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1、Thegallbladder,gallstones,andbeyond….LeslieKobayashi,MDJanuary31,2012AnatomyLiverBileductsPancreasDuodenumTransversecolonAnatomyFundusBodyInfundibulum/NeckCysticductSpiralValvesofHeisterAnatomyTriangleofcalotBorders:CHD,cysticduct,liveredgeContents:Cysticartery,n
2、odeofCalotDuctalAnatomyRightandLeftHepaticductsCommonHepaticductCysticductCommonbileductAberrantanatomyVascularNormally(>90%)cystica.arisesfromRHAReplacedrighthepatica.Replacedlefthepatica.Bile500-1500mLproduceddailyComposition:water,electrolytes,bilesalts,protei
3、ns,lipidsDuctalepitheliumproductsAlkalinephosphataseHCO3HepatocyteproductsBileinconjugatedsolubleformsynthesizedfromcholesterolPrimarilycholateandchenodeoxycholateBile95%ofbilere-absorbedintotheliverviaportalvein(enterohepaticcirculation)85-90%interminalileumviaa
4、ctivetransport10-15%deconjugatedincolon,absorbedpassively5%excretedinstoolCycles6-10xdaily80%ofbilestoredinGBinfastingstateGBFunctionstoreandconcentratebileAbsorption:NaCL,H2OoccursrapidlySecretion:mucus,H+GBaveragecapacity30-50mLCanincreaseto300mLwithobstruction
5、Normalejection50-70%in30-40minSignificanceDogallbladderproblemscreateasignificanthealthcareburden?YES!Healthburden6.2Billion$inUS1.8millionambulatorycarevisitsIncreased20%since1980’sCholecystectomymostcommonelectiveabdominalprocedureintheUS750,000annuallyWhydoest
6、hathappen?StonesTypesofstonesCholesterolstones(75%)FemalefatfertileBlackstones(20%)Hemolyticdiseases(Sicklecelldisease)CirrhosisBrownstones(5%)InfectionPSC*primarilyformintheductsCholesterolstonesLowcalcium,radiolucentCreatedwhenfractionalcholesterolcontentofbile
7、increased,andwithincompleteemptyingofGBAssociatedwithobesity,rapidweightloss,NativeAmerican/Hispanicheritage,↑TG’s,↓HDL,SpinalcordinjuryCholesterolstonesHormonalinfluenceEstrogenincreaseslithogenicityofbileIncreasedriskforfemalesIncreasedriskinobesityProgesterone
8、increasesSMrelaxationandbilestasis,decreasebilesaltsecretionIncreasedriskinpregnancyCholesterolstonesIncreaseriskofstoneformationTPNOctreotideCeftriaxoneDecrea
