Асute cholecystitid 3

Title Page

Authors: A.V. Zhura, A.V. BolshovSubject: Diseases of Gallbladder and Bile DuctsInstitution: Belarusian State Medical University (BSMU)Year: 2015

Preface

A methodological guide for the study of gallbladder and bile duct diseases. Contains diagnostic methods, etiology, pathogenesis, complications, and treatment trends. Recommended for students from the 4th to 6th year of medical faculty, especially for foreign students learning in English.

Historical Context

Interest in Gallstones:Noted in antiquity, with descriptions dating back to Alexander of Tralles (5th century). Early diagnosis examples by Antonio Benivieni highlighted the recognition of gallstone diseases. The first recorded surgical removal of gallstones occurred in 1618, marking a significant advancement in surgical practices. Over the last decade, notable advancements in bile duct surgery have been realized due to improved surgical techniques and a better understanding of the anatomy and physiopathology of the biliary system.

Objectives of the Study

1. Understand current methods for investigating the gallbladder and bile ducts.

2. Explore congenital anomalies of the biliary tract.

3. Understand functional disorders of gallbladder and bile ducts.

4. Learn how gallstones form and their classification.

5. Recognize symptoms, management, and treatment for biliary lithiasis.

6. Identify clinical features and management of bile duct strictures and cholangitis.

7. Diagnose acute and chronic cholecystitis.

Required Prior Knowledge

• Anatomy: Knowledge of the anatomy of the liver, gallbladder, and bile duct is essential for understanding the diseases affecting these organs.

• Physiology: Familiarity with normal functions of the liver and gallbladder is critical in recognizing pathological changes.

• Surgical Techniques: Understanding the surgical approaches to gallbladder and bile ducts is necessary for clinical practice.

• Pathology and Biochemistry: Knowledge of liver disease physiologic changes, cholesterol metabolism, bilirubin processing, and bile salt formation will aid in understanding gallbladder disorders.

Embryogenesis

Development of the biliary tree and liver initiates from a diverticulum of the embryonic foregut at approximately 18 days of gestation. The solid cranial portion forms the liver and intrahepatic bile ducts, while the hollow caudal portion differentiates into the gallbladder and extrahepatic bile ducts, illustrating the critical development stages impacting future biliary function.

Anatomy of the Extrahepatic Biliary System

Gallbladder:

• Measures 7-10 cm in length, holding 30-50 mL of bile.

• Anatomical areas include: fundus, corpus (body), infundibulum, neck.

• Closely anatomically related to the liver and the digestive tract, making knowledge of surrounding structures important for surgical procedures.

Arterial Supply and Variations:

• The gallbladder is chiefly supplied by the cystic artery, which arises from the right hepatic artery.

• Notable anatomical variations in the arterial supply have been reported in up to 50% of cases, which can complicate surgical interventions and necessitate thorough preoperative evaluation.

Calot's Triangle:

• A surgical landmark formed by the cystic duct, common hepatic duct, and cystic artery.

• Critical for identifying anatomical structures during cholecystectomy (gallbladder removal), as misidentification can lead to serious complications such as bile duct injury.

Function of the Extrahepatic Biliary System

• Produces 500-1000 mL of bile per day, which plays a crucial role in digestion, particularly in the emulsification and absorption of fats.

• Bile is concentrated and stored in the gallbladder, released primarily through the action of CCK (cholecystokinin) hormone upon meal stimulus.

Diagnostic Studies

Blood Tests:

• Elevated WBC count suggests cholecystitis.

• A combined elevation of bilirubin and alkaline phosphatase levels indicates potential cholangitis, which requires prompt intervention.

Ultrasonography:

• Considered the first-line imaging technique, showing stones with >90% specificity, allowing for a rapid and non-invasive assessment of gallbladder diseases.

Advanced Imaging:

• Includes Endoscopic Ultrasound (EUS), Magnetic Resonance Imaging (MRI), and Computed Tomography (CT) scans for detailed anatomical evaluation and identification of complications.

Classification of Gallbladder and Bile Duct Diseases

• Functional Disorders:

  • Includes biliary dyskinesia and sphincter of Oddi dysfunction.

• Gallstone Disease:

  • Encompasses acute and chronic conditions related to gallstone presence in the gallbladder or bile ducts.

• Cholangitis:

  • An infection secondary to obstruction, requiring prompt management to prevent sepsis.

• Bile Duct Strictures:

  • Often result from surgical interventions, inflammation, or malignancy, necessitating careful diagnosis and treatment.

• Sclerosing Cholangitis:

  • A chronic inflammatory condition that can lead to biliary cirrhosis and necessitates close monitoring and potential liver transplantation.

Biliary Lithiasis

Definition:

• Refers to the presence of stones in the gallbladder or bile ducts, presenting varied clinical implications depending on stone size and location.

Classification of Stones:

1. Cholesterol Stones:

   • Most common type, typically forming in the gallbladder due to supersaturation of cholesterol in bile; risk factors include obesity and rapid weight loss.

2. Pigment Stones:

   • Formed from bilirubin, often associated with hemolytic disorders; dark stones that may lead to infection.

3. Other Factors:

   • Conditions such as pregnancy, diabetes, and certain medications can also increase the risk of gallstone formation.

Clinical Forms of Gallstone Disease

• Includes asymptomatic, dyspeptic (indigestion), chronic pain, biliary colic, and complicated forms such as acute cholecystitis or pancreatitis, impacting treatment decisions based on severity and symptomatology.

Management of Gallstone Disease

• Standard Treatment:

  • Symptomatic cholecystitis generally requires laparoscopic cholecystectomy, a minimally invasive surgical approach.

• Chronic Calculous Cholecystitis:

  • May necessitate early surgical intervention, especially in the presence of complications.

• Complications:

  • Include mucocele, cholecystoenteric fistula, or Mirizzi's syndrome, each requiring careful surgical or therapeutic management.

Conclusion and Further Study

Continued education in anatomy, physiology, and surgical interventions is critical for the successful diagnosis and treatment of gallbladder and bile duct diseases, as well as understanding emerging research and techniques in the field.