Biliary disease. The way that I want you to
approach biliary disease is the same manner
in which we approached diverticular
disease, which was what? A story, okay?
So biliary disease. We’ll begin
with the gallbladder.
It obviously accumulates and concentrates
the bile with a synthesis of it beginning
in the liver with the help of
Do not forget that with bile production,
as you move from a hepatocyte to
hepatocyte to hepatocyte to
hepatocyte, it will travel through
your canaliculi. The bile
responses to hormonal
stimulation during meals --
tell me what kind of meal,
what kind of hormone
therefore bring in the bile?
It is a lipid meal causing
stimulation of CCK.
Therefore, causing contraction of your
gallbladder and extra-hepatic biliary tree.
At this point, when the bile has
been synthesized in the liver
it will move from your zone 1,
a bile duct.
It will come out into the gallbladder
and, at that time of contraction,
with the help of CCK, the
bile will then come out
through the bile duct and
it will pass through
the sphincter of Oddi,
which then relaxes,
allows for the bile to then get
into the intestine.
Responsible for what?
Can I ask you a question?
What if you had a stone?
We’ll get into that and the pain
will be called
postprandial type of right upper
quadrant pain when the time is right.
A couple of things that I wish
to point out to you here.
A schematic of the biliary tree of
I want you to focus upon the
cystic duct. You see it?
That cystic duct is incredibly
proximal to the head of the gallbladder.
Because if you have a
stone there, its presentation
will be completely
different from a stone.
Next, I want you to locate
the common bile duct.
You see it? Right underneath
the cystic duct.
It might take a second.
Make sure that you’re clear
and you’ve identified it. Good.
What we’ll do, I told you
I want you to approach
biliary disease as a story.
We’re going to first develop
a stone in the gallbladder.
At some point,
maybe the stone gets stuck
in the cystic duct.
Every time the gallbladder
was to contract, it’s obstructed.
So what do you think the wall
of the gallbladder is going to do?
Oh, it’s going to inflame.
This is called -- diagnosis, please?
How often do you find this in the U.S.?
How about if you’re a general surgeon,
which some of you will go on to become.
You’re going to be doing this quite a bit.
You have an obese patient and
there’s a history in which upon
consumption of fatty meal, “Aw, I have
pain in the right upper quadrant.”
These will be indications of a
We’ll talk further. Or you could
have the stone that comes
on the common bile duct and
that I want you to identify here would
be the pancreatic duct
and I told you earlier that you
could have a stone that travels down
into the common bile duct, which also
occludes a pancreatic duct,
backs up into the pancreas and
causes damage. Let’s continue.