LIVER BILLIARY TRACT 14 investigations

13.3 INTRAVENOUS CHOLECYSTOGRAPHY

When there is a failure of the gallbladder to be visualized  after

oral cholecystography, intravenous cholecystography is indicated.

*  It  is  also  a  means for  visualization  of  bile  ducts  in

   cholecystomized patients.

*  It is of little value, if bilirubin is greater than 3.5 mg/100

   ml.

13.4 PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY AND ENDOSCOPIC

Retrograde   Cholangiography  are  indicated  in   patient   with

jaundice.

13.5 T-TUBE CHOLANGIOGRAPHY

This is frequently performed in the operating room at the time of

exploration  of the biliary tract with injection of radio  opaque

material either inot the cystic duct or into the T-tube placed in

the common duct.

*  It can also be used in patients postoperatively

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LIVER BILLIARY TRACT 13 Investigations

13. DIAGNOSTIC TESTS for GB Disorders

13.1 ROUTINE ABDOMINAL X-RAYS

Plain films are indicated in biliary tract disease, since biliary

calculi in upto 20% of cases are calcified. Gallstones visibility

is denpendent upon the amount of calcium present in the stone. 

Ultrasonography  has  been adopted as  the  principle  diagnostic

test.

13.2 ORAL CHOLECYSTOGRAPHY

After  ingestion of telepaque 12 hours earlier, visualization  of

the normal gallbladder takes place.

*  Subsequent  to  the  ingestion of a  fatty  meal,  contraction

   begins  promptly  and within 40 minutes,  the  gallbladder  is

   reduced  to  at least one-third of one-fourth  of  its  normal

   size.

*  An abnormal cholecystogram may demonstrate poor  visualization

   of  the  gallbaldder  or presence of filling  defects  due  to

   presence of calculi or tumours.

*  Non-visualization may be due to :

   *  Failure to retain the oral medication

   *  Faulty absorption such as with pyloric obstruction

   *  Hepatic dysfunction

   *  Hepatic or cystic duct obstruction

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LIVER BILLIARY TRACT 12 Gall Stones

GALLSTONES

The etiology of gallstones has not been agreed upon.  In all  the

theories,  there  is  the need to explain  the  precipitation  of

cholesterol.

*  Infection and stasis are considered major factors.

*  In  the  infection theory, damage to  the  gallbladder  mucosa

   initiates stone formation.

*  This  damage to the wall results in a change of  permeability,

   bile  salts  diffuse  from  the bile  into  the  blood  stream

   decreasing  their  concentration  in  bile  and  reducing  the

   cholesterol holding capacity in the bile.

*  Constitutional  and  metabolic factors have  been  implicated. 

   The incidence of formation of stones is definitely related  to

   the sex and age.  In all age groups, stones are more  frequent

   in  females than in male, there is also an increase  with  age

   more  frequent  in  females than in male,  there  is  also  an

   increase with age in both sexes.

*  Major  elements  involved in the formation of  gallstones  are

   cholesterol,  bile  pigment and calcium.   Other  constituents

   include iron, phosphorus, carbonates and proteins.

*  Pure  cholesterol  stones are uncommon, usually  large,  round

   with a smooth surface.

*  Pure  bilirubin pigment stones are also uncommon and  are  met

   with in hemolytic jaundice.

*  Calcium   bilirubinate  stones  are  prevalent  in  Asia   and

   constitute 30 to 40% of all gallstones.

*  A nucleating factor that starts the process of stone formation

   is  important foreign bodies, ova, bacteria,  cellular  debris

   are some factors that play a role.

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LIVER BILLIARY TRACT 11 Choledocal Cyst & GB functions

BILIARY TRACT

10.1 CONGENITAL CHOLEDOCHAL CYST

Choledochal  cyst  is  a dilatation which  usually  involves  the

supraduodenal  portion of the common bile duct, but  may  involve

the  common  right and left hepatic ducts.  It  is  considered  a

congenital abnormality.

Clinical  manifestations  include pain, jaundice and  a  palpable

epigastric mass.

Diagnosis  is  confirmed  by ultrasound and treatment  is  by  an

excision  of  the  cyst  and internal  drainage  by  a  hepatico-

jejunostomy  by  a  Roux-en-Y.  Drainage  of  the  cyst  directly

without  excision  causes recurrent pancreatitis in  one  of  the

patients intestine.

11. GALL BLADDER FUNCTION

The gallbladder provides storage and concentrates the bile.

*  Sodium  chloride and water are selectively absorbed and  there

   is a secretion of mucus.

*  This  mucus  is  the "white bile" present in  mucocle  of  the

   gallbladder  when there is an obstruction of the  cystic  duct

   and no bile can enter.

*  Tonic  contractions  lasting  5 to  30  minutes  increase  the

   pressure within the gallbladder.

*  The  passage of bile into the duodenum is, however,  dependent

   upon the relaxation of the sphincter of Oddi

*  The stimulus for the contraction is cholescystokinin realeased

   from the intestinal mucosa in response to food and fats  being

   a strong stimulus

*  With injection of cholecystokinin, the gall bladder begins  to

   contract in 1 to 2 minutes.

*  Cholexystokinin  also  relaxes the sphincter of Oddi  and  the

   duodenal musculature

Gallbladder

The gallbladder functions as a reservoir for secreted bile during not only does it store bile, but also it concentrates bile. The concentrating ability of the gallbladder is based on the presence of active sodium transport at the basolateral membrane, water moves both trans and paracellularly down a concentration gradient leaving the lumen and entering the interestitial fluid and blood stream gallbladder contraction is circulating CCK from the S cells. Cholecystokinin has a direct effect on the gallbladder smooth muscle cells gallbladder to empty its contents into the common hepatic duct. The normal ejection fraction of the gallbladder should exceed 40%. Some patients have a low ejection fraction, called billiary dyskinesia, which may be associated with intermittent abdominal discomfort and a chronic feeling of nausea.

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