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Gall Bladder

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Gall Bladder Prof Dr Tharwat S. Kandiel Assist. Prof. Of General Surgery Gastro-intestinal Surgical Center Anatomy The gallbladder (or cholecyst, sometimes gall ... – PowerPoint PPT presentation

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Title: Gall Bladder


1
  • Gall Bladder
  • Prof Dr Tharwat S. Kandiel
  • Assist. Prof. Of General Surgery
  • Gastro-intestinal Surgical Center

2
Anatomy
  • The gallbladder (or cholecyst, sometimes gall
    bladder) is a pear-shaped organ that stores about
    50 mL of bile (or "gall") until the body needs it
    for digestion.

3
Anatomy
  • The gallbladder is about 7-10 cm long in humans
    and appears dark green because of its contents
    (bile), rather than its tissue. It is connected
    to the liver and the duodenum by the biliary
    tract.
  • The cystic duct leads from the gallbladder and
    joins with the common hepatic duct to form the
    common bile duct.
  • The common bile duct then joins with the
    pancreatic duct, and enters the duodenum through
    the hepatopancreatic ampulla at the major
    duodenal papilla.

4
Anatomy
Artery Cystic artery
Vein Cystic vein
Nerve Celiac ganglia, vagus
Precursor Foregut
5
Histology
  • The layers of the gallbladder are as follows
  • The gallbladder has a simple columnar epithelial
    lining characterized by recesses called Aschoff's
    recesses (lacunae of Luschka) , which are pouches
    inside the lining.
  • Under the epithelium there is a layer of
    connective tissue.
  • Beneath the connective tissue is a wall of smooth
    muscle that contracts in response to
    cholecystokinin, a peptide hormone secreted by
    the duodenum.
  • There is essentially no submucosa.

6
Function
  • The gallbladder stores about 50 mL of bile ,
    which is released when food containing fat enters
    the digestive tract, stimulating the secretion of
    cholecystokinin (CCK). The bile, produced in the
    liver, emulsifies fats and neutralizes acids in
    partly digested food.
  • After being stored in the gallbladder, the bile
    becomes more concentrated than when it left the
    liver, increasing its potency and intensifying
    its effect on fats. Most digestion occurs in the
    duodenum.

7
Anomalies
  • The gallbladder may be absent 0.075
  • The gallbladder and cystic duct may be absence.
  • the gallbladder is irregular in form or
    constricted across its middle more rarely, it is
    partially divided in a longitudinal direction.
  • two distinct gallbladders, each having a cystic
    duct that joined the hepatic duct. (0.026), The
    cystic duct may itself be doubled
  • The gallbladder has been found on the left side
    (to the left of the ligamentum teres) in subjects
    in whom there was no general tranposition of the
    thoracic and abdominal viscera.

8
  • The gallbladder may be intrahepatic or beneath
    the left lobe. Ectopic sites include retrohepatic
    positions, or in the anterior abdominal wall or
    falciform ligament, they may be suprahepatic or
    transversely position, floating, or
    retroperitoneal. They may be in the midline
    anterior epigastric above the left lobe or
    suprahepatic above the right hepatic lobe.

9
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10
Choledochal cyst
  • Choledochal cysts are congenital anomalies of the
    bile ducts. They consist of cystic dilatations of
    the extrahepatic biliary tree, intrahepatic
    biliary radicles, or both.
  • Douglas is credited with the first clinical
    report in a 17-year-old girl who presented with
    intermittent abdominal pain, jaundice, fever, and
    a palpable abdominal mass.
  • Pathophysiology The pathogenesis of choledochal
    cysts is most likely multifactorial.
  • A congenital etiology,
  • A congenital predisposition to acquiring the
    disease under the right conditions.

11
  • The vast majority of patients with choledochal
    cysts have an anomalous junction of the common
    bile duct with the pancreatic duct (anomalous
    pancreatobiliary junction APBJ). An APBJ is
    characterized when the pancreatic duct enters the
    common bile duct 1 cm or more proximal to where
    the common bile duct reaches the ampulla of
    Vater.
  • APBJs in more than 90 of patients with
    choledochal cysts.

12
  • The APBJ allows pancreatic secretions and enzymes
    to reflux into the common bile duct. In the
    relatively alkaline conditions found in the
    common bile duct, pancreatic pro-enzymes can
    become activated. This results in inflammation
    and weakening of the bile duct wall. Severe
    damage may result in complete denuding of the
    common bile duct mucosa.

13
  • From a congenital standpoint, defects in
    epithelialization and recanalization of the
    developing bile ducts during organogenesis and
    congenital weakness of the duct wall have also
    been implicated. The result is formation of a
    choledochal cyst.

14
Anatomy of Choledochal cyst
  • based on the Todani classification published in
    1977.
  • Type I choledochal cysts
  • most common 80-90 of the lesions.
  • Type I cysts are dilatations of the entire common
    hepatic and common bile ducts or segments of
    each.
  • They can be saccular or fusiform in
    configuration.
  • Type II choledochal cysts
  • isolated protrusions or diverticula that project
    from the common bile duct wall. They may be
    sessile or may be connected to the common bile
    duct by a narrow stalk.

15
  • Type III choledochal cysts are found in the
    intraduodenal portion of the common bile duct.
    Another term used for these cysts is
    choledochocele.

16
  • Type IVA cysts are characterized by multiple
    dilatations of the intrahepatic and extrahepatic
    biliary tree. Most frequently, a large solitary
    cyst of the extrahepatic duct is accompanied by
    multiple cysts of the intrahepatic ducts. Type
    IVB choledochal cysts consist of multiple
    dilatations that involve only the extrahepatic
    bile duct.
  • Type V choledochal cysts are defined by
    dilatation of the intrahepatic biliary radicles.
    Often, numerous cysts are present with interposed
    strictures that predispose the patient to
    intrahepatic stone formation, obstruction, and
    cholangitis. The cysts are typically found in
    both hepatic lobes. Occasionally, unilobar
    disease is found and most frequently involves the
    left lobe.

17
  • The patient may present at any age with
  • Obstructive jaundice
  • Cholangitis and
  • Abd signs, with RUQ swelling in some cases
  • It is a premalignant condition
  • Diagnosis by US and MRI
  • Radical excision of the cyst is the treatment of
    choice with Roux en Y reconstruction

18
Gall stones
  • Gall stones are the most common abdominal reason
    for admission to hospital in developed countries
    and account for an important part of healthcare
    expenditure. Around 5.5 million people have gall
    stones in the United Kingdom, and over 50 000
    cholecystectomies are performed each year.
  • Normal bile consists of 70 bile salts (mainly
    cholic and chenodeoxycholic acids), 22
    phospholipids (lecithin), 4 cholesterol, 3
    proteins, and 0.3 bilirubin.
  • There are two major types of gallstones, which
    seem to form due to distinctly different
    pathogenetic mechanisms.

19
Cholesterol Stones
  • About 90 of gallstones are of this type. These
    stones can be either
  • almost pure cholesterol Cholesterol stones
  • or mixtures of cholesterol and other substances
    cholesterol predominant (mixed) stones.

20
  • The key event leading to formation and
    progression of cholesterol stones is
    precipitation of cholesterol in bile.
  • Unesterified cholesterol is virtually insoluble
    in aqueous solutions and is kept in solution in
    bile largely by virtue of the detergent-like
    effect of bile salts.

21
Imbalance lead to stone formation
  • Hyper-secretion of cholesterol into bile due to
  • obesity,
  • acute high calorie intake,
  • chronic polyunsaturated fat diet, contraceptive
    steroids or pregnancy,
  • diabetes mellitus and
  • certain forms of familial hypercholesterolemia.

22
  • Hypo-secretion of bile salts due to
  • impaired bile salt synthesis and
  • abnormal intestinal loss of bile salts (e.g.
    recirculation failure due to ileal disease).
  • Impaired gallbladder function with incomplete
    emptying or stasis.
  • seen in late pregnancy
  • with oral contraceptive use,
  • in patients on total parenteral nutrition and
  • due to unknown causes, perhaps associated with
    neuro-endocrine dysfunction.

23
  • There are clearly important genetic determinants
    for cholesterol stone formation. For example, the
    prevelance of the disease in descendents of
    Chilean, Indians and in American Indians is
    extraordinarily high and not accounted for by
    environment.
  • There is also an important sex bias in
    development of stones - the prevelance in adult
    females is two to three times that seen in males

24
Age gt40 years Bile salt loss (ileal disease or resection)
Female sex (twice risk in men) Diabetes mellitus
Genetic or ethnic variation Cystic fibrosis
High fat, low fibre diet Antihyperlipidaemic drugs(clofibrate)
Obesity Gallbladder dysmotility
Pregnancy (risk increases with number of pregnancies) Prolonged fasting
Hyperlipidaemia Total parenteral nutrition

25
Pigment Stones
  • Roughly 10 of gallstones are pigment stones
  • composed of large quantities of bile pigments,
    along with lesser amounts of cholesterol and
    calcium salts.
  • Black pigment stones
  • consist of 70 calcium bilirubinate and are more
    common in patients with haemolytic diseases
    (sickle cell anaemia, hereditary spherocytosis,
    thalassaemia) and cirrhosis.

26
  • Brown pigment stones (accounting for lt5 of
    stones)
  • They form as a result of stasis and infection
    within the biliary system, usually in the
    presence of Escherichia coli and Klebsiella spp,
    which produce ß glucuronidase that converts
    soluble conjugated bilirubin back to the
    insoluble unconjugated state leading to the
    formation of soft, earthy, brown stones.
  • Ascaris lumbricoides and Opisthorchis senensis
    have both been implicated in the formation of
    these stones, which are common in South East Asia.

27
Effects and complications of Gall Stones
  • In the GB
  • Silent stones
  • Chronic cholecystitis
  • Acute cholecystitis
  • Gangrene
  • Perforation
  • Empeyma
  • Mucocele
  • carcinoma
  • In the bile ducts
  • Obstructive jaundice
  • Cholangitis
  • Acute pancreatitis
  • In the intestine
  • Acute intestinal obstruction (Gall stone ileus)

28
Cholecystitis
  • Definition
  • Cholecystitis refers to a painful inflammation of
    the gallbladder's wall. The disorder can occur a
    single time (acute), or can recur multiple times
    (chronic).
  • Cholecystitis is defined as inflammation of the
    gallbladder that occurs most commonly because of
    an obstruction of the cystic duct from
    cholelithiasis. Ninety percent of cases involve
    stones in the cystic duct (ie, calculous
    cholecystitis), with the other 10 representing
    acalculous cholecystitis. Although bile cultures
    are positive for bacteria in 50-75 of cases,
    bacterial proliferation may be a result of
    cholecystitis and not the precipitating factor.

29
Causes
  • Risk factors for calculous cholecystitis mirror
    those for cholelithiasis and include the
    following
  • Female sex
  • Certain ethnic groups (Race)
  • Obesity or rapid weight loss
  • Drugs (especially hormonal therapy in women)
  • Pregnancy
  • Increasing age

30
  • Acalculous cholecystitis is related to conditions
    associated with biliary stasis, to include the
    following
  • Critical illness
  • Major surgery or severe trauma/burns
  • Sepsis
  • Long-term TPN
  • Prolonged fasting

31
  • Other causes of acalculous cholecystitis include
    the following
  • Cardiac events, including myocardial infarction
  • Sickle cell disease
  • Salmonella infections
  • Diabetes mellitus
  • Patients with AIDS with cytomegalovirus,
    cryptosporidiosis, or microsporidiosis
  • Idiopathic cases exist.

32
History
  • Typical gallbladder colic is 1-5 hours of
    constant pain, most commonly in the epigastrium
    or right upper quadrant. Pain may radiate to the
    right scapular region or back. Peritoneal
    irritation by direct contact with the gallbladder
    localizes the pain to the right upper quadrant.
    Pain is severe, dull or boring, and constant (not
    colicky). Patients tend to move around to seek
    relief from the pain. Onset of pain develops
    hours after a meal, occurs frequently at night,
    and awakens the patient from sleep.
  • Associated symptoms include nausea, vomiting,
    pleuritic pain, and fever.

33
  • Indigestion, belching, bloating, and fatty food
    intolerance are thought to be typical symptoms of
    gallstones however, these symptoms are just as
    common in people without gallstones and
    frequently are not cured by cholecystectomy.

34
  • Most gallstones (60-80) are asymptomatic at a
    given time. Smaller stones are more likely to be
    symptomatic than larger ones. Almost all patients
    develop symptoms prior to complications.
  • Symptoms of cholecystitis are steady pain in the
    right hypochondrium or epigastrium, nausea,
    vomiting, and fever. Acute attack often is
    precipitated by a large or fatty meal.

35
Physical
  • Vital signs parallel the degree of illness.
    Patients with cholangitis are more likely to have
    fever, tachycardia, and/or hypotension. Patients
    with gallbladder colic have relatively normal
    vital signs.
  • Patients with cholecystitis are usually more ill
    appearing than simple biliary colic patients, and
    they usually lie still on the examination table
    since any movement may aggravate any peritoneal
    signs.

36
  • Abdominal examination
  • Epigastric or RUQ tenderness and abdominal
    guarding.
  • The Murphy sign (an inspiratory pause on
    palpation of the right upper quadrant) can be
    found on abdominal examination.
  • Positive Murphy sign was extremely sensitive
    (97) and predictive (PPV, 93) for
    cholecystitis. However, in elderly patients, this
    sensitivity may be decreased.

37
  • peritoneal signs should be taken seriously. Most
    uncomplicated cholecystitis does not have
    peritoneal signs thus, search for complications
    (eg, perforation, gangrene) or other sources of
    pain.
  • Gallbladder gangrene can be a complication in up
    to 20 of cases of cholecystitis and is usually
    in diabetics, elderly, or immunocompromised
    persons.
  • A palpable fullness in the RUQ may be appreciated
    in 20 of cases.

38
  • As in all patients with abdominal pain, perform a
    complete physical examination, including rectal
    and pelvic examinations in women.
  • In elderly patients and those with diabetes,
    occult cholecystitis or cholangitis may be the
    source of fever, sepsis, or mental status
    changes.
  • Jaundice is unusual in the early stages of acute
    cholecystitis and may be found in fewer than 20
    of patients.
  • A very high bilirubin think for common bile duct
    and pancreatic region disease.

39
DD
  • Abdominal Aortic Aneurysm
  • Acute Mesenteric Ischemia
  • Amebic Hepatic Abscesses
  • Appendicitis
  • Biliary Colic
  • Biliary Disease
  • Cholangiocarcinoma
  • Cholangitis
  • Choledocholithiasis
  • Cholelithiasis
  • Gallbladder Cancer
  • Gallbladder Mucocele
  • Gallbladder Tumors
  • Gastric Ulcers
  • Gastritis, Acute
  • Gastroesophageal Reflux Disease
  • Hepatitis, Viral
  • Myocardial Infarction
  • Nephrolithiasis
  • Pancreatitis, Acute
  • Peptic Ulcer Disease
  • Pneumonia, Bacterial
  • Pregnancy and Urolithiasis
  • Pyelonephritis, Acute
  • Renal Disease and Pregnancy
  • Renal Vein Thrombosis

40
Lab Studies
  • Labs with cholelithiasis and gallbladder colic
    should be completely normal.
  • Because biliary obstruction is limited to the
    gallbladder in uncomplicated cholecystitis,
    elevation in the serum total bilirubin and
    alkaline phosphatase concentrations may not be
    present.
  • An elevated WBC is expected but not reliable.
    Only 61 of patients with cholecystitis had a WBC
    greater than 11,000. A WBC greater than 15,000
    may indicate perforation or gangrene.

41
  • Mild elevation of amylase up to 3 times normal
    may be found in cholecystitis, especially when
    gangrene is present.
  • Prothrombin time (PT) and activated partial
    thromboplastin time (aPTT) are not expected to be
    elevated unless sepsis or underlying cirrhosis is
    present. Coagulation profiles are helpful if the
    patient needs operative intervention.
  • For febrile patients, send 2 sets of blood
    cultures to attempt to isolate the organism.
  • Although expected to be normal, urinalysis is
    essential in the workup of patients with
    abdominal pain to exclude pyelonephritis and
    renal calculi.
  • Conduct a pregnancy test for women of
    childbearing age.

42
Imaging Studies
  • Ultrasound and nuclear medicine studies are the
    best imaging studies for the diagnosis of both
    cholecystitis and cholelithiasis. Plain
    radiography, CT scans, and endoscopic retrograde
    cholangiopancreatography (ERCP) are diagnostic
    adjuncts.

43
Abd. radiographs (Plain X-Ray)
  • Adominal radiographs have low sensitivity and
    specificity in evaluating biliary system
    pathology, but
  • They can be helpful in excluding other abdominal
    pathology such as renal colic, bowel obstruction,
    perforation. Between 10 and 30 of stones have a
    ring of calcium and, therefore, are radiopaque. A
    porcelain gallbladder also may be observed on
    plain films.

44
  • Emphysematous cholecystitis, cholangitis,
    cholecystic-enteric fistula, or postendoscopic
    manipulation may show air in the biliary tree.
    Air in the gallbladder wall indicates
    emphysematous cholecystitis due to gas-forming
    organisms such as clostridial species and
    Escherichia coli.

45
Computed tomography scan
  • CT scan is recommended only for the evaluation of
    abdominal pain if the diagnosis is uncertain. CT
    scan can demonstrate gallbladder wall edema,
    pericholecystic stranding and fluid, and
    high-attenuation bile.
  • Advantages For complications of cholecystitis
    and cholangitis, gallbladder perforation,
    pericholecystic fluid, and intrahepatic ductal
    dilation, CT scan may be adequate. CT scan
    provides better information of the surrounding
    structures than sonogram and HIDA. CT scan is
    also noninvasive.
  • Disadvantages CT scan misses 20 of gallstones
    because the stones may be of the same
    radiographic density as bile. CT scan is also
    more expensive and takes longer since the patient
    usually has to drink oral contrast. Also, given
    the radiation dose, it may not be ideal in the
    pregnant patient.

46
Ultrasound
  • An ultrasound is the most common test used for
    the diagnosis of biliary colic and acute
    cholecystitis. It is 90-95 sensitive for
    cholecystitis and 78-80 specific. For simple
    cholelithiasis, it is 98 sensitive and specific.

47
Findings include gallstones or sludge and one or
more of the following conditions
  • Gallbladder wall thickening (gt2-4 mm) -
    False-positive wall thickening found in
    hypoalbuminemia, ascites, congestive heart
    failure, and carcinoma
  • Gallbladder distention (diameter gt4 cm, length
    gt10 cm)
  • Pericholecystic fluid from perforation or exudate
  • Air in the gallbladder wall (indicating
    gangrenous cholecystitis)
  • Sonographic Murphy sign (86-92 sensitive, 35
    specific), pain when the probe is pushed directly
    on the gallbladder (not related to breathing)

48
  • Some sonographers recommend the diagnosis of
    cholecystitis if both a sonographic Murphy sign
    and gallstones (without evidence of other
    pathology) are present.
  • Additional findings in the presence or absence of
    gallstones Dilated common bile duct or dilated
    intrahepatic ducts of the biliary tree indicate
    common bile duct stones. In the absence of
    stones, a solitary stone may be lodged in the
    common bile duct, a location difficult to
    visualize sonographically.

49
  • Advantages of sonography include the following
  • Images other structures (eg, aorta, pancreas,
    liver)
  • Identifies complications (eg, perforation,
    empyema, abscess)
  • Rapidly performed at the bedside
  • No radiation (important in pregnancy)
  • Disadvantages of sonography include the
    following
  • Operator dependent and patient dependent
  • Inability to image the cystic duct
  • Decreased sensitivity for common bile duct stones

50
  • Biliary scintigraphy (HIDA, diisopropyl
    iminodiacetic acid DISIDA), nuclear medicine
    studies
  • Sonography or nuclear medicine testing is the
    test of choice for cholecystitis. HIDA scans have
    sensitivity (94) and specificity (65-85) for
    acute cholecystitis. They are sensitive (65) and
    specific (6) for chronic cholecystitis. Oral
    cholecystography is not practical for the ED.
  • HIDA and DISIDA scans are functional studies of
    the gallbladder. Technetium-labeled analogues of
    iminodiacetic acid (IDA) or diisopropyl
    IDA-DISIDA are administered intravenously (IV)
    and secreted by hepatocytes into bile, enabling
    visualization of the liver and biliary tree.

51
  • Normal scans are characterized by normal
    visualization of gallbladder in 30 minutes.
  • With cystic duct obstruction (cholecystitis), the
    HIDA scan shows nonvisualization (ie, considered
    positive) of the gallbladder at 60 minutes and
    uptake in the intestine as the bile is excreted
    directly into the duodenum.
  • Obstruction of the common bile duct causes
    nonvisualization of the small intestine.
  • The rim sign is increased tracer adjacent to the
    gallbladder at 60 minutes and suggests gangrenous
    cholecystitis.

52
  • Advantages of HIDA/DISIDA scans include the
    following
  • Assessment of function
  • Normal-appearing gallbladder (by ultrasound)
    obstructed cystic duct abnormal on DISIDA scan
    but not ultrasound.
  • Simultaneous assessment of bile ducts
  • Disadvantages of HIDA/DISIDA scans include the
    following
  • High bilirubin (gt4.4 mg/dL) possibly decreases
    sensitivity
  • Recent eating or fasting for 24 hours also
    possibly affects study
  • No imaging of other structures in the area

53
  • Other Tests
  • Endoscopic retrograde cholangiopancreatography
    (ERCP)
  • ERCP provides both endoscopic and radiographic
    visualization of the biliary tract. It can be
    diagnostic and therapeutic by direct removal of
    common bile duct stones.
  • Magnetic Resonance cholangiopancreatography (MRCP)

54
TREATMENT Conservative treatment followed by
cholecystectomy
  • Symptoms of acute cholecystitis subside with
    conservative treatment in 90 of cases
  • Four principles
  • Naso-gastric suction IV fluid
  • analgesics
  • Antibiotics (broad spectrum effective against Gm
    ve aerobes)
  • Subsequent management ( if inflame. Subside? oral
    fluids ? fat free diet)

55
  • Cholecystectomy on the next available list or
    after 4-6 wks
  • Conservative treatment is not advised if there
    is
  • Uncertain diagnosis
  • The possibility of high retrocecal appendix or
  • Perforated DU cannot be excluded
  • Conservative treatment must be abandoned if pain
    and tenderness increased ?percutaneous
    cholecystostomy ? subsequent cholecystectomy

56
TREATMENT Routine early operations
  • Indications
  • Within 24 hrs of the onset of the attack
  • Experienced surgeons
  • Excellent operating facilities
  • cholecystectomy can be done either by open or
    laparoscopic approaches

57
Acalcuolous cholecystitis
  • Some patients have non-specific inflammation of
    the GB , wherease other have one of the
    Cholecystoses
  • Diagnosis either by oral cholecystography (
    chronic cases) or by isotopic scanning (acute
    cases)
  • Cholesterol crystal in the duod. aspirate may
    help diagnosis

58
  • Acute acalcuolous cholecystitis is seen more
    frequently in
  • Critical illness
  • Major surgery or severe trauma/burns
  • Sepsis
  • Long-term TPN
  • Prolonged fasting

59
The Cholecystoses
  • Not uncommon conditions affecting the GB where
    there is chronin inflamm. Changes with
    hyperplasia of of all tissue elemnts
  • Cholesterosis (Strawberry GB)
  • Submucous aggregations of cholesterol crystals
    and cholesterol esters (yellow seeds) in the red
    mucosa

60
  • Cholesterol polyposis of the GB
  • These are either cholesterol polyposis or
    adenomatous changes
  • Cholecystitis glandularis proliferans (polyp,
    adenomyomatosis and intramural diverticuolosis)
  • MM polyps- fleshy and granuolomatous
  • All layer of GB may be thickened
  • Sometimes incomplete septums forms
  • Intraparietal mixed calculi may be present

61
  • Diverticuolosis of the GB
  • Usually manifest as black pigment stones impacted
    in the out-pouchings of the lacunae of Luschka
  • Typhoid GB
  • S. Typhi or occasionally S Typhimurium can infect
    the GB leading to acute cholecystitis and more
    commonly chronic cholecystitis
  • The patient being typhoid carrier excreting the
    bacteria in the bils
  • Gall stones may be present

62
GB cancer
  • Rare ( common in certain area as India where it
    reaches 9 of biliary tract disease
  • Found in less than 1 of GB operations
  • In over 90 of cases gall stones are present
  • Presentations
  • Age 70s
  • Sex female (F-M 5-1)
  • Pathology
  • Scirrhous, but may be squamous cell mixed
    squamous adenocarcinoma
  • Spread direct, lymphatics and veins

63
  • Clinical P
  • Either extensive mass in the liver during
    investigations for jaundice or
  • At cholecystectomy at the time the histology is
    received
  • Treatment
  • Those diagnosed at cholecystectomy and confined
    to the mucosa have a good prognosis (add wide
    excision LN clearance or not ??)
  • Large T reaching serosa chemoradiotherapy
  • Median survival 1 year

64
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