Gallstones Case File

Gallstones Case File

Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo Papasakelariou, MD, FACOG

CASE 19

A 42-year-old woman is seen by her primary care physician complaining of intermittent colicky pain. She describes the pain as being right upper quadrant (RUQ), starting shortly after eating a meal, and lasting about 30 min. During these episodes, she feels bloated and nauseated. The patient also states that over the past 2 days, her stools have become very light in color, like the color of sand, and her skin has become yellow.

⯈ What is the most likely diagnosis?

⯈ What is the anatomic basis for the clinical condition?

ANSWER TO CASE 19:

Gallstones

Summary: A 42-year-old woman presents with intermittent colicky RUQ abdominal pain shortly after eating, that lasts for about 30 min. It is associated with bloating, nausea, and a 2-day history of acholic stools and icterus.

• Most likely diagnosis: Gallstones

• Anatomical basis for condition: Bile duct obstruction, probably by gallstones

CLINICAL CORRELATION

This middle-aged woman has the typical symptoms of biliary colic, which is intermittent crampy abdominal pain in the epigastric region of the RUQ, sometimes radiating to the right shoulder. These symptoms typically appear after meals, particularly fatty meals. The more concerning signs are the light-colored stools (acholic) and jaundice (icterus). Gallstones (cholelithiasis) are precipitated bile salts in the gallbladder, which may produce inflammation of the gallbladder (cholecystitis). Stones can pass into the cystic duct and into the common bile duct. Since the common bile duct is formed by the union of the cystic and common hepatic ducts, obstruction of the common bile duct prevents bilirubin produced in the liver from reaching the small intestines. The stools thus lack this pigment. As a secondary result of the obstruction, serum bilirubin is elevated, and precipitates in the skin, resulting in the yellow tint. Ultrasound can often make the initial diagnosis. Removal of a common bile duct stone can be performed by upper GI endoscopy through the ampulla of Vater or surgically.

APPROACH TO:

The Gallbladder

Objectives

1. Be able to describe the anatomy of the gallbladder and hepatobiliary duct system

2. Be able to describe the clinically important anatomical relationships of the cystic and common bile ducts

DEFINITION

CHOLECYSTITIS: Inflammation of the gallbladder often associated with gallstones

DISCUSSION

The gallbladder is an inverted, pear-shaped, fibromuscular sac that provides temporary storage and intermittent release of bile, which is produced in the liver. Its surface position can be approximated at the intersection of the right margin of the

Figure 19-1. Relationships of the gallbladder. (Reproduced, with permission, from Lindner HH. Clinical Anatomy. East Norwalk, CT: Appleton & Lange, 1989.)

rectus sheath (linea semilunaris) and the right costal margin. Its anterior surface is fused to the liver between the right and quadrate lobes, and its fundus, lateral, and posterior surfaces are covered with visceral peritoneum. It is anatomically divided into fundus, body, and neck, which is continuous with the cystic duct. The mucosa of the neck and cystic duct are spiral fold, which acts as a valve to keep the lumen of the duct and neck open to receive bile. The gallbladder and cystic duct are supplied by the cystic artery, typically a branch of the right hepatic artery (see Figure 19-1).

The biliary duct system begins as bile canaliculi between hepatocytes within the liver. The canaliculi empty into microscopic interlobular bile ducts, which unite to form increasingly large ducts, eventually forming segmental and lobar ducts draining anatomical subdivisions of the liver of the same name. Ultimately, right and left hepatic ducts emerge from the liver’s porta hepatis and unite to form the common hepatic duct within the hepatoduodenal ligament (a portion of the lesser omentum). The cystic duct joins the common hepatic duct from the right to form the common bile duct, which passes inferior within the hepatoduodenal ligament and then passes posterior to the first partbile canaliculi of the duodenum. It turns slightly to the right on or within the posterior surface of the pancreas. As it approaches the posteromedial wall of the duodenum, it is typically joined by the main pancreatic duct to form the hepatopancreatic ampulla, which opens on the major duodenal papilla.

At the porta hepatis, the right and left hepatic ducts are the most anterior structures. The hepatic arteries (right and left) lie posterior to the hepatic ducts, and the branches of the portal vein lie most posterior. The common hepatic duct (on the left), the cystic duct (on the right), and the inferior border of the liver (superior) form the cystohepatic triangle of Calot, which contains the right hepatic artery and its cystic artery branch.

Within the hepatoduodenal ligament, the anterior boundary of the epiploic foramen (of Winslow), the common bile duct lies to the right, the common hepatic artery lies to the left, and the portal vein lies posterior and between the duct and the artery.

COMPREHENSION QUESTIONS

19.1 Which of the following is the correct landmark for locating the normal position of the gallbladder during a physical examination?

A. The lowest point of the left subcostal margin

B. The junction between the left linea semilunaris and the subcostal margin

C. The lowest point of the right subcostal margin

D. The junction between the right linea semilunaris and the subcostal margin

E. The junction between the right linea semilunaris and the subcostal plane

19.2 During a surgical procedure in which you will remove the gallbladder, you will expect its blood supply, the cystic artery, to arise from which of the following arteries?

A. Right hepatic artery

B. Left hepatic artery

C. Proper hepatic artery

D. Common hepatic artery

E. Right gastric artery

19.3 During the surgical procedure described in question 19.2, your index finger is placed into the epiploic foramen. Which of the following structures would be inferior to your finger?

A. Caudate lobe of the liver

B. First part of the duodenum

C. Inferior vena cava

D. Portal vein

E. Hepatic artery

19.4 A 45-year-old woman with a history of gallstones visits the emergency department complaining of severe abdominal pain and vomiting for 1 day. The exam shows a distended abdomen and high-pitched bowel sounds. Radiographs of the abdomen show air in the biliary tree and the gallbladder. Which of the following is the most likely location for the gallstone to be found?

A. Common bile duct

B. Duodenum

C. Sphincter of Oddi

D. Jejunum

E. Ileum

F. Ascending colon

ANSWERS

19.1 D. The gallbladder is normally located at the junction between the right semilunar line and the right subcostal margin.

19.2 A. The cystic artery typically is a branch of the right hepatic artery.

19.3 B. The first part of the duodenum will lie inferior to a finger within the epiploic foramen.

19.4 E. The diagnosis is likely gallstone ileus, in which a large gallstone is impacted in the ileocecal valve. Air in the biliary tree is caused by a fistula between the bowel and the biliary tree, allowing air from the bowel to enter the biliary system. The gallstone causes bowel obstruction. This is a surgical emergency.

ANATOMY PEARLS

⯈ The gallbladder fossa lies between the right and quadrate lobes of the liver.

⯈ The cystic artery is usually a branch of the right hepatic artery.

⯈ The hepatic ducts are the most anterior structures at the porta hepatis.

⯈ The bile duct lie to the right within the hepatoduodenal ligament.

References

Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy, 2nd ed. New York, NY: Thieme Medical Publishers; 2012:168−169. 

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2014:277−280, 286−288. 

Netter FH. Atlas of Human Anatomy, 6th ed. Philadelphia, PA: Saunders; 2014: plates 280−281, 283.

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