gallbladder disorder

Gallbladder disorder
The gallbladder stores and concentrates bile produced by the liver. The hormone cholecystokinin, secreted by the small intestine, stimulates contraction of the gallbladder and relaxation of the sphincter of Oddi for delivery of bile into the small intestine. Bile aids function in fat emulsification (breakdown); absorption of fatty acids, cholesterol, and other lipids from the small intestine; and excretion of conjugated bilirubin from the liver.Cholelithiasis is the presence of stones in the gallbladder. Cholecystitis is inflammation of the gallbladder (may be acute or chronic). Choledocholithiasis is the presence of stones in the common bile duct.
Pathophysiology /Etiology:
A. Cholelithiasis
1- Stones occur when cholesterol supersaturates the bile in the gallbladder and precipitates out of the bile. The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant, producing inflammatory changes in the gallbladder.
2- .Pigment stones occur when free bilirubin combines with calcium.
• Found in patients with cirrhosis, hemolysis, and infections in the biliary tree.
• These stones cannot be dissolved.
• Incidence of stone formation increases with age due to increased hepatic secretion of cholesterol and decreased bile acid synthesis.
• Increased risk in patients with malabsorption of bile salts with GI disease, carcinoma of the gallbladder,
• Stone formation increases in users of contraceptives, estrogens, and cholesterol-lowering drugs, which are known to increase biliary cholesterol saturation
B – Cholecystitis
• Acute cholecystitis is an acute infection of the gallbladder.
• Most cases are caused by gallstone obstruction of the cystic duct, causing edema, inflammation, and bacterial invasion. This is called calculous cholecystitis.
• Acalculous cholecystitis is acute gallbladder inflammation in the absence of obstruction by gallstones.( Occurs after major surgical procedures, severe trauma, or burns.)
• Chronic cholecystitis occurs when the gallbladder becomes thickened, rigid, and fibrotic and functions poorly.( Results from repeated attacks of cholecystitis, presence of calculi,)

Clinical Manifestations
1- Biliary colic can be caused by the presence of gallstones.
• Steady, severe aching pain or sensation of pressure in the epigastrium or right upper quadrant, which may radiate to the right scapular area or right shoulder.
• Begins suddenly and persists for 1 to 3 hours until the stone falls back into the gallbladder or is passed through the cystic duct.
2- Acute cholecystitis causes biliary colic pain that persists more than 4 hours and increases with movement, including respirations.
• Also causes nausea and vomiting, low-grade fever, and jaundice (with stones or inflammation in the common bile duct).
• Right upper quadrant guarding and Murphy’s sign (inability to take a deep inspiration when examiner’s fingers are pressed below the hepatic margin) are present.
Management
• Supportive management includes: rest, IV fluids, pain management, and antibiotics (in the presence of a positive culture).
• Surgical management:
- Cholecystectomy, open or laparoscopic.
- Placement of a T-tube in the common bile duct to decompress the biliary tree and allow access into the biliary tree postoperatively.
- Intracorporeal lithotripsy is used to fragment stones in the gallbladder or common bile duct by ultrasound, pulsed laser, or hydraulic lithotripsy applied through an endoscope directly to the stones. The stone fragments are removed by irrigation and aspiration. A cholecystectomy may then be performed.
Cholecystectomy is the surgical removal of the gallbladder for acute and chronic cholecystitis.done through open laparotomy (gallbladder removed after making an abdominal incision) or laparoscopy (gallbladder removed from a small opening just above the umbilicus by the use of a laparoscope for viewing). During laparoscopy, three other small punctures are made in the abdomen to place other special instruments used to assist in removal and manipulation of the gallbladder. The organs in the abdomen can be viewed through the laparoscope as well as on a television monitor through a camera attached to the laparoscope.
Complications
• Necrosis, emphysema, or perforation of the gallbladder
• Adenocarcinoma of the gallbladder

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