MCQ Gall Bladder Benign diseases

• • Cholesterol is insoluble in water
• • Bile acid and phospholipids keep cholesterol in solution by the formation of micellesQ

• Decreased Biliary Lecithin: MDR-3 gene mutationQ
• Decreased Bile Acids: Mutation of CYP7A1 geneQ

Mutation of CYP7A1 resulting in deficiency of cholesterol 7-alpha hydroxylase, results in impaired hepatic conversion of cholesterol to bile acidsQ

• Cholesterol stones - 51–99% pure cholesterol
• Pigment stone - contain <30% cholesterolQ

• Black stones - composed of insoluble bilirubin pigment polymerQ related to hemolytic disorders, hard in consistency
• Brown stones - contain calcium bilirubinate, related to bile stasis and infection, they are rare in gall bladder, form in bile ducts, soft, friable in consistency, soft friable in consistency

• IOC for acute cholecystitis: USGQ, • USG is IOC for acute calculous cholecystitis, chronic cholecystitis and cholelithiasisQ.
• Gold standard acute cholecystitis: HIDA scanQ

• 90% of gallstones are mixed
• 90% gallstones are radioluscentQ.
• 90% kidney stones are radiopaqueQ
• In USA and Europe, Cholesterol stonesQ is most common, In India: Pigment stones (80%)Q more common.

• IOC - USG
• Gold standard - HIDA scan

The centre of Gallstone may contain radiolucent gas in a triradiate or biradiate fissure, this gives rise to characteristic dark shapes on radiograph

Hyperesthesia below right scapula in acute cholecystitis

No filling of GB with the radiotracer (99mTc-HIDA) after 4 hours indicates an obstructed cystic ductQ

• Bile acids: Chenodeoxycholic acid (CDCA) and Ursodeoxycholic acid (UDCA)Q are used.
• MOA - inhibit HMG-CoA reductaseQ, the rate limiting enzyme for cholesterol synthesis, thus decreases cholesterol saturation of bileQ

• • Radioluscent (cholesterol) stonesQ
• • Stones <10 mm in diameterQ
• • Functioning GBQ
• • Non-acute symptomsQ

• Between the gallbladder and duodenumQ
• 2nd MC site: Between gallbladder and transverse colonQ.

• Duodenal obstruction due to gallstones, usually in the bulb
• Treated by duodenostomy or pyloroplastyQ.

• It is surgical emergency.
• Unstable patients or a significant inflammation in RUQ: Unstable to withstand a prolonged operative procedure, the fistula can be addressed at a second laparotomyQ. Cholecystectomy should not be done in same episode in such cases.

Dr. Kurt Semm, the father of “pelviscopy,” in 1980Q

Eric MuheQ performed the in 1982.

In 1987, Phillipe Mouret performed the by using a camera attached to the laparoscopeQ

• • Poor pulmonary or cardiac reserveQ
• • Cirrhosis and portal hypertensionQ
• • Combined procedure
• • Suspected or known gallbladder cancerQ
• • Third-trimester pregnancyQ

• • Superiorly cystic arteryQ
• • Medially, common hepatic ductQ
• • Laterally, cystic ductQ

• • Superiorly, inferior surface of liverQ
• • Medially, common hepatic ductQ
• • Laterally, cystic ductQ

Hilar structure dissection occurs first followed by the removal of gallbladder in the triangle of Callot’sQ.

• Separates GB from the liver before the cystic duct and artery are ligatedQ
• Considered safer because it allows for the progressive demonstration of the anatomy down to the infundibulocystic junctionQ.

Expectant management Q

• Bile acids can induce hyperproliferation of the intestinal mucosaQ
• Cholecystectomy, which alters the enterohepatic cycle of bile acids, has been associated with a moderately increased risk of proximal colon cancersQ, dietary fat, fiber, or calciumQ neutralize their carcinogenic effect.

More fulminant course - Gangrene, empyema, or perforationQ

More fulminant course - GB stasis and ischemiaQ – detoriate rapidly

Inflammatory disease characterized by a focal or diffuse destructive inflammatory process with lipid-laden macrophagesQ

• • Inflammatory response to extravasated bile, possibly from ruptured Rokitansky-Aschoff sinusesQ.
• • Presence of hypoechoic nodules or bands in thickened GB wallQ together with calculi (cholesterol or mixed gallstones) in patient of chronic disease.
• • There is extension of yellow tissue into adjacent organs, fistulaes from GB to skin or duodenum may develop, may be mistaken for cancerQ.

Thickening of GB wall, sometimes presence of hypoattenuated bandsQ.

Acute cholecystitis - ischemia or gangrene of GB wall - infection by gas producing organismsQ, occurs more frequently in elderly men and patients with DMQ.

• • Anaerobes: Cl. welchii or Cl. perfringens (MC) Q
• • Aerobes: E. coliQ

• Type I - Obstruction of common duct by external compression only (no erosion) Q
• Type II - Erosion of less than one-third circumference of common ductQ
• Type III - Erosion of up to two-third circumference of common ductQ
• Type IV - Total/near total circumferential destruction of common ductQ
• Type V - Erosion of GB in common duct with cholecystoenteric fistula

• Type I - Partial cholecystectomyQ
• Type II and Type III - Partial cholecystectomy leaving behind a cuff of gallbladder for reconstruction of bile duct (choledochoplasty) with T-tube drainageQ
• Type IV and V - Bilioenteric anastomosisQ

• AcquiredQ histologic abnormality of the gallbladder epithelium that results in an excessive accumulation of lipid (cholesterols esters and triglyceride)Q within epithelial macrophage of the GB wall.
• Cholesterol stones are found in half of the casesQ.