Gall Bladder Stone

Gall Bladder Stone with the description of Anatomy of Gall bladder ,its physiology and pathogenesis etc.

1. السلام علیکم

2. محمد فیصل 17-11-16 2 Gall Stone GALL BLADDER STONE حصاۃ مرارہ معاونین :جنید نزیر،وسیم احمد ،دانش اختر پی جی اسکالرس:نیشنل انسٹیٹیوٹ آف یونانی میڈیسن بنگلور

3. CONTENTS Surgical Anatomy of Gall Bladder Physiology Gall Stone یونانی نقطہ نظر Causes Pathogenesis Types of Stones Features Effects of Gall Stone Complications Miscellaneous 17-11-16 Gall Stone

4. Pear-shaped sac, about 5–12 cm long Lying on the visceral surface of the right lobe of the liver in a fossa between the right and quadrate lobes Divided into four anatomic areas: Fundus The corpus (body) The Infundibulum The Neck 4 Anatomy 17-11-16 Gall Stone

5. 17-11-16 Gall Stone The two hepatic ducts from right and left lobes of the liver unite at the porta hepatis to form the common hepatic duct which is joined by the cystic duct from the gallbladder to form the common bile duct. The common bile duct enters the second part of the duodenum posteriorly . In about 70% of cases, it is joined by the main pancreatic duct to form the combined opening in the duodenum ( ampulla of Vater ). CONT……

6. In 30% cases, the common bile duct and the pancreatic duct open separately into the duodenum. The common bile duct in its duodenal portion is surrounded by longitudinal and circular muscles derived from the duodenum forming sphincter of Oddi . 17-11-16 Gall Stone CONT……

7. HISTOLOGY Serous layer 17-11-16 Gall Stone Mucosal layer Smooth muscle layer Perimuscular layer

8. Gallbladder drains through cystic duct into common hepatic duct to form common bile duct. It is supplied by cystic artery, a branch of right hepatic artery. Calot’s triangle is formed by common hepatic duct to the left, cystic duct below, and inferior surface of liver above. Cystic artery originating from right hepatic artery passes behind the common hepatic artery, enters the Calot’s triangle to reach the gallbladder. It contains lymph node of ‘Lund’ (Fred Bates Lund). 17-11-16 Gall Stone CONT……

9. 5. Maintenance of Pressure in Biliary System 17-11-16 Gall Stone FUNCTIONS OF GALLBLADDER Storage of Bile 2. Concentration of Bile 3. Alteration of pH of Bile 4. Secretion of Mucin

10. PROPERTIES AND COMPOSITION OF BILE SECRETION OF BILE STORAGE OF BILE Composition of bile 17-11-16 Gall Stone

11. Differences between liver bile and gallbladder bile Types of entities Liver bile Gallbladder bile pH 8 to 8.6 7 to 7.6 Specific gravity 1010 to 1011 1026 to 1032 Water content 97.6% 89% Solids 2.4% 11% Organic substances Bile Salts 0.5 g/ dL 6.0 g/ dL Bile Pigments 0.05 g/ dL 0.3 g/ dL Cholesterol 0.1 g/dL 0.5 g/dL Fatty Acids 0.2 g/ dL 1.2 g/ dL Lecithin 0.05 g/ dL 0.4 g/ dL Mucin Absent Present Inorganic substances Sodium 150 mEq /L 135 mEq /L Calcium 4 mEq /L 22 mEq /L Potassium 5 mEq/L 12 mEq/L Chloride 100 mEq /L 10 mEq /L Bicarbonate 30 mEq/L 10 mEq/L 17-11-16 Gall Stone

12. BILE SALTS Bile salts are the sodium and potassium salts of bile acids, which are conjugated with glycine or taurine . FORMATION OF BILE SALTS

13. Emulsification of Fats Absorption of Fats Choleretic Action Cholagogue Action Laxative Action Prevention of Gallstone Formation FUNCTIONS OF BILE SALTS 17-11-16 Gall Stone

14. Formation and circulation of bile pigments 17-11-16 Gall Stone

15. FILLING AND EMPTYING OF GALLBLADDER 2. Hormonal Factor When a fatty chyme enters the intestine from stomach, the intestine secretes the cholecystokinin , which causes contraction of the gallbladder. 17-11-16 Gall Stone 1. Neural Factor Stimulation of parasympathetic nerve ( vagus ) causes contraction of gallbladder by releasing acetylcholine. The vagal stimulation occurs during the cephalic phase and gastric phase of gastric secretion.

16. GALL STONE 17-11-16 Gall Stone

17. GALLSTONES Definitions: Gallstone is a solid crystal deposit that is formed by cholesterol, calcium ions and bile pigments in the gallbladder or bile duct. Cholelithiasis is the presence of gallstones in gallbladder Causes for Gallstone Formation 1. Reduction in bile salts and/or lecithin 2. Excess of cholesterol 3. Disturbed cholesterol metabolism 4. Excess of calcium ions due to increased concentration of bile 5. Damage or infection of gallbladder epithelium. It alters the absorptive function of the mucous membrane of the gallbladder. Sometimes, there is excessive absorption of water or even bile salts, leading to increased concentration of cholesterol, bile pigments and calcium ions 6. Obstruction of bile flow from the gallbladder. 17-11-16 Gall Stone یونانی نقطہ نظر سوء مزاج کمی جزئی

18. Geography Genetic factors( CYP7A1- cholesterol 7-hydroxylase) Age Sex Drugs Obesity Diet Gastrointestinal diseases Factors in pigment gallstones RISK FACTORS

19. PATHOGENESIS OF CHOLESTEROL, MIXED GALLSTONES AND BILIARY SLUDGE. 17-11-16 Gall Stone PATHOGENESIS. The mechanism of gallstone formation

20. Factors altering the cholesterol to bile salt ratio Obesity Drugs – Oral contraceptive pills – Clofi brate – Cholestyramine Ileal disease Ileal resection Altered enterohepatic circulation

21. III. Bile stasis: Occurs due to estrogen therapy, pregnancy, vagotomy and in patients who are on long term intravenous fluids or TPN IV. Increased bilirubin production due to any of the causes of haemolysis as in hereditary spherocytosis , sickle cell anaemia , thalassaemia , malaria, cirrhosis. Here pigment stones are common. II. Infections and Infestations: Bacteria like E. coli, Salmonella ,Parasites like Clonarchis sinensis and Ascaris lumbricoides are often associated. Moynihan’s aphorism: “A gallstone is a tomb stone erected to the memory of the organism within it.” 17-11-16 Gall Stone

22. 1. Cholesterol stones are 6% common, often solitary. Types

23. 2. Mixed stones are 90% common. It contains cholesterol, calcium salts of phosphate carbonate, palmitate , proteins, and are multiple faceted.

24. 3. Pigment stones are small, black or greenish black, multiple. Often they can be sludge like.

25. Features of Gallstones. Type Freq Com Gallbladder Changes Appearance Pure 06% i ) Cholesterol Cholesterolosis Solitary, oval, large, smooth, yellow gallstones white; on C/S radiating glistening crystals ii) Bile pigment No change Multiple, small, jet-black, mulberry shaped; on C/S soft black iii) Calcium carbonate No change Multiple, small, grey-white, faceted; C/S hard 2. Mixed 90% Cholesterol, bile pigment Chronic cholecystitis Multiple, multifaceted, variable size, and calcium carbonate on C/S laminated alternating dark- in varying combination pigment layer and pale-white layer 3. Combined 4% Pure gallstone nucleus with Chronic cholecystitis Solitary, large, smooth; on C/S Gallstones mixed gall stone shell, or central nucleus of pure gallstone mixed gallstone nucleus with with mixed shell or vice versa pure gall stone shell 17-11-16 Gall Stone

26. Saint’s triad Gallstones Diverticulosis of the colon Hiatus hernia Rarely centre of the stone contains radiolucent gas which is either triradiate ( Mercedes Benz sign) or biradiate (Seagull sign). Black pigment stones are common in gallbladder. It is usually calcium bilirubinate , calcium phosphate and bicarbonate stone with a matrix. It is common in haemolytic disorders. They are usually multiple, small black and hard in consistency. Only 10% of gallstones are radio-opaque, 90% are radiolucent. Miscellanous

27. Brown pigment stones are formed in biliary tree as primary biliary stones. It is commonly due to infection like Escherichia coli and bacteroides (98%) with bacterial nidus at the centre (often Ascaris lumbricoides or Clonorchis sinensis infestation or foreign body or stents). They secrete β glucuronidase to cause hydrolysis of soluble conjugated bilirubin to insoluble calcium bilirubinate . It also contains calcium palmitate , calcium stearate and cholesterol. They are brownish yellow, soft and mushy.

28. In the gallbladder i . Silent asymptomatic stones occurs in 10% of males and 20% of females. Effects of the Gallstones ii. Biliary colic with periodicity, severe within hours after meal (commonest presentation). Biliary colic is spasmodic pain often severe, in right upper quadrant and epigastrium radiating to chest, upper back and shoulder. It is self-limiting, recurs unpredictably, often precipitated by a fatty/heavy meal. Fever and increased WBC count may be observed. 17-11-16 Gall Stone

29. iii. Acute cholecystitis . iv. Chronic cholecystitis . v. Empyema gallbladder. vi. Perforation causing biliary peritonitis or pericholecystitic abscess. vii. Mucocele of gallbladder. viii. Carcinoma gallbladder.

30. complications of gallstones.

31. Gallstone Colic It is sudden, severe colicky abdominal pain in right upper quadrant which radiates to back and shoulder. This pain is due to sudden spasm of gallbladder wall when gallstone moves towards the neck of the gallbladder or cystic duct and gets impacted. Tachycardia and restlessness are common. Right hypochondrium is tender. It is precipitated by supine position while sleeping at night. It lasts for few hours and is episodic. It may precipitate acute cholecystitis or empyema gallbladder. There is reflex pylorospasm causing vomiting. Flatulent Dyspepsia It is discomfort in the abdomen, belching, heartburn, fat intolerance, sensation of fullness in the abdomen usually observed in fatty, fertile, flatulent female.

32. Silent gallstone Asymptomatic stone in the gallbladder , Usually it is cholesterol stone, often single It is accidentally discovered by U/S It need not be treated unless: – Patient is diabetic/ immunosuppressed – High chances of developing gallbladder carcinoma – Stone more than 2.5 cm/multiple stones – If gallbladder wall is thickened – If there is high risk for carcinoma GB

33. علاج: معمولی حالت میں صبح میں ۱۔ حجر الیہود، سنگ سرماہی ہر ایک ایک گرام باریک پیس کر جوارش زرعونی سات گرام میں ملاکر کھلائیں اوپر سے شیرہ کاکنج، شیرہ بادیان، شیرہ خیارین ہر ایک تین گرام ، عرق انناس ۱۵۰ م ل میں نکال کر شربت دینار ۲۵ م ل میں حل کرکے آب برگ سبز ترب مروق ۵۰ م ل شامل کرکے پلائیں شام میں ۲۔ معجون عقرب پانچ گرام ہمراہ عرق انناس ۱۲۵ م ل اور سکنجبین بزوری ۲۵ م ل استعمال کرائیں سوتے وقت ۳۔ روغن زیتون پچاس م ل پلائیں اصول علاج و علاج: ۱۔ درد کے وقت مریض کو آرام کرائیں، کسی ہوا دار کمرے میں لٹائیں ۲۔ درد کے مقام پہ محلل و مسکن ادویہ کے جوشاندے سے ٹکور کریں ۳۔ داخلی طور پر مفتتات حصات ادویہ کا استعمال کرائیں ۴۔قبض کی صورت میں زلال آلو بخارہ ساٹھ ملی لیٹر ۔۔۔۔پانی میں حل کرکے پلائیں ۵۔ تقلیل غذاء ،خصوصی طور پر چربی دار غذاؤں سے یکسر پرہیز کرائیں

34. Diagnosis & Management of Gallstones 1. U/S abdomen Ultrasound gallbladder showing echogenic lesion.

35. plain X-ray abdomen; Plain X-ray showing (A) Mercedes Benz sign, (B) Multiple faceted stones LFT; total WBC count. Gall Stone

36. Laparoscopic cholecystectomy ideal. Gall Stone

37. Open cholecystectomy is done through right subcostal Kocher’s incision. Gall Stone

38. Gall Stone شکریہ