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Gallbladder & Gallstone

Gallbladder & Gallstone

In vertebrates the gallbladder (cholecyst,gallbladder or biliar vesicle )is a small organ where bile is stored before it released into small intestine .The gall bladder is a hollow organ that sits just beneath the right of liver.

Gallbladder definition
Gall bladder is a pear shaped reservoir of bile situated in a fossa on the inferior surface of the right lobe of the liver
The fossa of the gallbladder extends from the right end of the porta hepatis to the inferior border of the liver.

1.Epigastric region
2.Right hypochondriac region
3.inferior surface of the liver
4.Between Quadrate and right lobes

The gall bladder is 7 to 10 cm long,3 cm broad at its widest part,and about 30 to 50 ml in capacity.

Biliary Apparatus
The biliary apparatus collects bile from the liver store it in the gallbladder,transmit it into the second part of the duodenum.
The apparatus consists of ;
1.the right and left hepatic ducts,
2.the common hepatic duct.
3.the gallbladder
4.the cystic duct
5.the common bile duct

Common Bile Duct
The bile duct form by the union of the cystic and common hepatic ducts near the porta hepatis.
Its about 5 to 6 cm long and has a diameter of about 6mm.
Its divided into four parts;
1.supraduodenal portion ,about 2.5 cm long,runs in the free edge of the lesser omentum.
2.reteroduodenal portion
3.infraduodenal portion ,on the posterior of the pancreas
4.intraduodenal portion ,passes through the wall of the second part of the duodenum, surrounded by the sphincter of oddi terminates by opening on the summit of the ampulla of vater.


  • Gallstones disease, or cholelithiasis, is one of the most common surgical problems Worldwide.
  • Gallstones are abnormal, inorganic masses formed in the gallbladder and, les commonly, in the common bile or hepatic ducts.
  • They are frequent cause of abdominal pain and dyspepsia
  • Although gallstones can from anywhere in the biliary tree, the most common point of origin is within the gallbladder. 

Risk factor of gallstones

Gender:  Gallstones from more commonly women than in men

Age: Gallstone prevalence increases with age.

Obesity: Obese individuals are more likely to from gallstones than thin individuals.

Pregnancy:  Pregnant women are more likely to form gallstones than women who have not been pregnant. Pregnancy increases the risk for cholesterol gallstones because during  pregnancy, bile contains more cholesterol , and the gallbladder does not contract normally.

Birth control pills and hormone therapy: The increased levels of hormones caused by either treatment mimics pregnancy.

Rapid weight loss by whatever means very low calorie diets or obesity surgery-causes cholesterol gallstones in up to 50% of individual. Many of the gallstones will disappear after the weight is lost, but many do not. Moreover, until they are gone, they may cause problems.Gallbladder & Gallstones.

Increased blood triglycerides: Gallstones occur more frequently in individuals with elevated blood triglyceride levels.

Types of Gallstones

  • Pathogenesis
  • Bile = bile salts, phospholipids, cholesterol
  • Also bilirubin which is conjugated before excretion
  • Gallstones due to imbalance rendering cholesterol & calcium salts insoluble

Pathogenesis involves 3 stages:

  1. Cholesterol superstations in bile
  2. Crystal nucleation
  3. Stone growth
  4. Mixed (80%)
  5. Pure cholesterol (10%)
  6. Pigmented (10%)
  7. Black stones (contain Ca bilirubinate, a/w cirrhosis and hemolysis)
  8. Brown stones (a/w biliary tract infection)
  • Disturbances of bile biochemical features – lithoqenicity of bile
  • Infection
  • Chronic cholecystitis, gallstones formation
  • Dysfunction of gallbladder and bile ducts


Symptomatic cholelithiasis : Wax /waning postprandial epigastria/ RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT

Acute cholecystitis : Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain+/- fever,    | WBC | LFT, + Murphy’s = inspiratory arrest

Chronic cholecystitis: Recurrent bouts of colic/acute chol’y leading to chronic GB wall infllamm/fibrosis. No fever/WBC

Acalculous cholecystitis  GB inflammation due to biliary stasis (5% of time) and not stones (95%). Seen in critically ill pts.

Gallstone in the common bile duct ( primary means originated there, secondary = form Choledocho-lithiasis  : GB)

Cholangitis: infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice , fever ( seen in 70% of pts), can lead to septic shock.


Prolonged fasting (5-10 days) can result in the formation of biliary sludge

(microlithiasis) which resolves by itself when feeding is reestablished – but it can lead to biliary symptoms or gallstone formation

Stages and Classification

  1.  Initial stage or ‘’prestone’’
  2. Viscous, nonhomogeneous bile
  3. Bile sludge with formation of microstones

2.  Formation of stones

  • Localization :

In gallbladder, in common bile duct, in hepatic ducts

  • Amount: single, plural
  • Composition: cholesterol , pigment, mixed
  • Clinical forms: asymptomatic (latent) and manifesting or symptomatic
  • Pain from with typical bile colics
  • Dyspeptic form
  • Masked form
  • Gallbladder & Gallstones

3 . Stage of chronic, recurrent cholecystitis with concremental

  • Stage of complications

Cholesterol and mixed stones

Demographic and genetic factors — familial disposition; hereditary aspects; greater prevalence in Northern Europe and North America, lower – in Asia

Obesity – increased biliary secretion of cholesterol

Weight loss – mobilization of tissue cholesterol leads to increased biliary cholesterol secretion while enterohepatic circulation of bile acids is decreased

Female sex hormones

Estrogens stimulate hepatic lipoproteins receptors, increase uptake of dietary cholesterol, and increase biliary cholesterol secretion

Natural and synthetic estrogens lead to decrease bile salt secretion and decreased conversion of cholesterol to cholesterol esters

Ileal disease or resection – malabsorbtion of bile acids leads to decreased bile acids pool and decreased biliary secretion of bile salts

Increasing age – increased biliary secretion of cholesterol, decreased size of bile acid pool, biliary secretion of bile salts, gallbladder motility

  • Gallbladder & Gallstones hypomotility  leading to stasis and formation of sludge
  • Fasting
  • Pregnancy
  • Drugs: octreotide
  • Prolonged parenteral nutrition
  • Clofibrate therapy – increased biliary secretion cholesterol
  • Decreased bile acid secretion
  • Primary bilary cirrhosis
  • Chronic intrahepatic
  • Miscellaneous
  • High-calorie, high-fat diet
  • Pigment stones
  • Demographic/genetic factors: Asia, rural setting
  • Chronic hemolysis
  • Alcoholic cirrhosis
  • Chronic biliary tract infection, parasite infestation
  • Increasing age
  • Pathogenic Mechanism
  • Lithogenecity of bile in form of:
  • Cholesterol + normal bile acids and lecithin
  • Bile acids + normal cholesterol and lecithin
  • Cholesterol + bile acids + normal lecithin
  • High concentration of bile acids may cause aseptic inflammation of gallbladder
  • Dysfunction of bile ducts and gallbladder – disturbances of gallbladder and sphincters synchronism
  • Dysfunction of gallbladder
  • Dysfunction of Oddi’ sphincter
  • Reflux of pancreatic juice into the gallbladder with the development of enzymatic
  • Reasons for motor dysfunction are:
  • Neurotic condition which cause asynchronism
  • Excessive intake of fatty and fried food leads to spasm of Oddi’s and Lutkens ‘sphincters
  • Long termed use of spasmolytic causes hypokinesia and atoniaof Oddi’ sphincter that in term lead to the reflux of duodenal contents into bile ducts
  • Peptic ulcer disease with localization in the bulb
  • Genetic predisposition
  • Occupational hazards ( vibration, sedentary)
  • Infection
  • Bacteria : Escherichia coli, Staphylococcus, Enterococcus, Klebsiella, Clostridium, Proteus
  • Virus of hepatitis
  • Parasite infestation in gallbladder and duodenum ( amoebiasis, opisthorchiasis  opisthorchiasis , lambliasis) may activate in gallbladder
  • The route of bile contamination:
  • Hematogenous from portal vein or hepatic artery
  • Lymphogenous
  • Ascending from intestine
  • This source for bile contamination – all focal chronic infection (tonsillitis, sinusitis, etc)
  • Decreasec immunoreactivity
  • Pain syndromes
  • Dyspeptic syndrome:
  • Gastric
  • Intestinal
  • Inflammatory syndrome (during exacerbation)
  • Cholestatic syndrome ( in obstructiob of common bile duct
  • Dyslipidemia
  • Complications
  • Cholangitis
  • Mechanical obstruction of bile ducts ( choledocholithiasis)
  • Gallbladder perforation and bile peritonitis
  • Empyema of gallbladder
  • Pericholecystitis
  • Gallbladder & Gallstones

Complications of Cholelithiasis

  • The physical examination might indicate complications of cholelithiasis.
  • Passage of gallstones from the gallbladder into the common bile duct can result in a complete or partial obstruction of the common bile duct.
  • Frequently, this manifests as jaundice.
  • In all races, jaundice is detected most reliably by examination of the sclera in natural for yellow discoloration
  • Pancreatitis, another complication of gallstone disease, presents with more diffuse abdominal pain, including pain in the epigastrium and left upper quadrant of the abdomen.
  • Cholecystitis means inflammation of the gallbladder. Like billary colic, it too is caused by sudden obstruction of the ducts by gallstone, usually the cystic duct.
  • Cholangitis is a condition in which bile in the common, hepatic, and intrahepatic ducts becomes infected
  • Charcot Traid ( right upper pain, fever, and jaundice)
  • Associated with common bile duct obstruction and cholangitis
  • Additional symptoms:
  • Alterations in mental status and hypotension, indicate Raynaud pented, a harbinger of worsening, ascending cholangitis.
  • Sharco symptoms: pain in the right upper abdomen, high fever jaundice.
  1. Gangrene of the gallbladder is a condition in which the inflammation of cholecystitis cuts off the supply of blood to the gallbladder.
  2. Without blood, the tissues of forming the wall of the gallbladder die, and this makes the wall very weak.
  3. The weakness combined with infection often leads to the rupture of the gallbladder.
  4. The infection then may spread throughout the abdomen, though often the rupture is confined to a small area around the gallbladder ( a confined perforation)
  5. Clinical manifestation complaints and anamnesis
  6. Pain syndrome depends on the stage of the disease:
  7. In gallstone–biliary colic. Characterized by sudden onset of severe pain with duration from 30 min to 5 h, subsiding gradually or rapidly, localized in the right hypochondria or epigastria radiated in the right scapula, right part of the chest, clavicle May be precipitated by fatty food, by consumption of a large meal following a period of prolonged fasting.
  8. In dyskinesia stage – dull , mild pain in the right hypochondria , epigastria fullness,
  9. Gastric dyspeptic syndrome : nausea and vomit with bile that don’t improve condition , heartburn, belching, bitter taste regurgitation with bile , loss of appetite
  10. Intestinal dyspeptic syndrome: steatorrhea, meteorism
  11. Inflammatory: fever , chills
  12. Cholestatic  syndrome: skin etching
  13. Clinical manifestation:  physical findings

Pain syndrome:

  1. Superficial palpation demonstrates tenderness in the right hypochondria, muscle rigidity.
  2. Deep palpation shows tenderness in the point of gallbladder, positive Ortner , Murphy, frenicus, kehr symptoms
  3. Cholestasis ;  jaundice, skin pigmentation, exanthema, xanthelasma.
  4. Inflammation: fever, skin hyperesthesia in right hypochondria and under the right scapula

Clinical manifestation:  Laboratory findings

For patients with uncomplicated cholelithiasis, blood work results usually are normal

However , labs can detect complications of gallstone disease; complications might after alter the course of treatment .


Chemical panel, including electrolytes, liver enzymes and bilirubin .

Choledocholithiasis can manifest with only elevation of serum alkaline phosphatase or bilirubin.

Nearly50% of patients with symptomatic gallstone disease will have abnormal transaminases.

Serum lipase and amylase levels are helpful in cases of diagnostic uncertainty or suspected concurrent pancreatitis

Clinical manifestation:  Imaging Studies


Approximately 15% of gallstones are radiopaque and can be visualized on plain X-ray.

A porcelain gallbladder should be removed surgically because of increased risk of gallbladder cancer.

Other causes of abdominal pain diagnosed with the assistance of X-ray include perforated viscous, bowel obstruction, calcific pancreatitis, and renal stone.

Ultrasound (US) is the most sensitive and specific test for the detection of gallstones

US provides information about the size of the common bile duct and hepatic duct and status of liver parenchyma and pancreas

Thickening of the gallbladder wall and the presence of pericholecystic fluid are radiographic signs of acute cholecystitis

CT Scanning Often is used in workup of abdominal pain without specific localizing signsor symptoms.

CT Scanning is not first line study for detection of gallstone because of greater cost and the invasive nature of test.

When present , gallstone usually are observed on CT Scan .

Ultrasonography Examination

Denotes Gallstone.

Denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone

Spectrum of Gallstone Disease

Symptomatic choleliithiasis can be herald to:

An attack of acute cholecystitis

Or ongoing chronic cholecystitis

May also resolve


Removal of the gallbladder laparoscopic

Cholecystectomy is the treatment of choice for symptomatic gallbladder disease.

Only gallstones that cause symptoms or complications require treatment.

There is generally no reason for prophylactic cholecystectomy in an asymptomatic person unless

The gallbladders is calcified gallstone are > 3cmdiameter

Laparoscopic Cholecystectomy

MiniLap graspers used in laparoscopic cholecystectomy to grasp dome of gallbladder and done of infundibulum.

Single Incision Laparoscopic cholecystectomy

Single Incision Laparoscopic cholecystectomy with two Umbilical

Two parts Laparoscopic cholecystectomy

Laparoscopic Appendectomy

Laparoscopic Right Colectomy

Laparoscopic Sigmoid Colectomy

Laparoscopic Incision Colectomy

Laparoscopic Nissen

Gallbladder & Gallstones

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