Gallbladder - Hogan

Question 1

Compare and contrast the three anatomical components of the gallbladder and their compositions.

Answer 1

Fundus - Rounded edge, contains mostly smooth muscle.

Corpus - Main storage area, contains mostly elastic tissue.

Neck - Funnel-shaped, deep in Hartmann’s Pouch.

Question 2

What signals increase (or decrease) bile secretion from the liver?

How much is made per day? How much of that is stored in the gallbladder?

Answer 2

Vagal stimulation and secretin increase bile production, while splanchnic stimulation decreases it.

0.5-1L. The gallbladder stores less than 100mL under normal conditions of fasting. (bear in mind bile production increases in feeding, much of the 1L is on-demand)

Question 3

As bile is concentrated in the liver, what happens to the relative concentrations of bile, sodium, chloride, and bicarbonate?

Answer 3

Bile increases

Sodium increases

Chloride decreases

Bicarbonate decreases

(no idea how these can be reconciled with a net absorption of water, sodium and chloride)

Question 4

If the gallbladder communicates with the biliary tree and not the liver directly, how is the gallbladder filled?

When and how is the gallbladder emptied?

Answer 4

Tonic contractions of the sphincter of oddi create positive pressure that drive bile into the gallbladder.

In feeding, CCK causes fairly rapid (30-40min) emptying by contraction of the gallbladder. This is coordinated with opening of the sphincter of Oddi by CCK and MMCs.

Question 5

Where are bile acids reabsorbed?

Answer 5

95% in the terminal ileum, 5% in the colon.

Question 6

Describe the innervation of the gallbladder.

What is the functional significance of this?

Answer 6

Sympathetic innervation via the celiac plexus (T8, T9).

As this is a common site of pain referral, gallbladder tract pain cannot be easily isolated.

Question 7

What is the most common gastrointestinal disorder in the US?

Answer 7

Gallstones.

Question 8

Compare the composition and formation of cholesterol and pigmented stones.

Answer 8

Cholesterol: Formed from cholesterol hypersecretion or inadequate bile acids, phospholipids. Needs a nucleation site and usually low gallbladder motility.

Pigmented: Unconjugated bilirubin deposition.

Question 9

Describe the epidemiology of gallstones–who gets them?

Answer 9

The four Fs: Fat, female, forty and fertile.

Caucasian and native american prevalences.

Question 10

Why do gastric bypass patients usually have cholecystectomies?

Answer 10

Gallstones occur often in people with rapid weight loss. May as well get it while you’re in there…

Question 11

What is biliary sludge, and when does it form?

Answer 11

Biliary sudge is a mixture of calcium bilirubinate and cholesterol crystals in the gallbladder which is prone to stone formation.

Seen in chronic cirrhotic diseases, hemolysis, crohn’s…and with drugs like ceftriaxone/octreotide/thiazides.

Question 12

Describe the clinical presentation of someone with cholecystitis.

What is it probably caused by?

Answer 12

RUQ pain, fever & leukocytosis. Lies still (positive Murphy’s sign). Normal LFTs.

Mostly stones, but sometimes stenosis.

Question 13

How are ultrasonography and cholescintigraphy used to diagnose stones?

Answer 13

Ultrasonography can visualize the stones or gallbladder thickening & edema.

Cholescintigraphy uses a radiolabeled metabolite that is secreted into bile to visualize patency.

Question 14

What is Charcot’s triad, and what is it classic for?

Answer 14

Fever + Jaundice + RUQ pain.

Featured in acute cholecystitis (probably more accurately cholangitis because of the jaundice).

Question 15

What organisms are often found in cultures in cholangitis?

Answer 15

E. Coli, Klebsiella, Enterobacteria and Enterococci.

Question 16

How does suppurative cholangitis compare to a less severe cholangitis?

Answer 16

Confusion and hypotension (septic shock, can result in organ failure and death).

Question 17

Besides transabdominal ultrasonography, how can acute cholangitis be imaged/diagnosed?

Answer 17

Imaging with MRCP or ERCP (ERCP can also be used to immediately clear a blockage)

Question 18

Acalculous cholecystitis occurs in __% of acute cholecystites. It is (severe/benign).

Primary sclerosing cholangitis has what other major association?

Answer 18

10%, very severe.

Most PSC patients have ulcerative colitis.

Question 19

Many cholecystectomies are unnecessary. Why is it hard to tell when it may not be necessary?

Answer 19

The clues to the severity of gallbladder disease are often obscured or difficult to find. For example, abdominal pain is nonspecific and can be hard to distinguish from many other referred pains.

Question 20

T/F:

1. Biliary pain is generally made worse with eating meals.
2. Nocturnal pain episodes are a classic feature.
3. GI symptoms like bloating & heartburn can indicate gallbladder disease.
4. Biliary pain is not associated with defecation.

Answer 20

1. False
2. True

3 False

4. True

Question 21

Distinguish the four groups of gallbladder disorders.

Who should definitely get cholecystectomy?

Answer 21

Type 1: Typical symptoms, gallstones (*surgery indicated*)

Type 2: Atypical symptoms, gallstones

Type 3: No symptoms, gallstones

Type 4: Typical symptoms, NO STONES

Question 22

How does group IV gallbladder disease experience symptoms?

What test is indicated here?

Answer 22

Biliary dyskinesia can result in pain from the same irritating factors as seen in gallstones.

GBEF (gallbladder ejection fraction)

Question 23

Describe what a GBEF entails.

What is an abnormal result?

Answer 23

Measurement of gallbladder ejection with an IV infusion of CCK to promote contraction.

GBEF < 40%