures in the area

■

Other Tests:

■

Endoscopic retrograde
cholangiopancreatography (ERCP)

■

ERCP provides both endoscopic and radiographic
visualization of the biliary tract. It can be diagnostic
and therapeutic by direct removal of common bile
duct stones.

■

Magnetic Resonance cholangiopancreatography
(MRCP)

TREATMENT; Conservative treatment
followed by cholecystectomy

Symptoms of acute cholecystitis subside with

conservative treatment in 90 % of cases

■

Four principles

Naso-gastric suction & IV fluid

analgesics

Antibiotics (broad spectrum effective against Gm –
ve aerobes)

Subsequent management ( if inflame. Subside→
oral fluids → fat free diet)

Cholecystectomy on the next available list or after 4-6

wks

■

Conservative treatment is not advised if there is:

Uncertain diagnosis

The possibility of high retrocecal appendix or

Perforated DU cannot be excluded

■

Conservative treatment must be abandoned if pain
and tenderness increased →percutaneous
cholecystostomy → subsequent cholecystectomy

TREATMENT; Routine early operations

Indications:

Within 24 hrs of the onset of the attack

Experienced surgeons

Excellent operating facilities

■

cholecystectomy can be done either by open
or laparoscopic approaches

Acalcuolous cholecystitis

■

Some patients have non-specific inflammation
of the GB , wherease other have one of the
Cholecystoses

■

Diagnosis either by oral cholecystography
( chronic cases) or by isotopic scanning (acute
cases)

■

Cholesterol crystal

in the duod. aspirate may

help diagnosis

Acute acalcuolous cholecystitis is seen more

frequently in:

■

Critical illness

■

Major surgery or severe trauma/burns

■

Sepsis

■

Long-term TPN

■

Prolonged fasting

The Cholecystoses

■

Not uncommon conditions affecting
the GB where there is chronin
inflamm. Changes with hyperplasia
of of all tissue elemnts

Cholesterosis (Strawberry GB)

■

Submucous aggregations of
cholesterol crystals and cholesterol
esters (yellow seeds) in the red
mucosa

Cholesterol polyposis of the GB

■

These are either cholesterol polyposis or
adenomatous changes

Cholecystitis glandularis proliferans (polyp,

adenomyomatosis and intramural diverticuolosis)

■

MM polyps- fleshy and granuolomatous

■

All layer of GB may be thickened

■

Sometimes incomplete septums forms

■

Intraparietal mixed calculi may be present

Diverticuolosis of the GB

■

Usually manifest as black pigment stones impacted in

the out-pouchings of the lacunae of Luschka

Typhoid GB

■

S. Typhi or occasionally S Typhimurium can infect the

GB leading to acute cholecystitis and more commonly

chronic cholecystitis

■

The patient being typhoid carrier excreting the

bacteria in the bils

■

Gall stones may be present

GB cancer

■

Rare ( common in certain area as India where it reaches 9% of

biliary tract disease

■

Found in less than 1% of GB operations

■

In over 90 % of cases gall stones are present

Presentations

■

Age= 70s

■

Sex= female (F-M= 5-1)

Pathology

■

Scirrhous, but may be squamous cell & mixed squamous

adenocarcinoma

■

Spread= direct, lymphatics and veins

Clinical P

■

Either extensive mass in the liver during investigations

for jaundice or

■

At cholecystectomy at the time the histology is

received

Treatment

■

Those diagnosed at cholecystectomy and confined to

the mucosa have a good prognosis (add wide excision

& LN clearance or not ??)

■

Large T reaching serosa= chemoradiotherapy

■

Median survival 1 year