|
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.
|
