Gallbladder and Extrahepatic Biliary System

A pear-shaped sac located on the inferior surface of the liver, with a capacity of 30 to 50 mL.

Gallbladder

The rounded, blind end of the gallbladder that extends beyond the liver's margin and contains most of the smooth muscles.

Fundus

The main storage area of the gallbladder, connecting with the cystic duct through the neck.

Body (corpus)

The deepest part of the gallbladder fossa, extending into the free portion of the hepatoduodenal ligament.

Neck

The artery that supplies blood to the gallbladder, usually a branch of the right hepatic artery.

Cystic artery

Consists of the right and left hepatic ducts, common hepatic duct, cystic duct, and common bile duct.

Biliary tree

Regulates the flow of bile and pancreatic juice into the duodenum, prevents regurgitation of duodenal contents into the biliary tree, and diverts bile into the gallbladder.

Sphincter of Oddi

The liver continuously produces bile, which is excreted into the bile canaliculi. It is responsive to neurogenic, humoral, and chemical stimuli.

Bile Formation

A nuclear medicine scan that tracks the flow of a radioactive tracer from the liver into the gallbladder and small intestine to evaluate the function of the biliary system.

HIDA Scan

A diagnostic test where iodine-containing tablets are taken orally to outline gallstones that are usually invisible on x-ray.

Oral Cholecystogram

The formation of gallstones, which can be cholesterol stones or pigment stones (black or brown) formed as a result of solids settling out of solution.

Gallstone Disease

Characterized by recurrent attacks of pain when a stone obstructs the cystic duct, resulting in increased tension in the gallbladder wall.

Chronic Cholecystitis

The standard diagnostic test for gallstones, which has a sensitivity of 89% and specificity of 88%.

Abdominal Ultrasound

Elective laparoscopic/open cholecystectomy is the treatment of choice for symptomatic gallstones.

Management

Inflammation of the gallbladder usually caused by gallstones obstructing the cystic duct, leading to gallbladder distention, inflammation, and edema of the gallbladder wall.

Acute Cholecystitis

Acute cholecystitis is initiated by the obstruction of the cystic duct by a gallstone, leading to inflammation and secondary bacterial contamination in some cases.

Pathogenesis

Gas may be seen in the gallbladder lumen and wall on radiographs and CT scans, indicating a secondary bacterial infection.

Emphysematous gallbladder

Begins as an attack of biliary colic but the pain does not subside, accompanied by fever, anorexia, nausea, and vomiting. Focal tenderness and guarding are present in the right upper quadrant.

Acute cholecystitis

Inspiratory arrest with deep palpation in the right subcostal area, characteristic of acute cholecystitis.

Murphy's sign

Common bile duct stones found in 6-12% of patients with gallstones. Can cause symptoms such as pain, nausea, and vomiting.

Choledocholithiasis

Magnetic Resonance Cholangiopancreatography, a specialized MRI exam to evaluate the hepatobiliary and pancreatic systems.

MRCP

Ascending bacterial infection in association with bile duct obstruction. Can cause liver damage, gallstones, enlarged spleen, enlarged veins, and blood infection.

Cholangitis

Fever, epigastric or right upper quadrant pain, and jaundice, indicative of cholangitis.

Charcot's triad

Endoscopic Retrograde Cholangiopancreatography, a diagnostic test to show the level and reason for bile duct obstruction and allow drainage.

ERCP

Surgical procedure to cut the sphincter of Oddi, used in the treatment of cholangitis and other bile duct disorders.

Sphincterotomy

Inflammation of the gallbladder without the presence of gallstones, often seen in severely ill patients.

Acalculous cholecystitis

Inflammation of the gallbladder without the presence of gallstones, often occurring in severely ill patients.

Acalculous cholecystitis

Unexplained fever, abdominal distension, tenderness of the abdomen, abdominal discomfort or pain (usually in the right upper quadrant), and elevated white blood cell count.

Symptoms of acalculous cholecystitis

Impaired circulation to the gallbladder, lack of stimulation to contract and release bile, gallbladder dysmotility, pregnancy, certain liver disorders, and infection.

Causes of acalculous cholecystitis

Surgical removal of the gallbladder (cholecystectomy), endoscopic gallbladder stent placement, and percutaneous cholecystostomy.

Treatment for acalculous cholecystitis

Perforation of the gallbladder and gangrene of the gallbladder, which can lead to shock, peritonitis, or sepsis.

Complications of severe cholecystitis

A cyst or hollow outpouching of the bile ducts, classified into different types based on location and structure.

Choledochal cyst

Type I (cyst of the bile duct), Type II (pouching or sac on the bile duct), Type III (cyst within the wall of the duodenum or pancreas), Type IV (extension into the liver), and Type V (multiple cysts along the bile duct inside the liver).

Types of choledochal cysts

Complete excision through surgery, especially for Type I, II, or IV cysts due to the risk of malignancy.

Treatment for choledochal cysts

Rare malignancy occurring predominantly in the elderly, with poor prognosis except when incidentally diagnosed at an early stage after cholecystectomy for cholelithiasis.

Carcinoma of the gallbladder

Fifth most common GI malignancy in Western countries, associated with cholelithiasis, polypoid lesions of the gallbladder, and calcified "porcelain" gallbladder.

Incidence and risk factors of gallbladder carcinoma

Papillary, nodular, and tubular subtypes, with papillary type having a better prognosis.

Pathology of gallbladder adenocarcinomas

Through lymphatics, venous drainage, and direct invasion into the liver parenchyma.

Spread of gallbladder cancer

Abdominal discomfort, right upper quadrant pain, nausea, vomiting, jaundice, weight loss, anorexia, ascites, and abdominal mass. Ultrasonography, CT scan, and MRI techniques used for diagnosis and staging.

Clinical manifestations and diagnosis of gallbladder cancer

Surgery remains the only curative option, with simple cholecystectomy for T1 lesions and extended cholecystectomy for T2 tumors. Prognosis is generally poor, with higher survival rates for early-stage tumors.

Treatment and prognosis of gallbladder cancer

Rare tumor arising from the biliary epithelium, often located at the hepatic duct bifurcation. Surgical resection and palliative procedures for biliary drainage are the main treatment options.

Bile duct carcinoma (cholangiocarcinoma)

Autopsy incidence is about 0.3%, with primary sclerosing cholangitis, choledochal cysts, ulcerative colitis, and biliary tract infections being common risk factors.

Incidence and risk factors of bile duct carcinoma

Over 95% are adenocarcinomas, divided into nodular, scirrhous, diffusely infiltrating, or papillary types. Anatomically, they are divided into distal, proximal, or perihilar tumors (Klatskin tumors).

Pathology of bile duct carcinoma

Type I (confined to the common hepatic duct) and Type II (involving the bifurcation without involvement of the secondary intrahepatic ducts).

Types of perihilar cholangiocarcinomas

A tumor that extends into the right secondary intrahepatic duct.

Type IIIa tumor

A tumor that extends into the left secondary intrahepatic duct.

Type IIIb tumor

A tumor that involves both the right and left secondary intrahepatic ducts.

Type IV tumor

The most common presentation of cholangiocarcinoma.

Painless jaundice

Inflammation of the bile ducts, which can be a presenting symptom in some patients with cholangiocarcinoma.

Cholangitis

A tumor marker that can be elevated in cholangiocarcinoma.

CA 19-9

A diagnostic imaging technique that can be used to visualize the biliary tree and determine the level of obstruction.

Ultrasound

Another diagnostic imaging technique that can be used to determine portal vein patency and evaluate the extent of the tumor.

CT scan

Obtaining a tissue sample for diagnosis, which may be difficult to obtain nonoperatively in cholangiocarcinoma.

Tissue diagnosis

The only potentially curative treatment for cholangiocarcinoma.

Surgical excision

A complex surgical procedure to remove the head of the pancreas, the first part of the small intestine, the gallbladder, and the bile duct.

Whipple procedure

The use of drugs to treat cancer, which can be used in patients with unresectable disease.

Chemotherapy

Radiation treatment given by placing radioactive material directly into the target.

Interstitial radiation therapy

A procedure used to treat certain types of cancer by placing radioactive material inside the body.

Brachytherapy

Cholangiocarcinoma is a rare tumor arising from the ________.

Bile Duct Carcinoma

Cholangiocarcinoma is a rare tumor arising from the ________.

Biliary Epithelium

About two thirds of Bile Duct Carcinomas are located at the ________.

Hepatic Duct Bifurcation

________ is a treatment option for Bile Duct Carcinoma.

Surgical Resection

________ aimed to provide biliary drainage are often the only therapeutic possibilities for Bile Duct Carcinoma.

Palliative Procedures

Palliative procedures aim to provide biliary drainage to prevent ________ in Bile Duct Carcinoma patients.

Liver Failure

Palliative procedures aim to provide biliary drainage to prevent liver failure and ________ in Bile Duct Carcinoma patients.

Cholangitis

Most patients with Bile Duct Carcinoma die within 1 year of diagnosis if they have ________.

Unresectable Disease

Most patients with unresectable Bile Duct Carcinoma die within 1 year of ________.

Diagnosis

For patients with symptomatic gallstones and suspected common bile duct stones, preoperative ________ ( ERCP) or an intraoperative cholangiogram is recommended.

ERCP

If an endoscopic cholangiogram reveals stones, ________ and ductal clearance of the stones is appropriate, followed by a laparoscopic / open cholecystectomy.

Sphincterotomy

An intraoperative cholangiogram at the time of ________ will also document the presence or absence of bile duct stones.

Laparoscopic / open cholecystectomy

________ via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting.

Laparoscopic common bile duct exploration

________ is an option if the endoscopic method has already been tried or is, for some reason, not feasible.

Open common bile duct exploration

If a choledochotomy is performed, a ________ is left in place.

T tube

________ is rarely done.

Roux-en-Y choledochojejunostomy

________ is both diagnostic and therapeutic.

ERCP

________.

Intraoperative cholangiogram