Question

3. Lower Digestive Tract

(C) Discuss the gallbladder and include one usual abnormal finding

Answer 1

Gall bladder

It is a pear shaped organ present beneath the liver. It is found in the right upper quadrant of the abdomen. It is part of biliary tract.

Anatomy

It has 3 sections :

• Fundus
• Body
• Neck

7-10 cm length and 4 cm diameter if fully distended.
capacity of 50 ml.

Histology

Innermost surface is lined by a layer of columnar cells with microvilli. There are lamina propria, muscular layer, perimuscular layer and serosa.
No muscularis mucosa.

Function

Main function of gall bladder is to store bile. Bile is essential for the digestion of fat in the food. Another function is concentration of bile. It is 3-10 times concentrated inside the gall bladder.

**Some of the common abnormal findings in gall bladder includes :

Cholelithiasis, Acute cholecystitis, Chronic cholecystitits, cholecystoses, gall bladder carcinoma.

Acute cholecystitis

It is Acute bacterial infection of the gall bladder.

Types:

o Calculous cholecystitis - Most common variety.

Caused by gall stones obstructing the outflow of bile or by oedema caused by the stones.

o Acalculous cholecystitis - Seen in patients with severe illnesses, on mechanical ventilators and on prolonged total parenteral nutrition. It occurs due to bile stasis and increased lithogenicity of bile.

o Acute emphysematous cholecystitis - Cause by gas forming organisms like Clostridium. It is a highly fulminant condition and urgent cholecystectomy should be done.

Clinical Presentation:

o Classical description includes a fat fertile female (3Fs) complaining of severe colicky right upper quadrant abdominal pain.

o The pain might radiate to the back or to the right shoulder tip.

o Abdominal tenderness and guarding.

o Murphy's sign-Palpate the edge of the patient's liver and ask the patient to take a deep inspiration.

Press inwards at the same time. This causes the patient to "wince in pain” at the peak of inspiration

o Boas' sign-Hyperaesthesia over the 9-11th ribs posteriorly on the right side.

Investigations:

o Leukocytosis, elevated ESR.

. Plain abdominal X-ray- For radio-opaque stones.

o Ultrasound abdomen.

o HIDA scan - The 99mTc labelled HIDA does not reach the GB due to oedema of the cystic duct wall. This is especially important for acalculous cholecystitis.

Treatment:

o Conservative management.

- Patient is admitted and a nasogastric tube decompression of the stomach is done.

- Analgesia in the form of morphine is provided.

- Patient is kept nil orally and IV fluids are given to maintain hydration.

- Broad spectrum antibiotics are given.

- Patient is scheduled for an elective cholecystectomy 6 weeks later.

o Laparoscopic cholecystectomy

Complications

• Chronic cholecystitis.
• Mucocoele.
• Pyocele.
• Perforation of the GB wall.
• Gangrene of the GB wall.
• GB cancer.
• Mirizzi's syndrome.