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Pear-shaped, the gallbladder measures ca. 8 cm by 3 cm and is located under the right lobe of the liver. It acts as a reservoir for the bile produced daily in the liver.
Function:
Bile is produced in the liver and aids the digestion of fatty food substances. Between 250 and 1000 millilitres of bile are produced each day. The most important constituents of bile are: water, bile salts, cholesterol , phospholipids . Between meals, the bile is stored in the gallbladder, which contracts once or twice as food is taken. This causes the bile to enter the duodenum via the common bile duct. 80 to 90% of the bile acids are later reabsorbed by the small intestine and re-enter the liver via the bloodstream (portal system). Here they become available once more for transfer into the gallbladder (entero-hepatic circulation). The bile acids possess a number of important metabolic functions: a) breakdown of fat, b) the transport of substances not soluble in water (e.g.: cholesterol, the fat-soluble vitamins A, D, E, K), c) the regulation of cholesterol metabolism, d) stimulation of intestinal movement, e) activation of the pancreatic fluid (lipase ) in the intestine and f) increasing the excretion of sodium and water from the large intestine. Bile also helps transport numerous substances, including those occurring naturally in the body as well as those which do not. Bile pigments such as bilirubin , for example, waste products of the red blood corpuscles, are eliminated with the bile fluid. Bile also removes numerous Drugs from the body.
Methods of Examination
Ultrasound (Sonography):
This represents the major procedure for establishing a diagnosis of gallstones and inflammatory disorders of the gallbladder. It permits an assessment to be made of the gallbladder and bile ducts. There are no side-effects and the procedure can be repeated as often as required. The patient must have nothing to eat of drink prior to the examination.
Conventional X-rays:
An X-ray examination is routine in the case of acute abdominal pain. Gallstones containing calcium can be recognised on conventional X-rays. X-rays also permit the detection of free air in the lower abdomen or the bile ducts.
Computerised Tomography (CAT):
A CAT examination does not normally take place until after a successful ultrasound scan. It helps to further clarify the nature of the disorder. This procedure is particularly valuable in the case of tumours.
Endoscopic bile duct imaging:
Endoscopic retrograde cholangiopancreaticography (ERCP): ERCP is used for diagnosing disorders of the bile duct system. It permits a direct imaging of the biliary system and the pancreatic duct by means of a contrast medium, and in addition it provides for possible therapeutic procedures, such as the removal of gallstones obstructing the duct.
When is ERCP required ? Indications: when the presence of bile duct stones is suspected, in the case of inherited and acquired changes in the bile ducts, and in order to detect or rule out the presence of malignancy in the bile ducts or pancreas.
When does ERCP involve an increased degree of risk ? In the case of serious disorders of the heart, lungs or kidneys; for patients with bleeding disorders or taking anti-coagulants; in cases where operations affecting the bile ducts or pancreas have already been performed.
Is ERCP a risky procedure ? Complications: serious complications are rare (1,0 %). Occasionally there is an iatrogenic (i.e. physician-produced) inflammation of the pancreas. In the case of therapeutic procedures involving cutting open Vater's papilla there are rare cases of bleeding and injury to the intestine wall.
How is ERCP carried out ? The method: a local anaesthetic is applied to the throat and the patient takes a pain-killer and a mild sedative. A flexible endoscope is then introduced via the oesophagus into the stomach and through the duodenum up to the opening into the bile duct (Vater's papilla). A very fine tube (catheter) is then passed through the endoscope and into the bile duct and pancreatic duct via Vater's papilla . The bile or pancreatic ducts are now filled with a contrast medium and displayed on X-rays. Various specialised instruments permit a number of therapeutic procedures: e.g. the removal of gallstones from the duct, the mechanical disintegration of fat or stones by means of a specially strengthened tiny basket or a pulsating laser beam, the widening of the opening of the common bile duct into the small intestine (papillotomy ) and the insertion of prostheses (stents ) through narrow parts of the bile ducts.
Percutaneous trans-hepatic cholangiography (PTC):
If an ERCP cannot be carried out, it is possible to scan the bile ducts with a fine needle passed through the skin (percutaneous ). In the case of blocked bile ducts it is also possible to allow the bile to drain out through a fine tube (drainage).
Magnetic-resonance-cholangio-pancreaticography (MRCP):
MRCP is a new technique that permits the simultaneous imaging of the bile ducts and the pancreatic duct. In addition, the organs themselves (e.g. liver, pancreas, gallbladder) can be imaged in the same examination with a high degree of accuracy. MRCP proceeds without the use of X-rays and thus carries no risk for the patient. An MRCP procedure is at present still relatively expensive, and in contrast to ERCP cannot yet provide any therapeutic measures.
Endosonography of the bile ducts and pancreas:
This is an ultra-sound examination of the bile ducts and pancreas by means of a specialised endoscope carrying an ultrasonic tip. This permits the imaging of the bile ducts and the pancreas from the stomach and the duodenum. Since in this way the sonic tip can be brought into close proximity with the target organ, changes in the target organs can be distinctly observed.
Recent developments also include ultrasonic mini-sensors, which can be passed through the traditional endoscope after it is inserted through the widened Vater's papilla, and into the bile ducts. This provides information about diseased conditions in the ducts.
Endo-sonography is employed in the diagnosis of tumours, their extent and depth of penetration, the relationship to vessels and lymph nodes, and other disorders of the two target organs.
Major Disorders
Diseases of the Gallbladder
1. Gallstones
2. Tumours of the Gallbladder
Diseases of the Bile Ducts
3. Bile Duct Gallstones
4. Infections of the Bile Ducts
5. Primary Sclerosing Cholangitis
6. Tumours of the Bile Ducts
Diseases of the Gallbladder
1. Gallstones
1. Definition:
Gallstones consist principally of a combination of cholesterol and bile acid. In size they vary from just a few millimetres to a number of centimetres. They originate mainly in the gallbladder. We speak of gallstones as a disorder when stones present in the gallbladder (or bile ducts) cause problems. Gallstones occur in 10 to 15% of the population. The frequency of gallstones increases with age. The development of gallstones is favoured by numerous factors: obesity, long periods of severe fasting, a diet rich in fat, high cholesterol levels, diabetes mellitus, pregnancy, infections of the bile ducts, certain drugs and genetic factors.
2. Symptoms and Signs
60 to 80% of people with gallstones go through life without any problems! Gallstone disease manifests itself through sudden attacks of persistent pain on the right side beneath the costal arch (biliary colic). The pains can radiate to the right shoulder and can cause sweating, nausea and even vomiting. Biliary colic typically appears after a rich meal high in fat.
3. Complications and Risks
a) Biliary colic
b) inflammation of the gallbladder
c) jaundice (caused through obstruction of the common bile duct by large gallstones lodging in the main exit from the gallbladder). The descent of gallstones into the common bile duct can lead to attacks of biliary colic, blocking of the bile ducts (causing jaundice) and the blocking of the pancreatic duct in the vicinity of the Vater's papilla, which can cause pancreatitis.
4. Diagnosis / Preliminary Investigation
Physical examination
Case history (questioning of the patient)
Blood sample (inflammation tests, liver function tests, bile pigments)
Conventional X-ray examination and ultrasonic abdomen scan.
5. Therapy and Treatment
Acute biliary colic can be treated in a traditional manner, i.e. without an immediate operation. Once the pain has subsided, however, the gallbladder must be surgically removed without delay in order to take away the gallstones, to prevent them from descending into the common bile duct and to prevent the formation of new stones. Satisfactory treatment other than surgery is not available. Although it is possible to disintegrate certain gall stones through shock-waves, or to dissolve them with chemical substances, these techniques do not prevent the formation of new stones. Without the removal of the gallbladder, gallstone disease is not generally cleared up.
Surgical Removal of the Gallbladder (Cholecystectomy)
The surgical removal of the gallbladder can generally be performed with the aid of laparoscopy (i.e. using instruments to view the abdominal cavity); The operation takes place under general anaesthetic. Four incisions (of 1 to 2 cm) permit a video camera and the surgical instruments to be inserted into the abdominal cavity. The abdominal cavity is inflated with a harmless gas (carbon dioxide). The surgeon follows the stages of the operation on the TV monitor. In around 90% of the cases the gallbladder can be removed in this relatively patient-friendly way. In rare cases, however, the traditional methods of open surgery must be resorted to. This can be necessary in the following situations: technical problems, insufficient view of the area involved (e.g. where the liver is too large) bleeding, anatomical abnormalities, extreme inflammation of the gallbladder. In the case of open surgical removal of the gallbladder an incision of approximately 12 cm is made along the right edge of the costal arch. The removal of the gallbladder is a very safe operation with an extremely low rate of complications. In rare cases there can be post-operative trauma. It is equally rare that postoperative bleeding is encountered, or that bile will leak from the area operated on (the gallbladder base). A serious but fortunately uncommon complication is an injury to the common bile ducts. Such an injury can lead either to a leaking of bile or to a narrowing (stenosis) in the bile ducts. These latter complications generally have to be corrected through surgery. Laparascopic cholecystectomy requires a hospital stay of approximately 3 days, while an open cholecystectomy would require about 7 days.
6. After-care
This is required only in the case of the appearance of fresh symptoms.
2. Tumours of the Gallbladder
1. Definition
Benign tumours of the gallbladder are rare. Those that do occur can be polyps, adenomas, papillomas , fibromas or leiomyomas . Malignant gallbladder tumours (gallbladder carcinoma) are the 5th most frequently occurring tumours in the gastro-intestinal tract and account for 3% of all malignant tumours. Women are more frequently affected than men.
2. Symptoms and Signs
Gallbladder tumours in the early stage rarely cause problems. The diagnosis is frequently made coincidentally, e.g. during an ultrasound examination for something else, or after the surgical removal of the gallbladder on account of gallstone problems.
Gallbladder tumours which cause problems (pain in the upper abdominal cavity, weight loss, jaundice, diarrhoea) are unfortunately already at an advanced stage.
3. Complications and Risks
Benign tumours (polyps) can degenerate over time and transform into malignant tumours. Malignant tumours can produce secondary tumours (Metastases ) Gallbladder tumours can lead to displacement of the bile ducts and to the development of jaundice.
4. Diagnosis / Preliminary Investigation
Physical examination
Case history (questioning the patient)
Blood sample (inflammation tests, liver function tests, bile pigments)
Ultrasound (sonography)
Computerised tomography (CT)
Assessment of the extent of the tumour and the ruling out of metastases
5. Therapy and Treatment
Benign gallbladder tumours less than 1 cm in diameter are not treated surgically. An ultrasound examination should however be carried out regularly (e.g. every 6 months). Every gallbladder tumour larger than 1 cm or obviously increasing in mass must be operated on. Surgery represents the only prospect for curing this extremely aggressive type of tumour. The operation consists of the removal of the gallbladder, the gallbladder base (liver resection) and the lymphatic tissue. In the case of advanced tumours a complete removal of the tumour is frequently no longer possible. In these cases, a partial resection of the tumour can be performed. Surgery is well capable of operating in order to cure or prevent the development of jaundice. In this procedure a connection is established between a common bile duct and a small intestine loop so as to ensure the unimpeded drainage of the bile fluid. Patients with an advanced gallbladder tumour who cannot be operated on because of their poor general state (advanced age, serious heart or lung problems) can alternatively be treated endoscopically in the case of jaundice. In this procedure (ERCP) a small tube (prosthesis, stent) is inserted into the closed common bile duct. In this way the draining of the biliary fluid can be ensured for a long period.
6. After-care and Prognosis
Gallbladder carcinoma can be cured only in the early stage (through surgery). Advanced gallbladder carcinomas carry a low level of life expectancy.
Disorders of the Bile Ducts
3. Gallstones
1. Definition
Bile duct stones are almost always formed only in the gallbladder. The formation of stones in the bile ducts is uncommon. It tends to occur as a result of bile drainage problems, of infections of the bile ducts or because the bile ducts have become the site of too many foreign bodies.
2. Symptom and Signs
Colic-like pain in the upper abdominal cavity Jaundice, pale-coloured stools, darkening of the urine
3. Complications and Risks
Gallstones can cause a total closure of the bile ducts. This leads to attacks of colic and jaundice, and can lead to inflammations of the ducts (cholangitis : fever, shivering fits). The common bile duct and the pancreatic duct unite to form a short common duct, which opens in the duodenum at Vater's papilla. Gallstones which remain lodged in the area of Vater's papilla, block not only the flow of bile (icterus), but also the flow of pancreatic fluid. This can lead to an inflammation of the pancreas (pancreatitis). Pancreatitis is a serious, frequently life-threatening disorder. A chronic (i.e. lasting for years) blockage and/or inflammation of the tiny bile ducts in the liver can damage the liver cells. Normal liver tissue is destroyed and replaced with scar-tissue (biliary Cirrhosis). Other possible complications are: Perforation of the bile duct wall, the collection of pus in the liver tissue (Liver abscess)
4. Diagnosis / Preliminary Investigations
Physical examination
Case history (questioning the patient)
Blood sample (inflammation tests, liver function tests, bile pigments)
Ultrasound (only about 50% of gallstones are revealed through ultrasound scans)
ERCP: ERCP is the major technique for establishing a diagnosis and for carrying out simultaneous treatment.
MRCP: Bile duct stones can be diagnosed in almost 100% of cases and narrowing of the bile ducts in 90%. Direct therapeutic intervention is however not possible.
PTC: alternative technique when ERCP cannot be used.
Computerised tomography (CT): a CT examination is important for ruling out tumours and for assessing the likelihood of pancreatitis caused by gallstones.
5. Therapy and Treatment
ERCP provides not only a sound diagnosis but also permits simultaneous therapy, i.e. endoscopic removal of stones. Frequently the opening of the common bile duct into the duodenum (Vater's papilla) must be widened with a specialised instrument (papillotomy). Large gallstones can also be crushed mechanically. In cases where this is not technically possible, the disintegration of the stones can be effected through laser techniques. Antibiotics and bile duct drainage (with a draining catheter) are needed in the case of inflammations (Cholangitis)
Role of surgery: a patient with bile duct stones is initially treated endoscopically (ERCP for papillotomy and stone removal) by a gastro-enterologist. Only in very rare cases is it necessary for a surgeon to remove gallstones. Once the acute symptoms have subsided, however, the gallbladder, as the site of the formation of the stones, must be removed in an operation. This can be done in a relatively patient-friendly manner through laparoscopic techniques.
4. Infections of the Bile Ducts
1. Definition
Severe infections of the bile ducts can be life-threatening. Most inflammations of the bile ducts are caused by gallstones (60 to 70%) or by a narrowing of the ducts, or else they appear as a consequence of endoscopic interventions (ERCP). In rare cases the problem is due to Caroli syndrome (an inherited disease, the enlargement of the bile ducts in the liver), bile duct tumours, parasites and infections of the pancreas. A precondition for the development of the infection is the obstruction of the bile drainage system with increased pressure in the bile duct system and the presence of micro-organisms.
2. Symptoms and Signs
Pain, fever, shivering fits, jaundice (icterus)
3. Complications and Risks
Blood poisoning (sepsis)
4. Diagnosis / Preliminary Investigations
Physical examination
Case history (questioning the patient)
Blood sample (inflammation tests, liver function tests, bile pigments)
Ultrasound (sonography); if necessary computerised tomography (CT), ERCP
5. Therapy and Treatment
Bed-rest, antibiotics, analgesics ERCP: endoscopic treatment of the bile ducts and measures for removing stones
6. Prognosis
Untreated cholangitis carries a high rate of mortality.
5. Primary Sclerosing Cholangitis
1. Definition
This is a chronic inflammation of the bile ducts both within and outside the liver. It is characterised by the alternate narrowing and enlarging of numerous ducts. The cause is unknown. Middle-aged men are particularly affected. It is frequently associated with chronic inflammatory intestinal disease (e.g. ulcerative colitis) The final stage is marked by total liver transformation and scarring (liver cirrhosis)
2. Symptoms and Signs
Fatigue, jaundice, itching, fever
3. Complications and Risks
One of the main complications is the inflammation of the bile ducts (cholangitis). If the disorder persists over several years the liver becomes scarred (cirrhosis of the liver). There is a risk of degeneration (the formation of a malignant tumour of the bile ducts, cholangiocarcinoma). There is a risk that malignant tumours will develop in the intestine on account of chronic inflammatory intestinal disease.
4. Clarification and Preliminary Investigation
Physical examination
Case history (questioning the patient)
Blood sample (liver function tests, typical antibodies, bilirubin, inflammation tests)
The decisive diagnostic technique is ERCP (scanning the bile ducts)
Tissue sample from the liver (biopsy);
if required MRCP
5. Therapy and Treatment
Treatment encompasses the underlying disease and the complications. This is a chronic disorder with no possibility of a cure. Drug therapy can be carried out using ursodeoxycholic acid. ERCP can be used in order to treat severe narrowing of the bile ducts.
Patients who have suffered from PSC over a period of years develop cirrhosis of the liver with its attendant complications. There is also the risk of degeneration (the development of a malignant tumour). Patients with PSC must undergo regular examinations. On account of liver cirrhosis and the risk of degeneration the possibility of a liver transplant is frequently indicated.
6. After-care
Regular check-ups and blood tests (with the family physician and at a teaching hospital with specialists in liver disorders).
6. Tumours of the Bile Ducts
1. Definition
Malignant tumours of the bile ducts (cholangiocarcinoma) are rare. The common bile ducts as well as the tiny bile ducts within the liver can be affected. The condition is found most frequently among men in their sixties and seventies. There is also frequent incidence in patients with primary sclerosing cholangitis.
2. Symptoms and Signs
Jaundice, lack of appetite, pain in upper abdomen, weight loss
3. Complications and Risks
Spreading and development of secondary cells (metastases), along the bile ducts and infiltrating the liver.
4. Clarification and Preliminary Investigation
The techniques of choice are ERCP and magnetic resonance tomography (MRCP). ERCP permits the precise location of the tumour to be established, and it provides for the removal of a tissue sample which will generally confirm the diagnosis. Endosonography, and computerised tomography CAT are available as additional useful investigative techniques.
5. Therapy and Treatment
Surgery represents the only possibility of curing this aggressive type of tumour. The method of operating will depend on the location of the tumour. Apart from the resection of the bile ducts proper, a considerable liver resection is frequently also required, as is a resection of the pancreas and the duodenum.
Often a curative resection (i.e. total removal) of the tumour is not possible. In these cases the operation attempts to ensure proper drainage of the biliary fluid. This is necessary both to treat jaundice and to prevent its occurrence. Alternatively, patients who cannot be operated on (for reasons of extreme age, or severe heart or lung problems) can benefit from a clearing of the bile ducts by means of ERCP procedures.
6. After-care and Prognosis
In the case of advanced bile duct tumours the prognosis is very unfavourable. Regular follow-up examinations are required.
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