Gallbladder lies beneath segments IV and V

  Cystic artery branches off right hepatic artery

•  Is found in the triangle of Calot (cystic duct [lateral], common bile duct [medial], liver [superior])

  Right hepatic (lateral) and retroduodenal branches of the gastroduodenal artery (medial) supply the hepatic and common bile duct (9- and 3-o’clock positions when performing endoscopic retrograde cholangiopancreatography [ERCP]); considered longitudinal blood supply

  Cystic veins drain into the right branch of the portal vein

  Lymphatics are on the right side of the common bile duct

  Parasympathetic fibers come from left (anterior) trunk of the vagus

  Sympathetic fibers from T7–10 (splanchnic and celiac ganglions)

  Gallbladder has no submucosa; mucosa is columnar epithelium

  Common bile duct and common hepatic duct do not have peristalsis

  Gallbladder normally fills by contraction of sphincter of Oddi at the ampulla of Vater

•  Morphine – contracts the sphincter of Oddi

•  Glucagon – relaxes the sphincter of Oddi

  Normal sizes: common bile duct (CBD) < 8 mm (< 10 mm after cholecystectomy), gallbladder wall < 4 mm, pancreatic duct < 4 mm

  After cholecystectomy, total bile salt pools ↓

  Highest concentration of CCK and secretin cells are in the duodenum

  Rokitansky–Aschoff sinuses – epithelial invaginations in the gallbladder wall; formed from ↑ gallbladder pressure

  Ducts of Luschka – biliary ducts that can leak after a cholecystectomy; lie in the gallbladder fossa

  Bile excretion regulation

•  ↑ bile excretion – CCK, secretin, and vagal input

•  ↓ bile excretion – somatostatin, sympathetic stimulation

•  Gallbladder contraction – CCK causes constant, steady, tonic contraction

  Essential functions of bile:

•  Fat-soluble vitamin absorption

•  Essential fat absorption

•  Bilirubin and cholesterol excretion

  Gallbladder – forms concentrated bile by active resorption of NaCl and water

•  Active resorption of conjugated bile salts occurs in the terminal ileum (50%)

•  Passive resorption of nonconjugated bile salts can occur in the small intestine (45%) and colon (5%)

•  Postprandial gallbladder emptying is maximum at 2 hours (80%)

•  Bile secreted by hepatocytes (80%) and bile canalicular cells (20%)

•  Color of bile is mostly due to conjugated bilirubin

•  Stercobilin – breakdown product of conjugated bilirubin in gut; gives stool brown color

•  Urobilinogen – conjugated bilirubin is broken down in the gut and reabsorbed; gets converted to urobilinogen and eventually urobilin, which is released in the urine (yellow color)

CHOLESTEROL AND BILE ACID SYNTHESIS

  HMG CoA → (HMG CoA reductase) → cholesterol → (7-alpha-hydroxylase) → bile salts (acids)

  HMG CoA reductase – rate-limiting step in cholesterol synthesis

GALLSTONES

  Occur in 10% of the population; vast majority are asymptomatic

  Only 10% of gallstones are radiopaque

  Nonpigmented stones

•  Cholesterol stones – caused by stasis, calcium nucleation, and ↑ water reabsorption from gallbladder

•  Also caused by ↓ lecithin and bile salts

•  Found almost exclusively in the gallbladder

•  Most common type of stone found in the United States (75%)

  Pigmented stones – most common worldwide

•  Calcium bilirubinate stones – caused by solubilization of unconjugated bilirubin with precipitation

•  Dissolution agents (monooctanoin) do not work on pigmented stones

•  Black stones

•  Can be caused by hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN

•  Factors for development – ↑ bilirubin load, ↓ hepatic function, and bile stasis → get calcium bilirubinate stones

•  Almost always form in gallbladder

•  Tx: cholecystectomy if symptomatic

•  Brown stones (primary CBD stones, formed in ducts, Asians)

•  Infection causing deconjugation of bilirubin

•  E. coli most common – produces beta-glucuronidase, which deconjugates bilirubin with formation of calcium bilirubinate

•  Need to check for ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi

•  Most commonly form in the bile ducts (are primary common bile duct stones)

•  Tx: almost all patients with primary stones need a biliary drainage procedure – sphincteroplasty (90% successful)

•  Cholesterol stones and black stones found in the CBD are considered secondary common bile duct stones

CHOLECYSTITIS

  Caused by obstruction of the cystic duct by a gallstone

  Results in gallbladder wall distention and wall inflammation

  Symptoms: RUQ pain, referred pain to the right shoulder and scapula, nausea and vomiting, loss of appetite

•  Attacks frequently occur after a fatty meal; pain is persistent (unlike biliary colic)

  Murphy’s sign – patient resists deep inspiration with deep palpation to the RUQ secondary to pain

  Alkaline phosphatase and WBCs are frequently elevated

  Suppurative cholecystitis associated with frank purulence in the gallbladder → can be associated with sepsis and shock

  Most common organisms in cholecystitis – E. coli (#1), Klebsiella, Enterococcus

  Stone risk factors – age > 40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)

  Ultrasound – 95% sensitive for picking up stones → hyperechoic focus, posterior shadowing, movement of focus with changes in position

•  Best initial evaluation test for jaundice or RUQ pain

•  Findings suggestive of acute cholecystitis – gallstones, gallbladder wall thickening (> 4 mm), pericholecystic fluid

•  Dilated CBD (> 8 mm) suggests CBD stone and obstruction

  HIDA scan – technetium taken up by liver and excreted in the biliary tract

  CCK-CS test (cholecystokinin cholescintigraphy)

•  Most sensitive test for cholecystitis (also uses HIDA above)

•  Indications for cholecystectomy after CCK-CS test:

•  If gallbladder not seen (the cystic duct likely has a stone in it)

•  Takes > 60 minutes to empty (chronic cholecystitis)

•  Ejection fraction < 40% (biliary dyskinesia)

  Indications for immediate ERCP (signs that a common bile duct stone is present) – jaundice, cholangitis, U/S shows stone in CBD

  Indications for pre-op ERCP (any of following needs to be persistently high for > 24 hours to justify pre-op ERCP) – AST or ALT (> 200), bilirubin (> 4), or amylase or lipase (> 1,000)

•  < 5% of patients undergoing cholecystectomy will have a retained CBD stone → 95% of these are cleared with ERCP

  Tx for cholecystitis – cholecystectomy; cholecystostomy tube can be placed in patients who are very ill and cannot tolerate surgery

  ERCP – best treatment for late common bile duct stone

•  Sphincterotomy allows for removal of stone

•  Risks: bleeding, pancreatitis, perforation

  Biliary colic – transient cystic duct obstruction caused by passage of a gallstone

•  Resolves within 4–6 hours

  Air in the biliary system most commonly occurs with previous ERCP and sphincterotomy

•  Can also occur with cholangitis or erosion of the biliary system into the duodenum (ie gallstone ileus)

  Bacterial infection of bile – dissemination from portal system is the most common route (not retrograde through sphincter of Oddi)

  Highest incidence of positive bile cultures occurs with postoperative strictures (usually E. coli, often polymicrobial)

ACALCULOUS CHOLECYSTITIS

  Thickened wall, RUQ pain, ↑ WBCs, no stones

  Occurs most commonly after severe burns, prolonged TPN, trauma, or major surgery

  Primary pathology is bile stasis (narcotics, fasting), leading to distention and ischemia

  Also have ↑ viscosity secondary to dehydration, ileus, transfusions

  Ultrasound shows sludge, gallbladder wall thickening, and pericholecystic fluid

  HIDA scan is positive

  Tx: cholecystectomy; percutaneous drainage if patient too unstable

EMPHYSEMATOUS GALLBLADDER DISEASE

  Gas in the gallbladder wall – can see on plain film

  ↑ in diabetics; usually secondary to Clostridium perfringens

  Symptoms: severe, rapid-onset abdominal pain, nausea, vomiting, and sepsis

  Perforation more common in these patients

  Tx: emergent cholecystectomy; percutaneous drainage if patient is too unstable

GALLSTONE ILEUS

  Fistula between gallbladder and duodenum that releases stone, causing small bowel obstruction; elderly

•  Can see pneumobilia (air in the biliary system) on plain film

  Terminal ileum – most common site of obstruction

  Tx: remove stone through enterotomy proximal to obstruction

•  Perform cholecystectomy and fistula resection if patient can tolerate it (if old and frail, just leave the fistula)

COMMON BILE DUCT INJURIES

  Most commonly occur after laparoscopic cholecystectomy

  Intraoperative CBD injury – if < 50% the circumference of the common bile duct, can probably perform primary repair; in all other cases, will likely need hepaticojejunostomy (or choledochojejunostomy)

  Persistent nausea and vomiting or jaundice following laparoscopic cholecystectomy → get U/S to look for fluid collection

•  If fluid collection is present, may be bile leak → percutaneous drain into the collection

•  If fluid is bilious, get ERCP → sphincterotomy and stent if due to cystic duct remnant leak, small injuries to the hepatic or common bile duct, or a leak from a duct of Luschka

•  Larger lesions (ie complete duct transection) will require hepaticojejunostomy or choledochojejunostomy (see below for timing)

•  If fluid collection not present and the hepatic ducts are dilated, likely have a completely transected common bile duct (PTC tube initially, then hepaticojejunostomy or choledochojejunostomy)

•  For lesions that cause early symptoms (≤ 7 days) – hepaticojejunostomy

•  For lesions that cause late symptoms (> 7 days) – hepaticojejunostomy 6–8 weeks after injury (tissue too friable for surgery after 7 days)

  Sepsis following laparoscopic cholecystectomy → fluid resuscitation and stabilize

•  May be due to complete transection of the CBD and cholangitis → get U/S to look for dilated intrahepatic ducts or fluid collections (pathway same as above)

  Anastomotic leaks following transplantation or hepaticojejunostomy → usually handled with percutaneous drainage of fluid collection followed by ERCP with temporary stent (leak will heal)

Stay updated, free articles. Join our Telegram channel

Join