The Gall bladder:
It is a pear shaped organ measuring about 7.5 to 12.5 cm long. It is capable of considerable distention in certain pathological conditions.

The Anatomical subdivisions are
a) fundus
b) body
c) neck; which terminate in the narrow infundibulum.
The mucus membrane contains indentations of the mucosa that sink into the muscle coat. These are crypts of Luschka

The cystic duct:
It is about 2.5 cm in length. It contains the spiral valve of Heister.

The common hepatic duct:
It is usually less than 2.5 cm long. It is formed by the union of right and left hepatic duct.

The common bile duct:
It is about 7.5 cm long. It is formed by the union of the cystic and common hepatic ducts. It is divided into four parts;
a) the supraduodenal portion
b) the retroduodenal portion
c) the infraduodenal portion
d) the intraduodenal potion. It is surrounded by the sphincter of Oddi

The common bile duct terminates by opening on the summit of the papilla of Vater.

Arterial supply of Gall bladder:
Gall bladder is supplied by cystic artery, which is a branch of the right hepatic artery and occasionally an accessory cystic artery from gastroduodenal artery.

Lymphatic drainage:
The lymph vessels of Gall bladder drain into the cystic lymph nodes of Lund; which lies in the fork created by the junction of the cystic and common hepatic ducts. Efferent vessels from this lymph node go to the hilum of the liver and to the coeliac lymph nodes.

Surgical physiology:
Bile consists of 97% water, 1-2 % bile salts and 1 % pigments, cholesterol and fatty acids. Liver excretes bile at a rate estimated at 40 ml per hour.

Functions of Gall bladder:
1. Reservoir of bile:
During fasting, resistance to flow through the sphincter is high and bile excreted by the liver is diverted to the gall bladder. After feeding the resistance to the flow through the sphincter of oddi is reduced, the gallbladder contents and bile enters the duodenum. This motor response of the biliary tract is effected by the hormone cholecystokinin released by the upper intestinal mucosa in response to food, particularly fats.
2. Concentration of bile:
The bile is concentrated 5 to 10 times, by the active absorption of water, sodium, chloride and bicarbonates by the mucus membrane of the gall bladder.
3. Secretion of mucin:
About 20 ml is secreted per day.

GALLSTONES (CHOLELITHIASIS)

Gallstones are the commonest biliary pathology.

Classification:
According to their chemical composition, gallstones are classified into
a) Cholesterol stones: Comprises 6 %, usually solitary ( Cholesterol Solitaire)
b) Mixed stones: Account for 90% of gallstones. Their main content is cholesterol, calcium carbonate, calcium phosphate, calcium bicarbonate, calcium palmitate and proteins. Usually multiple and often faceted.
c) Pigment stones: They contain calcium bilirubinate. They are usually small, black and multiple.

Sea gull sign or Mercedes Benz sign:
The center of the stone may contain radioluscent gas in a triaradiate or biradiate fissure and this gives rise to characteristic dark shapes on x-ray, which is known as Sea gull sign or Mercedes Benz sign.

Incidence of gallstone:
A ‘ Fat, Fertile, Flatulent Female of Fifty’ is the classical sufferer from symptomatic gallstones. Stones are rarer in Africa and in South India; but not in North India.

Causative factors:
They may be divided into
1. Metabolic
2. Infective
3. Bile stasis

Cholesterol and Mixed stones:
1. Metabolic:
Cholesterol insoluble in water is held in solution by the detergent action of bile acids and phospholipids, with which it forms Micelles. Bile containing cholesterol stones has an excess of cholesterol relative to bile salts and Phospholipids, thus allowing cholesterol crystals to form. Such a bile is termed ‘ supersaturated or lithogenic’. Bile cholesterol increases with age and is raised in individuals who are obese and who are taking contraceptive pills and Clofibrate (a drug used in hyperlipoproteinemia). The concentration of bile salts is reduced by oestrogen and by those factors which interrupt the enterohepatic circulation of bile salts (ileal diseases, resection or by pass and Cholestyramine therapy). These conditions are associated with an increased incidence of stones.

2. Infection:
Organisms can be cultured from the center of gallstones. The radioluscent center of many gallstones represents mucus plugs, originally formed around bacteria.
3. Bile stasis:
Oestrogens in pregnancy and truncal vagotomy reduce gall bladder contractility. Gallstones are formed in such situations. Patients on long term parenteral nutrition also have a high incidence of stones.

Pigment stones:
They are seen in patients with hemolysis; in which bilirubin production is increased. For example: Hereditary Spherocytosis, Sickle Cell Anemia, Thalassemia, Malaria and mechanical destruction of red cells by prosthetic heart valves. They are also seen in patients with benign or malignant strictures. They are also common in Cirrhosis. They are often associated with Ascaris lumbricoides infestation. E. coli may be found in the bile of the patients with pigment stones. E.coli produce enzyme beta glucoronidase, which converts bilirubin to its unconjugated insoluble form.

Saint’s triad:
It constitutes;
1. Gallstone
2. Diverticulosis of colon
3. Hiatus hernia

The effects and complications of gallstones:
Gallstones are usually found in the gall bladder; but may also be present in the bile ducts. The effects and complications of gallstones may be summarized as follows;

1. In the gall bladder:
Silent stones
Chronic cholecystitis Gangrene
Acute choecystitis Perforation
Empyema

2. In the bile duct :
Mucocele
Carcinoma
Obstructive jaundice
Cholangitis
Acute pancreatitis

3. In the intestines :
Acute intestinal obstruction

Silent gallstones:
Gallstones may present in the gall bladder without producing any symptoms for long time. They may be detected accidentally on X-ray, taken for another condition. Treatment should be instituted only when symptoms occur.

Chronic calculous cholecystitis:
The gall bladder, which contains stones, may have a thickened fibrotic wall. Bacteria can be cultured from the bile and from the gall bladder wall. It may be asymptomtic or symptomatic. Symptoms are supposed to be due to either
a) Inflammation of the gall bladder wall or
b) Obstruction of the outlet of the gall bladder by a stone impacted in Hartmann’s pouch.

Symptoms:
1. Right hypochondrial pain:
It may be excruciating in certain cases, but not colicky in nature. Sometimes it may be merely a discomfort. It may radiate to between the shoulder blades. It may be associated with nausea and vomiting. Fatty foods often precipitate the complaint. On examination there is tenderness of hypochondrium- Murphy’s sign is positive (catching pain experienced by while palpating the gall bladder area during deep inspiration)
2. Flatulent dyspepsia:
This term is used to describe a feeling of fullness after food associated with belching and heart burn. It is brought on by large or a fatty meal.

Diagnosis is established by the following investigations:
1. USG abdomen is usually the only investigation needed to show gallstones
2. Plain X-ray abdomen
3. Oral cholecystography

Treatment
a) General measure
Patient should be put on a low fat diet
Fluid and electrolyte balance should be maintained
c) Medicinal measures to alleviate the pain and dissolution of gallstones
using bile acids ( chenodeoxycholic acid and ursodeoxycholic acid)
d) Surgical Procedure
• Lithotripsy
• Cholecystostomy
• Cholecystectomy

Acute calculous cholecystitis:
The gall bladder already affected by the chronic cholecystitis is acutely inflamed (acute exacerbation of chronic cystitis). In majority of cases the gallstones are found impacted in Hartmann’s pouch or obstructing the cystic duct.
The organisms, which can be cultured from the bile, are
1. E.coli
2. Klebsiella
3. Streptococcus faecalis
4. Salmonella Typhi

Sequele to an attack of acute cholecystitis include
1. Empyema
2. Perforation of inflamed and distended gall bladder.
3. Gangrene

Symptoms:
1. Sudden onset of pain in right hypopchondrium
2. Severe nausea and vomiting
3. Fever

Signs:
1. On examination tenderness and rigidity in right hypochondrium
2. Boas’s sign positive (there is an area of hyperaesthesia between 9th and 11th ribs on right side)

Diagnosis is established by performing the following investigations

1. X-ray – chest and plain abdomen to show the radiopaque stones
2. Examination of blood - Neutrophilia
3. Cholecystography
4. USG abdomen

Differential diagnosis

1. Appendicitis
2. Perforated peptic ulcer
3. Pancreatitis
4. Acute pyelonephritis
5. Myocardial infarction
6. Right lower lobe pneumonia

Treatment:
1. Conservative treatment followed by Cholecystectomy
2. Nasogastric aspiration and intravenous fluid administration
3. Cholecystostomy ( in severely ill and elderly patients)
4. Extracorporeal shock wave lithotrypsy

Mucocele of the gall bladder:
This occurs when a stone obstructs the neck of the gall bladder, but the content remains sterile. The bile is absorbed and replaced by mucus secreted by the gall bladder epithelium. The gall bladder may be palpable.

Empyema of gall bladder:
The gall bladder appears to be filled with pus, it may be a sequel of acute cholecystitis or the result of a Mucocele becoming infected. Treatment is Cholecystectomy.

Stones in the Bile ducts:
Stones may be present in intra and extra hepatic bile ducts. Usually they originate in the gall bladder and pass down the cystic duct. Sometimes they form in the ducts and are then called ‘ primary duct stones’. This may happen;
a) Secondary to infestation of the biliary tree by Ascaris lumbricoids and Clonorchis Sinesis.
b) Any condition causing prolonged biliary obstruction

Consequences of duct stones:
1. Obstruction to the bile flow
2. Infection ( Cholangitis)

Symptoms:
1. Pain in the right hypochondrium
2. Jaundice – it may be intermittent or persistent. Obstructive in type with dark urine and pale stool with pruritis
3. Fever and rigor

These three symptoms together constitute Charcot’s triad. It indicates acute Cholangitis.

Signs:
Tenderness may be elicited in epigastrium and right hypochondrium.
The gall bladder is impalpable.

Courvoisier’s law:
Gall bladder distention seldom occurs in obstruction of the common bile duct due to stone (because the obstruction is partial), where as obstruction of common bile duct due to other causes (example; malignant obstructions which is often complete) results in distention of gall bladder.

Differential diagnosis:
1. viral hepatitis
2. drug induced jaundice
3. primary biliary cirrhosis
4. pancreatic carcinoma
5. malignant jaundice

Diagnosis is established by performing the following investigations:

1. Liver function test
2. USG abdomen
3. Endoscopic Retrograde Cholangio Pancreatico Graphy
4. Percutaneous Trans hepatic Cholangiography

Complications:
1. Biliary cirrhosis
2. Suppurative Cholangitis
3. Liver abscess
4. Septicemia
5. Clotting abnormalities

Management:
1. Treatment of liver failure if present
2. High intake of glucose to build up the store of liver glycogen
3. Vitamin K administration
4. Rehydration using IV dextrose 5% or Mannitol

Surgical intervention:
1. Endoscopic Papillotomy:
This procedure is performed in patients who are unfit for operation or who have previously had a Cholecystectomy. Stones are extracted after performing ERCP. If stones cannot be removed insertion of a stent will relieve the symptoms temporarily.
2. Percutaneous removal of stones:
If stones are detected on a postoperative T-tube cholangiogram, it is possible to extract them through the T-tube.
3. Supra duodenal Choledochotomy and Trans duodenal
Choledochotomy:
These are procedure adopted for removal of stone from the common
bile duct and Ampulla of vater.
4. Choledochoduodenostomy:
Performed when multiple stones are present in common bile duct.

Miasm:
Sycotic on Psoric background.

The rubrics related to Cholelithiasis:( In Synthesis 7.0)
1. Abdomen: Gallstones (727)
2. Abdomen: Pain; colic gallstone (746)
3. Abdomen : Liver and region of liver; complaints of ( 732)
4. Abdomen : Distention; eating after ( 722)
5. Abdomen : Flatulence (725)
6. Abdomen: Inflammation; gall bladder (731)
7. Abdomen : Pain; hypochondria, right (740)
8. Stomach : Eructations; empty (666)
9. Stomach: Heart burn ( 672)
10. General : Food; fat , aggr ( 1608)
11. Skin: Discoloration; yellow ( 1526)
12. Urine : Bile, containing ( 869)
13. Stool: Clay colored (821)
14. Chill : Shaking ( 1490)
15. Skin: itching ; jaundice; during ( 1545)

Therapeutics of Cholelithiasis:
Drainage remedies liver and bile ducts:
1. Solidago
2. Chelidonium
3. Cardus marianus
4. Taraxacum
5. Hydrastis
6. Chionanthus
7. China
8. Myrica
9. Berberies

Ground remedies:
5. Lycopodium
6. Phosphorus
7. Sulphur
8. Natrum sulphuricum
9. Lachesis
10. Arsenicum album
11. Sepia
12. Nux vomica

Functional remedies:
1. Chelidonium
2. Podophyllum

Organopathic remedies:
1. Fel tauri
2. Bilis
3. Proxitasis

Remedies useful in painful spasms of the bile ducts:
1. Colocynthis
2. Dioscoria villosa
3. Bryonia
4. Chamomilla

Specifics useful in cholecystis:
1. Ricinus communis
3. Vipera

Remedies prepared from the organic substances:
4. Liver extract
5. Bile extract
6. Biliary salts
7. Calculus biliaris
8. Cholestrinum
9. Lecithin
10. Lutein

Choleretics and cholagogs:
1. Polypode
2. Cyanara scolymus
3. Combratum
4. Boldo
5. Rosemary

Reference:
1. Short practice of surgery( 21st edition) – Bailey & Love
2. A manual on Clinical Surgery ( 4th edition) – S. Das
3. Therapeutics of the diseases of Liver and of the Bile ducts – Fortier – Bernoville
4. Synthesis – Frederick Schroyens
5. Repertory of the Homoeopathic Materia medica – Kent.J.T.