Gallbladder

In vertebrates, the gallbladder is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although the structure and position of the gallbladder can vary significantly among animal species. It receives and stores bile, produced by the liver, via the common hepatic duct and releases it via the common bile duct into the duodenum, where the bile helps in the digestion of fats.

The gallbladder can be affected by gallstones, formed by material that cannot be dissolved – usually cholesterol or bilirubin, a product of haemoglobin breakdown. These may cause significant pain, particularly in the upper-right corner of the abdomen, and are often treated with removal of the gallbladder called a cholecystectomy. Cholecystitis, inflammation of the gallbladder, has a wide range of causes, including result from the impaction of gallstones, infection, and autoimmune disease.

Gallbladder
Gallbladder (organ)
2425 Gallbladder
The gallbladder sits beneath the liver.
Details
PrecursorForegut
SystemDigestive system
ArteryCystic artery
VeinCystic vein
NerveCeliac ganglia, Vagus nerve[1]
Identifiers
LatinVesica biliaris, vesica fellea
MeSHD005704
TAA05.8.02.001
FMA7202
Anatomical terminology

Structure

The gallbladder is a hollow organ that sits in a shallow depression below the right lobe of the liver, that is grey-blue in life.[2] In adults, the gallbladder measures approximately 7 to 10 centimetres (2.8 to 3.9 inches) in length and 4 centimetres (1.6 in) in diameter when fully distended.[3] The gallbladder has a capacity of about 50 millilitres (1.8 imperial fluid ounces).[2]

The gallbladder is shaped like a pear, with its tip opening into the cystic duct.[4] The gallbladder is divided into three sections: the fundus, body, and neck. The fundus is the rounded base, angled so that it faces the abdominal wall. The body lies in a depression in the surface of the lower liver. The neck tapers and is continuous with the cystic duct, part of the biliary tree.[2] The gallbladder fossa, against which the fundus and body of the gallbladder lie, is found beneath the junction of hepatic segments IVB and V.[5] The cystic duct unites with the common hepatic duct to become the common bile duct. At the junction of the neck of the gallbladder and the cystic duct, there is an out-pouching of the gallbladder wall forming a mucosal fold known as "Hartmann's pouch".[2]

Microanatomy

Gallbladder - intermed mag
Micrograph of a normal gallbladder wall. H&E stain.

The gallbladder wall is composed of a number of layers. The gallbladder wall's innermost surface is lined by a single layer of columnar cells with a brush border of microvilli, very similar to intestinal absorptive cells.[2] Underneath the epithelium is an underlying lamina propria, a muscular layer, an outer perimuscular layer and serosa. Unlike elsewhere in the intestinal tract, the gallbladder does not have a muscularis mucosae, and the muscular fibres are not arranged in distinct layers.[6]

The mucosa, the inner portion of the gallbladder wall, consists of a lining of a single layer of columnar cells, with cells possessing small hair-like attachments called microvilli.[2] This sits on a thin layer of connective tissue, the lamina propria.[6] The mucosa is curved and collected into tiny outpouchings called rugae.[2]

A muscular layer sits beneath the mucosa. This is formed by smooth muscle, with fibres that lie in longitudinal, oblique and transverse directions, and are not arranged in separate layers. The muscle fibres here contract to expel bile from the gallbladder.[6] A distinctive feature of the gallbladder is the presence of Rokitansky–Aschoff sinuses, deep outpouchings of the mucosa that can extend through the muscular layer, and which indicate adenomyomatosis.[7] The muscular layer is surrounded by a layer of connective and fat tissue.[2]

The outer layer of the fundus of gallbladder, and the surfaces not in contact with the liver, are covered by a thick serosa, which is exposed to the peritoneum.[2] The serosa contains blood vessels and lymphatics.[6] The surfaces in contact with the liver are covered in connective tissue.[2]

Variation

The gallbladder varies in size, shape, and position between different people.[2] Rarely, two or even three gallbladders may coexist, either as separate bladders draining into the cystic duct, or sharing a common branch that drains into the cystic duct. Additionally, the gallbladder may fail to form at all. Gallbladders with two lobes separated by a septum may also exist. These abnormalities are not likely to affect function and are generally asymptomatic.[8]

The location of the gallbladder in relation to the liver may also vary, with documented variants including gallbladders found within,[9] above, on the left side of, behind, and detached or suspended from the liver. Such variants are very rare: from 1886 to 1998, only 110 cases of left-lying liver, or less than one per year, were reported in scientific literature.[10][11][2]

An anatomical variation can occur, known as a Phrygian cap, which is an innocuous fold in the fundus, named after its resemblance to the Phrygian cap.[12]

Development

The gallbladder develops from an endodermal outpouching of the embryonic gut tube.[13] Early in development, the human embryo has three germ layers and abuts an embryonic yolk sac. During the second week of embryogenesis, as the embryo grows, it begins to surround and envelop portions of this sac. The enveloped portions form the basis for the adult gastrointestinal tract. Sections of this foregut begin to differentiate into the organs of the gastrointestinal tract, such as the esophagus, stomach, and intestines.[13]

During the fourth week of embryological development, the stomach rotates. The stomach, originally lying in the midline of the embryo, rotates so that its body is on the left. This rotation also affects the part of the gastrointestinal tube immediately below the stomach, which will go on to become the duodenum. By the end of the fourth week, the developing duodenum begins to spout a small outpouching on its right side, the hepatic diverticulum, which will go on to become the biliary tree. Just below this is a second outpouching, known as the cystic diverticulum, that will eventually develop into the gallbladder.[13]

Function

Biliary system multilingual
1. Bile ducts: 2. Intrahepatic bile ducts, 3. Left and right hepatic ducts, 4. Common hepatic duct, 5. Cystic duct, 6. Common bile duct, 7. Ampulla of Vater, 8. Major duodenal papilla
9. Gallbladder, 10–11. Right and left lobes of liver. 12. Spleen.
13. Esophagus. 14. Stomach. 15. Pancreas: 16. Accessory pancreatic duct, 17. Pancreatic duct.
18. Small intestine: 19. Duodenum, 20. Jejunum
21–22. Right and left kidneys.
The front border of the liver has been lifted up (brown arrow).[14]

The main purpose of the gallbladder is to store bile, also called gall, needed for the digestion of fats in food. Produced by the liver, bile flows through small vessels into the larger hepatic ducts and ultimately through the cystic duct (parts of the biliary tree) into the gallbladder, where it is stored. At any one time, 30 to 60 millilitres (1.0 to 2.0 US fl oz) of bile is stored within the gallbladder.[15]

When food containing fat enters the digestive tract, it stimulates the secretion of cholecystokinin (CCK) from I cells of the duodenum and jejunum. In response to cholecystokinin, the gallbladder rhythmically contracts and releases its contents into the common bile duct, eventually draining into the duodenum. The bile emulsifies fats in partly digested food, thereby assisting their absorption. Bile consists primarily of water and bile salts, and also acts as a means of eliminating bilirubin, a product of hemoglobin metabolism, from the body.[15]

The bile that is secreted by the liver and stored in the gallbladder is not the same as the bile that is secreted by the gallbladder. During gallbladder storage of bile, it is concentrated 3-10 fold[16] by removal of some water and electrolytes. This is through the active transport of sodium and chloride ions[17] across the epithelium of the gallbladder, which creates an osmotic pressure that also causes water and other electrolytes to be reabsorbed.[15]

Clinical significance

Gallstones

Gallstones form when the bile is saturated, usually with either cholesterol or bilirubin.[18] Most gallstones do not cause symptoms, with stones either remaining in the gallbladder or passed along the biliary system.[19] When symptoms occur, severe "colicky" pain in the upper right part of the abdomen is often felt.[18] If the stone blocks the gallbladder, inflammation known as cholecystitis may result. If the stone lodges in the biliary system, jaundice may occur; and if the stone blocks the pancreatic duct, then pancreatitis may occur.[19] Gallstones are diagnosed using ultrasound.[18] When a symptomatic gallstone occurs, it is often managed by waiting for it to be passed naturally.[19] Given the likelihood of recurrent gallstones, surgery to remove the gallbladder is often considered.[19] Some medication, such as ursodeoxycholic acid, may be used; and lithotripsy, a procedure used to break down the stones, may also be used.[19]

Inflammation

Known as cholecystitis, inflammation of the gallbladder is commonly caused by obstruction of the duct with gallstones, which is known as cholelithiasis. Blocked bile accumulates, and pressure on the gallbladder wall, may lead to the release of substances that cause inflammation, such as phospholipase. There is also the risk of bacterial infection. An inflamed gallbladder is likely to cause pain and fever, and tenderness in the upper, right corner of the abdomen, and may have a positive Murphy's sign. Cholecystitis is often managed with rest and antibiotics, particularly cephalosporins and, in severe cases, metronidazole.[19]

Gallbladder removal

A cholecystectomy is a procedure in which the gallbladder is removed. It may be removed because of recurrent gallstones, and is considered an elective procedure. A cholecystectomy may be an open procedure, or one conducted by laparoscopy. In the surgery, the gallbladder is removed from the neck to the fundus,[20] and so bile will drain directly from the liver into the biliary tree. About 30 percent of patients may experience some degree of indigestion following the procedure, although severe complications are much rarer.[19] About 10 percent of surgeries lead to a chronic condition of postcholecystectomy syndrome.[21]

Cancer

Cancer of the gallbladder is uncommon and mostly occurs in later life. When cancer occurs, it is mostly of the glands lining the surface of the gallbladder (adenocarcinoma).[19] Gallstones are thought to be linked to the formation of cancer, and other risk factors include large (>1 cm) gallbladder polyps and having a highly calcified "porcelain" gallbladder.[19]

Cancer of the gallbladder can cause attacks of biliary pain, yellowing of the skin (jaundice), and weight loss. A large gallbladder may be able to be felt in the abdomen. Liver function tests may be elevated, particularly involving GGT and ALP, with ultrasound and CT scans being considered medical imaging investigations of choice.[19] Cancer of the gallbladder is managed by removing the gallbladder, however As of 2010 the prognosis remains poor.[19]

Cancer of the gallbladder may also be found incidentally after surgical removal of the gallbladder, with 1-3% of cancers identified in this way. Gallbladder polyps are mostly benign growths or lesions resembling growths that form in the gallbladder wall[22] and are only associated with cancer when they are larger in size (>1 cm).[19] Cholesterol polyps, often associated with cholesterolosis ("strawberry gallbladder", a change in the gallbladder wall due to excess cholesterol[23]), often cause no symptoms and are thus often detected in this way.[19]

Tests

Ultrasound image of gallbladder stone Gallstone 091937515
An ultrasound showing the gallbladder (central dark area) with a large gallstone (white circular area found near the middle).

Tests used to investigate for gallbladder disease include blood tests and medical imaging. A full blood count may reveal an increased white cell count suggestive of inflammation or infection. Tests such as bilirubin and liver function tests may reveal if there is inflammation linked to the biliary tree or gallbladder, and whether this is associated with inflammation of the liver, and a lipase or amylase may be elevated if there is pancreatitis. Bilirubin may rise when there is obstruction of the flow of bile. A CA 19-9 level may be taken to investigate for cholangiocarcinoma.[19]

Ultrasound is often the first medical imaging test performed when gallbladder disease such as gallstones are suspected.[19] An abdominal X-ray or CT scan is another form of imaging that may be used to examine the gallbladder and surrounding organs.[19] Other imaging options include MRCP (magnetic resonance cholangiopancreatography), ERCP and percutaneous or intraoperative cholangiography.[19] A cholescintigraphy scan is a nuclear imaging procedure used to assess the condition of the gallbladder.[24]

Society and culture

To have 'gall' is associated with bold behaviour, whereas to have 'bile' is associated with bitterness.[25]

In the Chinese language, the gallbladder (Chinese: ) is associated with courage and a myriad of related idioms, including using terms such as "a body completely [of] gall" (Chinese: 渾身是膽) to describe a brave person, and "single gallbladder hero" (Chinese: 孤膽英雄) to describe a lone hero.[26]

In the Zangfu theory of Chinese medicine, the gallbladder not only has a digestive role, but is seen as the seat of decision-making.[26]

Other animals

Most vertebrates have gallbladders, but the form and arrangement of the bile ducts may vary considerably. In many species, for example, there are several separate ducts running to the intestine, rather than the single common bile duct found in humans. Several species of mammals (including horses, deer, rats, and laminoids),[27][28] several species of birds, lampreys and all invertebrates lack a gallbladder altogether.[29]

The bile from several species of bears is used in traditional Chinese medicine; bile bears are kept alive in captivity while their bile is painfully extracted, in an industry characterized by animal cruelty.[30][31]

History

Depictions of the gallbladder and biliary tree are found in Babylonian models found from 2000 BCE, and in ancient Etruscan model from 200 BCE, with models associated with divine worship.[32]

Diseases of the gallbladder have affected humans since antiquity, with gallstones found in the mummy of Princess Amenen of Thebes dating to 1500 BCE.[32][33] Some historians believe the death of Alexander the Great may have been associated with an acute episode of cholecystitis.[32] The existence of the gallbladder has been noted since the 5th century, but it is only relatively recently that the function and the diseases of the gallbladder has been documented,[33] particularly in the last two centuries.[32]

The first descriptions of gallstones appear to have been in the Renaissance, perhaps because of the low incidence of gallstones in earlier times owing to a diet with more cereals and vegetables, and less meat.[34] Anthonius Benevinius in 1506 was the first to draw a connection between symptoms and the presence of gallstones.[34] Courvoisier after examining a number of cases in 1890 that gave rise to the eponymous Courvoisier's law stating that in an enlarged, nontender gallbladder, the cause of jaundice is unlikely to be gallstones.[32]

The first surgical removal of a gallstone (cholecystolithotomy) was in 1676 by physician Joenisius, who removed the stones from a spontaneously occurring biliary fistula.[32] Stough Hobbs in 1867 performed the first recorded cholecystotomy,[34] although such an operation was in fact described earlier by French surgeon Jean Louis Petit in the mid eighteenth century.[32] German surgeon Carl Langenbuch performed the first cholecystectomy in 1882 for a sufferer of cholelithiasis.[33] Before this, surgery had focused on creating a fistula for drainage of gallstones.[32] Langenbuch reasoned that given several other species of mammal have no gallbladder, humans could survive without one.[32]

The debate whether surgical removal of the gallbladder or simply gallstones was preferred was settled in the 1920s, with consensus that removal of the gallbladder was preferred.[33] It was only in the mid and late parts of the twentieth century that medical imaging techniques such as use of contrast medium and CT scans were used to view the gallbladder.[32] The first laparoscopic cholecystectomy performed by Erich Mühe of Germany in 1985, although French surgeons Phillipe Mouret and Francois Dubois are often credited for their operations in 1987 and 1988 respectively.[35]

See also

References

  1. ^ Ginsburg, Ph.D., J.N. (August 22, 2005). "Control of Gastrointestinal Function". In Thomas M. Nosek, Ph.D. Gastrointestinal Physiology. Essentials of Human Physiology. Augusta, Georgia, United State: Medical College of Georgia. pp. p. 30. Archived from the original on April 1, 2008. Retrieved June 29, 2007.
  2. ^ a b c d e f g h i j k l Gray's Anatomy 2008, p. 1187-81.
  3. ^ Jon W. Meilstrup (1994). Imaging Atlas of the Normal Gallbladder and Its Variants. Boca Raton: CRC Press. p. 4. ISBN 978-0-8493-4788-7.
  4. ^ Nagral, Sanjay (2005). "Anatomy relevant to cholecystectomy". Journal of Minimal Access Surgery. 1 (2): 53–8. doi:10.4103/0972-9941.16527. PMC 3004105. PMID 21206646.
  5. ^ Shakelford's Surgery of Alimentary Tract, ed.7. 2013
  6. ^ a b c d Young, Barbara; et al. (2006). Wheater's functional histology: a text and colour atlas (5th ed.). [Edinburgh?]: Churchill Livingstone/Elsevier. p. 298. ISBN 978-0-443-06850-8.
  7. ^ Ross, M.; Pawlina, W. (2011). Histology: A Text and Atlas (6th ed.). Lippincott Williams & Wilkins. p. 646. ISBN 978-0-7817-7200-6.
  8. ^ Leeuw, Th.G.; Verbeek, P.C.M.; Rauws, E.A.J.; Gouma, D.J. (September 1995). "A double or bilobar gallbladder as a cause of severe complications after (laparoscopic) cholecystectomy". Surgical Endoscopy. 9 (9): 998–1000. doi:10.1007/BF00188459. PMID 7482221.
  9. ^ Segura-Sampedro, JJ; Navarro-Sánchez, A; Ashrafian, H; Martínez-Isla, A (February 2015). "Laparoscopic approach to the intrahepatic gallbladder. A case report". Revista Espanola de Enfermedades Digestivas : Organo Oficial de la Sociedad Espanola de Patologia Digestiva. 107 (2): 122–3. PMID 25659400. Archived from the original on March 4, 2016.
  10. ^ Dhulkotia, A; Kumar, S; Kabra, V; Shukla, HS (March 1, 2002). "Aberrant gallbladder situated beneath the left lobe of liver". HPB. 4 (1): 39–42. doi:10.1080/136518202753598726. PMC 2023911. PMID 18333151.
  11. ^ Naganuma, S.; Ishida, H.; Konno, K.; Hamashima, Y.; Hoshino, T.; Naganuma, H.; Komatsuda, T.; Ohyama, Y.; Yamada, N.; Ishida, J.; Masamune, O. (March 6, 2014). "Sonographic findings of anomalous position of the gallbladder". Abdominal Imaging. 23 (1): 67–72. doi:10.1007/s002619900287. PMID 9437066.
  12. ^ Meilstrup JW; Hopper KD; Thieme GA (December 1991). "Imaging of gallbladder variants". AJR Am J Roentgenol. 157 (6): 1205–8. doi:10.2214/ajr.157.6.1950867. PMID 1950867.
  13. ^ a b c Gary C. Schoenwolf; et al. (2009). Larsen's human embryology (Thoroughly rev. and updated 4th ed.). Philadelphia: Churchill Livingstone/Elsevier. pp. "Development of the Gastrointestinal Tract". ISBN 978-0-443-06811-9.
  14. ^ Standring S, Borley NR, eds. (2008). Gray's anatomy : the anatomical basis of clinical practice. Brown JL, Moore LA (40th ed.). London: Churchill Livingstone. pp. 1163, 1177, 1185–6. ISBN 978-0-8089-2371-8.
  15. ^ a b c Hall, Arthur C. Guyton, John E. (2005). Textbook of medical physiology (11th ed.). Philadelphia: W.B. Saunders. pp. 802–804. ISBN 978-0-7216-0240-0.
  16. ^ KO, CYNTHIA (2005). "Biliary Sludge Is Formed by Modification of Hepatic Bile by the Gallbladder Mucosa". CLINICAL GASTROENTEROLOGY AND HEPATOLOGY.
  17. ^ Meyer, G.; Guizzardi, F.; Rodighiero, S.; Manfredi, R.; Saino, S.; Sironi, C.; Garavaglia, M. L.; Bazzini, C.; Bottà, G. (June 2005). "Ion transport across the gallbladder epithelium". Current Drug Targets. Immune, Endocrine and Metabolic Disorders. 5 (2): 143–151. ISSN 1568-0088. PMID 16089346.
  18. ^ a b c "Cholelithiasis - Hepatic and Biliary Disorders - MSD Manual Professional Edition". MSD Manual Professional Edition. Retrieved 18 October 2017.
  19. ^ a b c d e f g h i j k l m n o p q Britton, the editors Nicki R. Colledge, Brian R. Walker, Stuart H. Ralston; illustrated by Robert (2010). Davidson's principles and practice of medicine (21st ed.). Edinburgh: Churchill Livingstone/Elsevier. pp. 977–984. ISBN 978-0-7020-3085-7.
  20. ^ Neri V; Ambrosi A; Fersini A; Tartaglia N; Valentino TP (2007). "Antegrade dissection in laparoscopic cholecystectomy". Journal of the Society of Laparoendoscopic Surgeons. 11 (2): 225–8. PMC 3015719. PMID 17761085.
  21. ^ nhs.uk, Complications of a gallbladder removal
  22. ^ "Gallbladder Polyps". MayoClinic. Retrieved March 19, 2015.
  23. ^ Strawberry gallbladder – cancerweb.ncl.ac.uk.
  24. ^ "HIDA scan - Overview". Mayo Clinic. Retrieved 18 October 2017.
  25. ^ J. A. Simpson (1989). The Oxford English dictionary (2nd ed.). Oxford: Clarendon Press. gall, bile. ISBN 978-0-19-861186-8.
  26. ^ a b Yu, Ning (January 1, 2003). "Metaphor, Body, and Culture: The Chinese Understanding of Gallbladder and Courage". Metaphor and Symbol. 18 (1): 13–31. doi:10.1207/S15327868MS1801_2.
  27. ^ C. Michael Hogan. 2008. Guanaco: Lama guanicoe, GlobalTwitcher.com, ed. N. Strömberg Archived March 4, 2011, at the Wayback Machine
  28. ^ Higashiyama, H; Sumitomo, H; Ozawa, A; Igarashi, H; Tsunekawa, N; Kurohmaru, M; Kanai, Y (2016). "Anatomy of the Murine Hepatobiliary System: A Whole-Organ-Level Analysis Using a Transparency Method". The Anatomical Record. 299 (2): 161–172. doi:10.1002/ar.23287. PMID 26559382.
  29. ^ Romer, Alfred Sherwood; Parsons, Thomas S. (1977). The Vertebrate Body. Philadelphia, PA: Holt-Saunders International. p. 355. ISBN 978-0-03-910284-5.
  30. ^ Actman, Jani (5 May 2016). "Inside the Disturbing World of Bear-Bile Farming". National Geographic. Retrieved 23 October 2017.
  31. ^ Hance, Jeremy (9 April 2015). "Is the end of 'house of horror' bear bile factories in sight?". The Guardian. Retrieved 23 October 2017.
  32. ^ a b c d e f g h i j Eachempati, Soumitra R.; II, R. Lawrence Reed (2015). Acute Cholecystitis. Springer. pp. 1–16. ISBN 9783319148243.
  33. ^ a b c d Jarnagin, William R. (2012). Blumgart's Surgery of the Liver, Pancreas and Biliary Tract E-Book: Expert Consult - Online. Elsevier Health Sciences. p. 511. ISBN 978-1455746064.
  34. ^ a b c Bateson, M. C. (2012). Gallstone Disease and its Management. Springer Science & Business Media. pp. 1–2. ISBN 9789400941731.
  35. ^ Reynolds, Walker (January–March 2001). "The First Laparoscopic Cholecystectomy". Journal of the Society of Laparoendoscopic Surgeons. 5 (1): 89–94. PMC 3015420. PMID 11304004.
Books
  • Standring S, Borley NR, eds. (2008). Gray's anatomy : the anatomical basis of clinical practice. Brown JL, Moore LA (40th ed.). London: Churchill Livingstone. ISBN 978-0-8089-2371-8.

External links

Abdominopelvic cavity

The abdominopelvic cavity is a body cavity that consists of the abdominal cavity and the pelvic cavity. It contains the stomach, liver, pancreas, spleen, gallbladder, kidneys, and most of the small and large intestines. It also contains the urinary bladder and internal reproductive organs.

Adenomyomatosis

Adenomyomatosis is a benign condition characterized by hyperplastic changes of unknown cause involving the wall of the gallbladder. Adenomyomatosis is caused by an overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky–Aschoff sinuses, also called entrapped epithelial crypts.

Bile

Bile or gall is a dark green to yellowish brown fluid, produced by the liver of most vertebrates, that aids the digestion of lipids in the small intestine. In humans, bile is produced continuously by the liver (liver bile), and stored and concentrated in the gallbladder. After eating, this stored bile is discharged into the duodenum. The composition of hepatic bile is 97% water, 0.7% bile salts, 0.2% bilirubin, 0.51% fats (cholesterol, fatty acids, and lecithin), and 200 meq/l inorganic salts.About 400 to 800 ml of bile is produced per day in adult human beings..

Biliary dyskinesia

Biliary dyskinesia is a disorder of some component of biliary part of the digestive system in which bile physically can not move normally in the proper direction through the tubular biliary tract. It most commonly involves abnormal biliary tract peristalsis muscular coordination within the gallbladder in response to dietary stimulation of that organ to squirt the liquid bile through the common bile duct into the duodenum. Ineffective peristaltic contraction of that structure produces postprandial (after meals) right upper abdominal pain (cholecystodynia) and almost no other problem. When the dyskinesia is localized at the biliary outlet into the duodenum just as increased tonus of that outlet sphincter of Oddi, the backed-up bile can cause pancreatic injury with abdominal pain more toward the upper left side. In general, biliary dyskinesia is the disturbance in the coordination of peristaltic contraction of the biliary ducts, and/or reduction in the speed of emptying of the biliary tree into the duodenum.

Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, using a video camera, or via an open surgical technique.The surgery is usually successful in relieving symptoms, but up to 10% of people may continue to experience similar symptoms after cholecystectomy, a condition called postcholecystectomy syndrome. Complications of cholecystectomy include bile duct injury, wound infection, bleeding, retained gallstones, abscess formation and stenosis (narrowing) of the bile duct.

Cholecystitis

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.More than 90% of the time acute cholecystitis is from blockage of the cystic duct by a gallstone. Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity, diabetes, liver disease, or rapid weight loss. Occasionally acute cholecystitis occur as a result of vasculitis, chemotherapy, or during recovery from major trauma or burns. Cholecystitis is suspected based on symptoms and laboratory testing. Abdominal ultrasound is then typically used to confirm the diagnosis.Treatment is usually with laparoscopic gallbladder removal, within 24 hours if possible. Taking pictures of the bile ducts during the surgery is recommended. The routine use of antibiotics is controversial. They are recommended if surgery cannot occur in a timely manner or if the case is complicated. Stones in the common bile duct can be removed before surgery by endoscopic retrograde cholangiopancreatography (ERCP) or during surgery. Complications from surgery are rare. In people unable to have surgery, gallbladder drainage may be tried.About 10–15% of adults in the developed world have gallstones. Women more commonly have stones than men and they occur more commonly after age 40. Certain ethnic groups are more often affected; for example, 48% of American Indians have gallstones. Of all people with stones, 1–4% have biliary colic each year. If untreated, about 20% of people with biliary colic develop acute cholecystitis. Once the gallbladder is removed outcomes are generally good. Without treatment, chronic cholecystitis may occur. The word is from Greek, cholecyst- meaning "gallbladder" and -itis meaning "inflammation".

Cholecystography

Oral cholecystography is a radiological procedure used to visualize the gallbladder and biliary channels, developed in 1924 by American surgeons Evarts Ambrose Graham and Warren Henry Cole. It is usually indicated in cases of suspected gallbladder disease, and can also be used to determine or rule out the presence of intermittent obstruction of the bile ducts or recurrent biliary disease after biliary surgery.A radiopaque cholegraphic (contrast) agent, usually iopanoic acid (Telepaque) or its sodium or calcium salt, is orally administered, which is absorbed by the intestine. This excreted material will collect in the gallbladder, where reabsorption of water concentrates the excreted contrast. Since only 10% of gallstones are radiopaque, the remaining 90% will appear as translucent on an opaque background in an abdominal X-ray.

If needed, IV cholecystography and cholangiography may be done.Current medical practice prefers ultrasound and CT over oral cholecystography.

Cholecystostomy

A cholecystostomy or cholecystotomy is a procedure where a stoma is created in the gallbladder, which can facilitate placement of a tube for drainage, first performed by American surgeon, Dr. John Stough Bobbs, in 1867. It is sometimes used in cases of cholecystitis where the person is ill, and there is a need to delay or defer cholecystectomy. The first endoscopic cholecystostomy was performed by Drs. Todd Baron and Mark Topazian in 2007 using ultrasound guidance to puncture the stomach wall and place a plastic biliary catheter for gallbladder drainage.

Cholescintigraphy

Cholescintigraphy or hepatobiliary scintigraphy is scintigraphy of the hepatobiliary tract, including the gallbladder and bile ducts. The image produced by this type of medical imaging, called a cholescintigram, is also known by other names depending on which radiotracer is used, such as HIDA scan, PIPIDA scan, DISIDA scan, or BrIDA scan. Cholescintigraphic scanning is a nuclear medicine procedure to evaluate the health and function of the gallbladder and biliary system. A radioactive tracer is injected through any accessible vein and then allowed to circulate to the liver, where it is excreted into the bile ducts and stored by the gallbladder until released into the duodenum.

In the absence of gallbladder disease, the gallbladder is visualized within 1 hour of the injection of the radioactive tracer. If the gallbladder is not visualized within 4 hours after the injection, this indicates either cholecystitis or cystic duct obstruction, such as by cholelithiasis (gallstone formation). This investigation is usually conducted after an ultrasonographic examination of the abdominal right upper quadrant for a patient presenting with abdominal pain. If the noninvasive ultrasound examination fails to demonstrate gallstones, or other obstruction to the gallbladder or biliary tree, in an attempt to establish a cause of right upper quadrant pain, a cholescintigraphic scan can be performed as a more sensitive and specific test. Cholescintigraphic scans are not generally a first-line form of imaging owing to their increased cost and invasiveness.Cholescintigraphy for acute cholecystitis has sensitivity of 97%, specificity of 94%. Several investigators have found the sensitivity being consistently higher than 90% though specificity has varied from 73–99%, yet compared to ultrasonography, cholescintigraphy has proven to be superior. The scan is also important to differentiate between neonatal hepatitis and biliary atresia, because an early surgical intervention in form of Kasai portoenterostomy or hepatoportoenterostomy can save the life of the baby as the chance of a successful operation after 3 months seriously decreases.

Cholesterolosis of gallbladder

In surgical pathology, strawberry gallbladder, more formally cholesterolosis of the gallbladder and gallbladder cholesterolosis, is a change in the gallbladder wall due to excess cholesterol.The name strawberry gallbladder comes from the typically stippled appearance of the mucosal surface on gross examination, which resembles a strawberry. Cholesterolosis results from abnormal deposits of cholesterol esters in macrophages within the lamina propria (foam cells) and in mucosal epithelium. The gallbladder may be affected in a patchy localized form or in a diffuse form. The diffuse form macroscopically appears as a bright red mucosa with yellow mottling (due to lipid), hence the term strawberry gallbladder.

It is not tied to cholelithiasis (gallstones) or cholecystitis (inflammation of the gallbladder).

Common bile duct

The common bile duct, sometimes abbreviated CBD, is a duct in the gastrointestinal tract of organisms that have a gall bladder. It is formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi.

When the sphincter of Oddi is closed, newly synthesized bile from the liver is forced into storage in the gall bladder. When open, the stored and concentrated bile exits into the duodenum. This conduction of bile is the main function of the common bile duct. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi.

Gallbladder cancer

Gallbladder cancer is a relatively uncommon cancer, with an incidence of fewer than 2 cases per 100,000 people per year in the United States. It is particularly common in central and South America, central and eastern Europe, Japan and northern India; it is also common in certain ethnic groups e.g. Native American Indians and Hispanics. If it is diagnosed early enough, it can be cured by removing the gallbladder, part of the liver and associated lymph nodes. Most often it is found after symptoms such as abdominal pain, jaundice and vomiting occur, and it has spread to other organs such as the liver.

It is a rare cancer that is thought to be related to gallstones building up, which also can lead to calcification of the gallbladder, a condition known as porcelain gallbladder. Porcelain gallbladder is also rare. Some studies indicate that people with porcelain gallbladder have a high risk of developing gallbladder cancer, but other studies question this. The outlook is poor for recovery if the cancer is found after symptoms have started to occur, with a 5-year survival rate close to 3%.

Gallbladder disease

Gallbladder diseases are diseases involving the gallbladder.

Gallstones may develop in the gallbladder as well as elsewhere in the biliary tract. If gallstones in the gallbladder are symptomatic, surgical removal of the gallbladder, known as cholecystectomy may be indicated.

Gallstones form when the tenuous balance of solubility of biliary lipids tips in favor of precipitation of cholesterol, unconjugated bilirubin, or bacterial degradation products of biliary lipids. For cholesterol gallstones, metabolic alterations in hepatic cholesterol secretion combine with changes in gallbladder motility and intestinal bacterial degradation of bile salts to destabilize cholesterol carriers in bile and produce cholesterol crystals. For black pigment gallstones, changes in heme metabolism or bilirubin absorption lead to increased bilirubin concentrations and precipitation of calcium bilirubinate. In contrast, mechanical obstruction of the biliary tract is the major factor leading to bacterial degradation and precipitation of biliary lipids in brown pigment stones.About 104 million new cases of gallbladder and biliary disease occurred in 2013.

Gallstone

A gallstone is a stone formed within the gallbladder out of bile components. The term cholelithiasis may refer to the presence of gallstones or to the diseases caused by gallstones. Most people with gallstones (about 80%) never have symptoms. When a gallstone blocks the bile duct, a cramp-like pain in the right upper part of the abdomen, known as biliary colic (gallbladder attack) can result. This happens in 1–4% of those with gallstones each year. Complications of gallstones may include inflammation of the gallbladder (cholecystitis), inflammation of the pancreas (pancreatitis), jaundice, and infection of a bile duct (cholangitis). Symptoms of these complications may include pain of more than five hours duration, fever, yellowish skin, vomiting, dark urine, and pale stools.Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity, diabetes, liver disease, or rapid weight loss. The bile components that form gallstones include cholesterol, bile salts, and bilirubin. Gallstones formed mainly from cholesterol are termed cholesterol stones, and those mainly from bilirubin are termed pigment stones. Gallstones may be suspected based on symptoms. Diagnosis is then typically confirmed by ultrasound. Complications may be detected on blood tests.The risk of gallstones may be decreased by maintaining a healthy weight through sufficient exercise and eating a healthy diet. If there are no symptoms, treatment is usually not needed. In those who are having gallbladder attacks, surgery to remove the gallbladder is typically recommended. This can be carried out either through several small incisions or through a single larger incision, usually under general anesthesia. In rare cases when surgery is not possible medication may be used to try to dissolve the stones or lithotripsy to break down the stones.In developed countries, 10–15% of adults have gallstones. Rates in many parts of Africa, however, are as low as 3%. Gallbladder and biliary related diseases occurred in about 104 million people (1.6%) in 2013 and they resulted in 106,000 deaths. Women more commonly have stones than men and they occur more commonly after the age of 40. Certain ethnic groups have gallstones more often than others. For example, 48% of Native Americans have gallstones. Once the gallbladder is removed, outcomes are generally good.

Gastrointestinal disease

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

Human digestive system

The human digestive system consists of the gastrointestinal tract plus the accessory organs of digestion (the tongue, salivary glands, pancreas, liver, and gallbladder). Digestion involves the breakdown of food into smaller and smaller components, until they can be absorbed and assimilated into the body. The process of digestion has many stages. The first stage is the cephalic phase of digestion which begins with gastric secretions in response to the sight and smell of food. The next stage starts in the mouth.

Chewing, in which food is mixed with saliva, begins the mechanical process of digestion. This produces a bolus which can be swallowed down the esophagus to enter the stomach. Here it is mixed with gastric acid until it passes into the duodenum where it is mixed with a number of enzymes produced by the pancreas. Saliva also contains a catalytic enzyme called amylase which starts to act on food in the mouth. Another digestive enzyme called lingual lipase is secreted by some of the lingual papillae on the tongue and also from serous glands in the main salivary glands. Digestion is helped by the chewing of food carried out by the muscles of mastication, by the teeth, and also by the contractions of peristalsis, and segmentation. Gastric acid, and the production of mucus in the stomach, are essential for the continuation of digestion.

Peristalsis is the rhythmic contraction of muscles that begins in the esophagus and continues along the wall of the stomach and the rest of the gastrointestinal tract. This initially results in the production of chyme which when fully broken down in the small intestine is absorbed as chyle into the lymphatic system. Most of the digestion of food takes place in the small intestine. Water and some minerals are reabsorbed back into the blood in the colon of the large intestine. The waste products of digestion (feces) are defecated from the anus via the rectum.

Magnetic resonance cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts in a non-invasive manner. This procedure can be used to determine if gallstones are lodged in any of the ducts surrounding the gallbladder.

It was introduced in 1991.

Porcelain gallbladder

Porcelain gallbladder is a calcification of the gallbladder believed to be brought on by excessive gallstones, although the exact cause is not clear. As with gallstone disease in general, this condition occurs predominantly in overweight female patients of middle age. It is a morphological variant of chronic cholecystitis. Inflammatory scarring of the wall, combined with dystrophic calcification within the wall transforms the gallbladder into a porcelain-like vessel. Removal of the gallbladder (cholecystectomy) is the recommended treatment.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts which normally allow bile to drain from the gallbladder. Affected individuals may have no symptoms or may experience signs and symptoms of liver disease such as yellow discoloration of the skin and eyes, itching, and abdominal pain.

The bile duct scarring which occurs in PSC narrows the ducts of the biliary tree and impedes the flow of bile to the intestines. Eventually, it can lead to cirrhosis of the liver and liver failure. PSC increases the risk of various cancers including liver cancer, gallbladder carcinoma, colorectal cancer, and cholangiocarcinoma. The underlying cause of PSC is unknown. Genetic susceptibility, immune system dysfunction, and abnormal composition of the gut flora may play a role. This is further suggested by the observation that approximately 75% of individuals with PSC also have inflammatory bowel disease (IBD), most often ulcerative colitis.There is no effective medical treatment for primary sclerosing cholangitis. The most definitive treatment for PSC is a liver transplant but it can recur after transplantation. Few people affected by PSC require a liver transplant.

PSC is a rare disease and most commonly affects people with IBD. Approximately 3–7.5% of people with ulcerative colitis have PSC and 80% of people with PSC have some form of IBD. Diagnosis usually occurs in younger people in their 30s or 40s. Individuals of Northern European ancestry are affected more often than people of Southern European or Asian descent. Men are affected more often than women. The disease was initially described in the mid-1800s but was not fully characterized until the 1970s with the advent of improved medical imaging techniques such as endoscopic retrograde cholangiopancreatography (ERCP).

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