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Gall bladder and bile ducts



As in many other organs and tissues, in the human liver, secretory processes are subordinated to a certain rhythm. Bile secretion prevails during the day, glycogen production prevails at night. The effect of a nightly decrease in the secretion of bile, which has a physiological basis, is enhanced even more with biliary dyskinesia (a violation of the coordinated work of the smooth muscles of the ducts and gallbladder, which has a different nature). Relatively normal liquid bile, directly pouring out from the liver, while remaining in the gallbladder due to the impurity of mucus secreted by the epithelium of this organ, as well as due to the absorption of water and electrolytes, becomes thicker and darker (dark green).

The structure of the mucous membrane of the gallbladder corresponds to the functions of absorption and excretion. It contains many folds, sometimes looking like villi, and is covered with a high single-layer prismatic epithelium (Fig. 17.16, A). In the area of ​​the neck of the gallbladder, the folds of the mucous membrane, fused together, form Heyster spiral valves (spiral folds, Geister valves; L. Heister). These valves continue into the cystic duct. They help keep bile between meals. In the epithelium, goblet cells are often found, the number of which increases sharply with a number of diseases of the biliary tract. Under the epithelium is a well-developed fibrous lamina propria. The outflow of bile from the gallbladder is stimulated by the entry of food (in particular, its fatty components) into the duodenum. An outpouring of bile is ensured by



Fig. 17.16.

The gallbladder is normal and with gallstone disease

.

A - folded-villous mucous membrane of the gallbladder of an adult. B - gallstones of a mixed type in the cavity of the bladder.

muscle contractions and associated relaxation of the sphincter of Oddi (R. Oddi; sphincter of the hepatic-pancreatic ampoule in the junction of the mouths of the common bile and pancreatic ducts located inside the large papilla of the duodenum). Initially, the gallbladder releases only part of its contents into the duodenum. Then small amounts of bile enter there at regular intervals. But nevertheless, 30-50 ml of bile always remains in the bladder. Between periods of release of bile into the intestine, its new flow is uniformly and through the same cystic duct flows from the liver into the gall bladder. Here the bile is again concentrated. However, its small volumes bypassing the cystic duct enter directly into the duodenum. Thus, a small amount of bile reaches the lumen of the intestine even in those periods when it passes through the cystic duct in the direction opposite to the path of its release from the bladder.

Small budding of the mucous membrane of the gallbladder can penetrate the muscle membrane and even penetrate it. As cystic dilated glandular cavities lined with either high or flattened epithelium, they are called the Rokytansky – Aschoff sinuses (C. Rokitansky, L. Aschoff). The secondary origin of these buddings, or sinuses, appearing, apparently, with inflammation is assumed. In some people, tubular canals are visible under the serous membrane of the gallbladder, often associated with intrahepatic bile ducts. These are the ducts of Lushka (the true ducts of Lushka, H. Luschka; there are also Lushka's ducts - ducts of the mucous glands of the gallbladder, which grow with gallstone disease and sometimes reach the serous membrane of the organ). The ducts of Lushka are also lined with prismatic epithelium. Under the serous membrane of the gallbladder, fatty tissue is located, in which the blood and lymph vessels, nerves, and paraganglia are located. Outside, the organ is covered with a peritoneum, except for the zone that is closely adjacent to the liver or even enters it.

Gallstone disease (cholelithiasis). Gallstones (bile calculi) are formed from the components of bile - cholesterol, bile pigments and calcium salts. Along with other organic material, these components are represented in stones in various proportions. Stones usually form in the gallbladder, but often also in the extrahepatic, and occasionally in the intrahepatic bile ducts. Cholesterol stones are rare in developing countries, but are very common among North American Indians. Gallstones are more often found in older people, in particular women, especially those who have given birth again. Among the diseases in which stone formation is noted, diabetes and obesity should be mentioned. In addition, stones are formed with the long-term use of oral contraceptives and after the endured ileum resection (due to a decrease in the bile acid content).

The mechanisms of stone formation are still actively discussed. The main predisposing factors are the composition of bile, local factors in the gallbladder and infections (cholecystitis). Let us dwell on these factors.

The composition of bile. Bile is a secretory product produced by hepatocytes and plays an important role in the digestion and absorption of lipids in the intestines. In clinical practice, it is popular to divide the secreted bile into portions, depending on its location: duodenal (portion A), cystic (B) and hepatic (C). The indicated portions differ in composition. The relative density of gallbladder bile is 1.04 (water in it occupies about 87% of the mass), and hepatic - 1.01 (97% of the water). The concentration of the main components in portion B is 5-10 times higher than in portion C. In portions A and C, bile is golden yellow, and in portion B it is dark olive or brown. Within 1 day, a healthy person produces 500-1000 ml of bile (10 ml per 1 kg of body weight).

An important component of most gallstones is cholesterol (cholesterol). It is synthesized in the liver and excreted in the bile. Despite the absolute insolubility in water, cholesterol passes into a soluble state under the action of phospholipids and bile salts. These substances, acting together, form molecular aggregates (mixed clusters) that maintain stability in the liquid part of bile. Phospholipids are mainly represented by lecithins (96%) and small amounts of lysolecithin and phosphatidylethanolamine. In an aqueous medium, phospholipids are distributed in the form of liquid crystals. As a secondary solvent system, they also interact with cholesterol. The ratio of cholesterol to the concentration of conjugates of bile acids and phospholipids in bile determines the formation of mixed clusters or phospholipid-cholesterol aggregates. And this in turn determines the overall solubility of cholesterol in bile.

Primary bile acids are synthesized in the liver from cholesterol. The most important of them are cholic and chenodeoxycholic (anthropodeoxycholic) acids (the first is monocarboxylic trioxy acid, found in bile in the form of sodium salts of glycocholic and taurocholic acids; the second is a derivative of cholic acid). They are secreted into the bile as conjugates with the amino acids glycine and taurine, the ratio of which in the conjugate is 3: 1. In the colon, primary bile acids undergo bacterial dehydroxylation, resulting in the formation of secondary bile acids - deoxycholic and lithocholic. So they are the main bile acids, which, together with other forms of lesser importance, make up the bile acid fund. More than 85% of this fund is subject to reverse absorption in the distal small intestine and large intestine and again enters the bloodstream through the so-called enterohepatic circulation. This part has a detergent-like (cleansing) effect, contributing to the formation of mixed clusters.

The tendency to the formation of gallstones occurs when there is a relative predominance of cholesterol over bile acids and phospholipids - lithogenic bile (contributing to stone formation). It appears as a result of either an increase in cholesterol concentration in bile, or a decrease in the volume of the bile acid fund. Such changes are usually characteristic of patients with gallstones, but have not yet received a theoretical explanation. The presence of lithogenic bile alone is considered insufficient to explain the formation of gallstones. It is known that it can be in persons who possess and do not possess such stones. It is shown that with the same degree of lithogenicity of bile, cholesterol is capable of much more rapid formation of microcrystals in the bile of patients with stones than not. Thus, we can assume the presence of some other factors contributing to the crystallization of cholesterol.

Local factors in the gallbladder. The significance that the mucous membrane of the gallbladder and the mucus and glycoprotein produced by it have in stone formation is unknown. The role of local stagnation of bile is also obscure.

Infections The involvement of infection in the formation of cholesterol or pigment stones is questioned. In most people, bile is sterile and remains so in many patients with stones. However, infection can increase the effects of local factors and thus contribute to the growth of stones and the formation of new or mixed stones.

Types of stones. The most common are stones, consisting mainly of cholesterol. In addition, all stones contain calcium salts and a mucous skeleton. As for stones consisting only of pigments or calcium carbonate, this is rare.

Cholesterol (cholesterol) stones are classified as mixed, or layered (colloidal crystalline), pure cholesterol and complex cholesterol.
Touch each of these species. Mixed, or layered, gallstones are the most common option. As a rule, they are multiple and very numerous (see Fig. 17.16, B). Their sizes vary from the size of a grain of sand to stones with a diameter of more than 1 cm. The shape of the stones is also diverse and often multifaceted. On the surface of the cut, such stones have a distinct layered structure, dark brown layers alternate with paler ones. These layers consist mainly of cholesterol and bile pigments, respectively. But in each of them there are impurities of calcium salts and organic material. The stones can be freely placed in the bile or be closely packed in a contracted gall bladder having thickened walls.

Pure cholesterol stones are usually single, rounded, and their diameter can exceed 3 cm. They have a pale yellow color, a soapy surface and float in water. When they split, they discover a crystalline structure consisting of beams of cholesterol crystals that radially diverge from the center. There is no lamination. However, due to the secondary deposition of bile pigments and calcium salts, such stones have a layered cortical zone. This happens with gallstone disease complicated by bacterial cholecystitis. In this case, the stones are called complex cholesterol. They reach the largest sizes.

Stones from bile pigments, as a rule, are also multiple, black, have an irregular, sometimes star-shaped form, consist mainly of bile pigments and can be brittle or dense. Such stones are often found in chronic hemolytic anemia and are formed with an excess of bile pigments in bile. They are also detected in patients with invasive parasitic diseases (for example, malaria). The gall bladder almost never changes.

Calcium stones are rare. If they are found, then in the form of multiple small, pale, yellowish and very hard stones.

Gallbladder cholesterosis develops as a result of multiple small focal deposition of cholesterol esters (esters) with birefringence. These esters are deposited in the macrophages of the mucous membrane, which leads to the creation on the surface of the mucous membrane of thin, distinct, yellow stripes resembling scales. Delayed in the apical sections of the stroma of the villi of the mucous membrane of the gallbladder, cholesterol esters can lead to polyp-like thickening of the villi. Gallbladder cholesterosis is associated with the formation of cholesterol stones in 30% of patients.

Cholecystitis. This inflammation of the gallbladder is one of the most common causes of abdominal pain and often results in cholecystectomy.

Acute cholecystitis. It is almost always associated with the presence of stones. In the early stages of the disease, bacteria cannot be isolated and cultured from the gallbladder. Therefore, it is believed that chemical factors initially cause inflammation. Difficulty for the exit of bile leads to an increase in the concentration of its components, which has an irritating effect, accompanied by inflammation. Further, a secondary infection that enhances inflammation may occur. Among the possible pathogens, two are named - E. coli and Streptococcus faecalis. They are believed to enter the gallbladder through the lymphatic vessels. Acute cholecystitis rarely develops in the absence of stones. In such a situation, it is usually associated with some kind of infection.

Edema, fibrinous exudate, neutrophilic infiltration, and sometimes ulceration and hemorrhage are noted in the wall of the affected gallbladder. In the case of a stable blockage of the cystic duct by a stone, a clot of exudate, or edematous walls of an organ, more severe changes develop. Pus appears in the lumen of the bladder, and phlegmonous inflammation begins in the wall or less often, in the case of superficial damage to the mucous membrane, empyema of the gallbladder develops. Small abscesses or zones of necrosis can form inside the gallbladder wall. Then wall breaks and penetration of the contents of abscesses or gall bladder into the abdominal cavity are possible. As an outcome of fibrinous cholecystitis, fibrotic adhesions between the gallbladder and surrounding organs are observed. Acute cholecystitis is a recurring disease that can go into a chronic process.

Chronic cholecystitis. It can occur as a result of repeated attacks of acute cholecystitis. However, in many patients this disease begins gradually, initially accompanied by mild dyspeptic symptoms, less often weak biliary colic (pain in the right hypochondrium). Often gallstones are found. The wall of the gallbladder can be wrinkled, as a rule, has a fibrous thickening. Under the microscope, sclerosis of the own plate of the mucous membrane and hypertrophy of the muscular membrane of the gallbladder (Fig. 17.17), Rokytansky-Ashoff sinuses are determined. In the case of rupture of one or more sinuses and penetration of bile into the wall of the gallbladder, a granulomatous reaction may appear, and signs of chronic inflammation and subsequent fibrosis spread much further than the rupture zone.

Complications of cholelithiasis and cholecystitis. Since both diseases have a close pathogenetic relationship, it is advisable to consider their complications together. Gallstones, single or multiple, exist without



Fig. 17.17.

Chronic cholecystitis

; atrophy and sclerosis of the mucous membrane, hypertrophy of the muscle membrane.

any symptoms. But if the stone is wedged into the neck of the gallbladder or stuck in the cystic duct, the organ is stretched by bile. Pigments are absorbed from stagnant bile. The remaining contents become transparent and acquire a mucous consistency - the gallbladder mucocele develops (stretching of accumulated mucus). In the presence of infection, the contents become cloudy and gradually turn into pus - empyema and (or) phlegmon of the gallbladder occurs. Inflammation in the wall of the gallbladder may be accompanied by necrosis. With a through necrotic lesion of the wall of the bubble, it may rupture with the penetration of the contents into the abdominal cavity and the development of peritonitis. Stones can clog the common bile duct, causing bile colic, symptoms of extrahepatic obstruction, and obstructive (mechanical) jaundice. If the stone is not tightly adjacent to the walls of the duct, then jaundice is intermittent. Often a secondary infection develops with downward cholangitis. Sometimes calculous obstruction (obstruction by stones) of the bile duct leads to biliary cirrhosis. In chronic cholecystitis, the wall of the gallbladder becomes thickened and is often in a reduced state around numerous stones located in the body cavity. Outside, adhesions between the gallbladder and surrounding organs are noted, and inside - ulceration caused by chronic stone damage. In the presence of large stones (cholesterol type), ulcer penetration and fistula formation from the gallbladder to the duodenum, less often the large intestine, occur. In this situation, air and bacteria enter the affected gallbladder, and gallstones enter the intestines. Finally, long-existing irritation of the mucous membrane of the gallbladder with stones leads in some patients to the development of carcinoma of the gallbladder, less commonly, cancer of the large bile ducts.

Tumors and congenital malformations of the biliary tract. Benign neoplasms of this tract, both epithelial (papilloma) and non-epithelial (fibroma, lipoma), are extremely rare.

Gallbladder carcinoma. This is a fairly rare tumor. У 80 % больных она возникает на основе желчнокаменной болезни. Вместе с тем из огромного числа лиц, имеющих желчные камни, лишь у 2 % развивается рак. Зона малигнизации чаще всего находится в дне или шейке желчного пузыря. Как правило, опухоль отличается медленным, но инвазивным ростом. Изредка желчный пузырь поражается целиком, и его обнаружение возможно лишь по небольшой полости, заполненной камнями. Опухоль может врастать или же метастазировать в печень, а также в лимфатические узлы ворот печени. В большинстве случаев опухоль представлена аденокарциномой. Иногда в результате вторичной метаплазии эпителия желчного пузыря развивается плоскоклеточный рак.

Карцинома может также возникать в крупных желчных протоках. Обычно это небольшая и медленно растущая опухоль, вызывающая обтурационную желтуху. Типичной является локализация в дистальной трети общего желчного протока и в зоне стыка пузырного и печеночного протоков. Что касается карциномы ампуллярной части, то, как правило, крайне трудно определить, откуда развивается опухоль — из желчного или панкреатического протока.

Congenital malformations. Известно довольно большое количество аномалий желчного пузыря, которые могут изменять его размеры, форму, местоположение, отношение к печени и т.д. В связи с этими аномалиями (особенно у молодых лиц) встречаются также желчные камни. Кроме того, изредка наблюдаются различные формы и степени атрезии (отсутствия) внепеченочных желчных путей, приводящей к билиарному циррозу. Кисты общего желчного протока, которые сопровождаются мешковидными расширениями желчевыводящих путей, возникающими выше кисты, а также желтухой и холангитом, тоже относятся к весьма редким врожденным аномалиям.

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Желчный пузырь и желчные протоки

  1. ЗАНЯТИЕ 6 ТЕМА. БОЛЕЗНИ ПЕЧЕНИ, ЖЕЛЧНОГО ПУЗЫРЯ, ЖЕЛЧНЫХ ПРОТОКОВ И ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ
    Motivational characteristic of the topic. Знание патологоанатомических проявлений болезней и синдромов гепато-холецисто-панкреатической зоны необходимо для успешного усвоения этих страданий человека на клинических кафедрах. В практической работе врача эти знания необходимы для клиникоанатомического анализа секционных случаев и биопсий печени. The general purpose of the lesson. Научиться по морфологическим признакам
  2. ЗАБОЛЕВАНИЯ ПЕЧЕНИ, ЖЕЛЧНОГО ПУЗЫРЯ, ЖЕЛЧНЫХ ПРОТОКОВ И ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ
    В этой главе продолжено изложение патологии пищеварительной системы. Согласно традициям, ряд заболеваний печени и желчных путей, несмотря на их инфекционную этиологию, рассматривается не в главе 14, посвященной инфекциям, а здесь. То же касается сахарного диабета, описание которого по соображениям целесообразности включено в эту
  3. Liver, gall bladder and bile ducts
    The liver of the newborn is relatively large, especially its left lobe, to which the spleen is adjacent. Cases of agenesis of the liver are rare, they are more often found to be underdeveloped. On the back or on the lower surface of the liver, you can sometimes see congenital notches, often located in the sagittal direction. If these depressions are significant, the liver is divided into additional lobes.
  4. Киста общего желчного протока
    Синонимы Киста холедоха. ОПРЕДЕЛЕНИЕ Киста общего желчного протока — врожденное расширение желчного протока, которое в 2-5% случаев вызывает полное нарушение проходимости желчевыводящих протоков и может быть причиной внепеченочного холестаза. КОД ПО МКБК83.5 Желчная киста. СКРИНИНГ УЗИ плода позволяет выявить кисту общего желчного протока (начиная с 19-й недели гестации). КЛАССИФИКАЦИЯ По
  5. Атрезия внепеченочных желчных протоков
    синонимы Билиарная атрезия, непроходимость внепеченочных желчных протоков. ОПРЕДЕЛЕНИЕ АВЖП — прогрессирующая облитерация внепеченочных желчных протоков, начинающаяся в период внутриутробного развития, с постепенным вовлечением в процесс внутрипеченочной желчной системы и формированием билиарного цирроза. КОД ПО МКБ-Q44.2 Атрезия желчных протоков. ЭПИДЕМИОЛОГИЯ АВЖП — наиболее частая причина
  6. Gall bladder (problems)
    The gall bladder is a hollow organ that contains bile coming from the liver and prevents it from flowing into the intestine in between meals. During the digestion of food, the gallbladder opens and expels bile through the bile duct into the duodenum. Bile is necessary so that the intestines can absorb fats from food. Most common problem related
  7. Features of the gallbladder
    The gall bladder is located under the right lobe of the liver and has a fusiform shape, its length reaches 3 cm. It acquires a typical pear-shaped form by 7 months, by 2 years reaches the edge of the liver. The main function of the gallbladder is the accumulation and secretion of hepatic bile. The bile of a child is different in composition from the bile of an adult. It has few bile acids, cholesterol, salts, a lot
  8. Cholecystitis (inflammation of the gallbladder)
    Causes Typically, the presence of stones in the gallbladder or its ducts. Pathological thickening of bile as a result of a viral infection, errors in diet, abnormal structure of the gallbladder, overweight, prolonged stressful situation, diseases of the gastrointestinal tract and liver. Symptoms Pain in the upper right abdomen, fever, fat intolerance, may be temporary
  9. Gallstones
    Causes Impaired metabolism in the liver (bile is oversaturated with cholesterol). Overweight women get sick more often. One of the reasons is a sedentary lifestyle combined with errors in the diet (excess fat, fried, spicy and smoked foods, alcohol). In complex cases, cancer of the biliary tract and gall bladder can occur. Symptoms Soreness on palpation in the right
  10. Gall bladder cancer
    Epidemiology. Gallbladder cancer accounts for 2-8% of all malignant tumors and in frequency it takes 5-6 place among digestive tumors. Ill men relate to women in a ratio of 1:14. 90% of patients older than 60 years. For 100 planned cholecystectomies for chronic calculous cholecystitis, there is a histological finding of 3 cases of cancer in situ of the gallbladder.
  11. Diseases of the biliary tract and gallbladder
    Diseases of the biliary system are very common. Patients with this pathology in the general population are on average 2, and among women - almost 10 times more than patients with peptic ulcer. Among the numerous diseases of the biliary tract, it is advisable to single out mainly functional disorders (dyskinesias), inflammatory (cholecystitis), and metabolic (gallstone
  12. Diseases of the gallbladder and biliary tract in children
    Questions for repetition: 1. Duodenal sounding and its assessment. 2. The main pain points in the disease of the gallbladder and biliary tract. Test questions: 1. Biliary dyskinesia. Concept. Etiopathogenesis. Classification. 2. Clinical and diagnostic criteria for biliary dyskinesia: 2.1. hypermotor type 2.2. hypomotor type 3. Treatment of dyskinesia
  13. LIVER. Gallbladder
    The liver (hepar) is the largest gland of the human body (Fig. 78). Its weight is about 1500 g. It performs several main functions: digestive, forms a protein, detoxifies, hematopoietic, carries out metabolism, etc. The liver is located in the right hypochondrium and in the epigastrium. In shape, it resembles a wedge, has an upper and lower surface. Upper (diaphragmatic)
  14. Diseases of the liver and gall bladder
    With the development of possibilities for diagnosing diseases of internal organs, it was found that liver disease (hepatopathy) is much more common than previously thought, and that many vague signs of disease are based on hepatosis. Due to the importance and variety of functions, the liver is endowed with a natural ability for high regeneration. Therefore arising under the influence of different
  15. Nutrition for diabetes with diseases of the liver and gall bladder
    Nutrition in the treatment of this disease should improve metabolic processes that are disturbed by diabetes and diseases of the liver and gall bladder. Products that improve liver function, enhance biliary excretion, and help normalize intestinal activity are introduced into the diet of a diabetic. Foods that impede liver function are excluded from nutrition. It is recommended to include milk and
  16. Diseases of the liver, gallbladder and pancreas
    DISEASES OF THE LIVER, GALL BLADDER AND Pancreas
  17. Nutrition for exacerbation of liver inflammation and acute gallbladder inflammation
    Nutrition is recommended for patients with acute cholecystitis and hepatitis, chronic cholecystitis and hepatitis, liver cirrhosis with moderate liver failure, cholelithiasis, as well as with simultaneous damage to the liver and biliary tract, stomach and intestines. Food is cooked in water or steamed, wiped. Excluded foods that enhance fermentation and rotting in
  18. Recommended products for exacerbation of liver inflammation and acute gallbladder inflammation
    Recommended: yesterday’s wheat bread; soups are prepared on a mucous broth with grated cereals, vegetables or on vegetable broths with finely chopped vegetables - potatoes, carrots, zucchini, pumpkin, boiled cereals - rice, semolina, oatmeal, noodles, and egg-milk mixture can be added to soups, which is prepared mix raw eggs with an equal volume of milk, and season
  19. Питание для больных сахарным диабетом легкой степени тяжести с заболеваниями печени и желчного пузыря с нормальной массой тела, получающим сахароснижающие препараты (диета на 2500 калорий)
    НАБОР ПРОДУКТОВ НА ДЕНЬ Хлеб черный 300 г. Картофель 100 г. Овощи 800 г. Крупа гречневая, овсяная или перловая 50 г. Мясо (говядина II категории или куры) 160 г. Бульон мясной 300 г. Белок яйца 2 штуки. Творог обезжиренный 200 г. Молоко 600 г. Кефир или простокваша 200 г. Масло сливочное 25 г. Масло растительное 25 г. Колбаса диетическая 50 г. Сахар 20 г. ПРИМЕРНОЕ МЕНЮ НАДЕНЬ
  20. Diseases of the liver and biliary tract in newborns
    The earliest manifestation of most diseases of the liver and biliary tract is cholestasis syndrome. Depending on the level of damage to the hepatobiliary system, it is customary to isolate diseases manifesting with extrahepatic and intrahepatic cholestasis. Diseases of the hepatobiliary system, manifested by extrahepatic cholestasis The causes of extrahepatic cholestasis in newborns can be: • Atresia
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