4. Diseases of the Gallbladder - Sarm

• Stone formation is due to

  • high cholesterol
  • nucleation
  • stasis due to obstruction
• Stone formation - common sex (5F)

  • fair
  • female
  • fat
  • forty
  • fertile
• stones acute attack is precipitated by large or fatty meal
• Patients with stones will try to move around to seek relief from the pain
• What size stones are more likely to be symptomatic?

  small
• cholecystitis is inflammation of gallbladder wall
• acute calculous cholecystitis caused by obstruction of cystic duct leading to distention of gallbladder
• acute calculous cholecystitis can obstruct blood flow and lymphatics leading to

  • mucosal edema
  • ischemia
  • necrosis
• acute calculous cholecystitis can be sterile or infected
• bilirubin level > 3.5 mg/dL indicate common bile duct stone or ascending cholangitis
• elevated amylase or lipase - gallstone pancreatitis
• acalculous cholecystitis - inflammation without stone

  • common in DM
• gallstone perforation - if localized

  • abscess formation is common
• Free perforation of gallbladder can occur releasing bile and inflammatory mater intraperitoneally causing peritonitis
• fistula formation can lead to gallstone ileus
• choledocholithiasis - stones found in common bile duct
• Choledocholithiasis - presentation

  • jaundice
  • ascending biliary traction infection - cholangitis
• Ascending cholangitis - if untreated leads to Reynolds pentad
• What is gold standard for diagnosing gallbladder stones?

  US
• Courvoisier syndrome - jaundice and a gallbladder that is enlarged but is not painful.
• Choledocholithiasis treatment

  • drainage of bile by ERCP with cholecystectomy
• gallbladder stones are radiopaque because it is made of ca2+

  • porcelain gallbladder
• Use US for secondary choledocholithiasis
• Mirizzi syndrome - common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct
• Carcinoma of gallbladder is due to irritation of GB mucosa by stones causing chronic inflammation
• GB tumor can locate

  • fundus (most common)
  • body
  • neck
• Gallbladder cancer - clinical presentation

  • calcified stones - mimic cholelithiasis
  • jaundice
  • hepatomegaly
  • generalized pruritis
• ** gallbladder carcinoma - generalized pruritus in jaundiced pts
• Gallbladder cancer - spread

  • early lymphatic
  • direct invasion
  • intraperitoneal seeding
• Imaging of choice for gallbladder cancer?

  USG