Gallbladder: A brief review!

The Gallbladder is a small sac that stores digestive fluid (bile) from the liver and is located just below it. Bile circulates this fluid through the cystic duct to the small intestine, in order to help break down the foods we eat, especially fatty ones.

Gallbladder location on the body

The gallbladder is located on the lower surface of the liver, on the border between the right and left lobe. Anatomically, it is separated into 3 parts: the bottom, the body, and the neck.

The bottom is completely covered by the peritoneum, projecting 1-3cm from the anterior surface of the liver, and corresponds externally to the point where the 9th side joins on the right, with the outer edge of the rectus abdominis muscle. The body, before it forms the neck and passes into the cystic duct, is presented with a stretch called the “Hartmann pouch”, where gallstones are usually wedged. The neck is the part that does not touch the liver surface. It has two curves and takes the shape of an “S”, i.e. like a pipette. It gradually decreases in width and ends in the cystic duct, which joins the bile duct.

The gallbladder is in direct contact with the transverse colon and the 1st degree of the duodenum. That is why the development of fistula, with these organs, is a relatively common phenomenon in complicated cholecystitis.

Gallbladder pain location

The pain occurs in the right abdominal area and can spread to the right shoulder, getting worse with movements or coughing. The abdomen is sensitive to touch or pressure and the pain may coexist with nausea, vomiting, fever, chills, and bloating.

Unusual gallbladder symptoms

Specific symptoms can vary, although most of them are common between different types of gallbladder diseases. Unusual gallbladder symptoms are listed below:

• Pain that may extend below the right shoulder back
• Pain that seems vague or sharp
• The pain increases when you inhale deeply
• Chest pain
• Heartburn, indigestion, and excessive gas
• Vomiting, nausea, fever
• Chills
• Dizziness
• Soft abdomen, especially in the right upper quadrant
• Unusual stool color, usually light in color

Porcelain gallbladder

The porcelain gallbladder is characterized by the calcification of its wall. Its diagnosis is made by ultrasound (US) examination, which detects thickening and calcification of the gallbladder’s wall. It is accompanied by gallbladder cancer, in 20% of cases.

Acalculous cholecystitis_Definition _

It represents inflammation of the gallbladder without the presence of obvious lithiasis. The pathological process of acalculous cholecystitis differs from acute cholecystitis, as in the second the primary initiating event is the occlusion of the cystic duct. It typically occurs secondarily in hospitalized and critically ill patients.

_Symptoms_

Data from the patient’s history are of limited value. Often, many patients are severely ill (possibly on mechanical support) and are unable to give a history or describe their symptoms. The objective examination may reveal fever and tenderness in the right hypochondrium.

_Diagnosis_

The diagnosis includes laboratory tests, such as white blood cells (WBC), liver biology values, and blood cultures, as well as imaging tests: ultrasound (US), and computed tomography (CT).

_Treatment_

Conservative treatment involves placing a double pigtail stent between the gallbladder and the duodenum, during ERCP. But the definite treatment for acalculous cholecystitis is cholecystectomy, for patients who can tolerate surgery.

_Complications_

Perforation or gangrene of the gallbladder.

Chronic cholecystitis_Definition_

It refers to recurrent mild episodes of biliary colic, which progressively lead to chronic inflammation and scarring of the gallbladder (wall thickening, inflammatory infiltration, loss of elasticity, and fibrosis). Chronic cholecystitis is almost always caused due to gallstones.

_Symptoms_

The main symptom is biliary colic, which is due to the temporary obstruction of the cystic duct by gallstones. Other symptoms that can be seen are intolerance to fatty foods, wheezing, bloating, indigestion. On physical examination, there is tenderness in the right upper abdomen. The pain can often be found in the epigastrium or left abdomen, or hit in the back.

_Diagnosis_

Ultrasound is the first diagnostic test with 95% accuracy. Another useful test is cholecystography. If both tests are negative, but the symptoms persist, an ERCP should be performed.

Complications

Acute cholecystitis, cholelithiasis, gallbladder adenocarcinoma, are the most usual complications of chronic cholecystitis. However, cholecystectomy is not an indication for their prevention.

_Treatment_

Surgical treatment is always indicated when there are symptoms. It is done either with the classical method (open cholecystectomy) or with the laparoscopic method, which has an advantage in the time and cost of hospitalization, but also in the return of the patient to his duties.

As a conservative treatment, methods such as stone crushing and stone dismantling have been used in the past, with sound waves and drugs, respectively, without satisfactory results and with a high recurrence rate.