Lecture Notes: General Surgery

Harold Ellis, Sir Roy Calne, Christopher Watson

Self-assessment Questions

31 The gallbladder and bile ducts

  • 1. Developmentally, how do the gallbladder, liver and hepatic ducts form?

    Correct answer:

    A diverticulum grows out from the ventral wall of the foregut (primitive duodenum), which differentiates into the hepatic ducts and the liver. A lateral bud from this diverticulum becomes the gallbladder and cystic duct.

  • 2. What are the principal developmental anomalies of the gallbladder and bile ducts which may present to the surgeon during cholecystectomy?

    Correct answer:

    (1) A long cystic duct travelling alongside the common hepatic duct to open near the duodenal orifice. (2) Congenital absence of the gallbladder.
    (3) Congenital obliteration of the ducts (biliary atresia, one of the causes of neonatal jaundice).
    (4) Absence of the cystic duct, the gallbladder opening directly onto the side of the common bile duct.
    (5) A long mesentery to the gallbladder, which allows acute torsion of the gallbladder to occur with consequent gangrene and rupture.
    (6) Anomalies of the arrangement of the blood vessels supplying the gallbladder are common.
    (7) Cystic dilatation of the main bile ducts (choledochal cyst). (8) Congenital duplication of the gallbladder.

  • 3. In which age group are gallstones typically found?

    Correct answer:

    They are rare in children (although they should still be considered in the differential diagnosis of abdominal pain in children if the diagnosis is not to be overlooked, and should always be considered in children with spherocytosis or elliptocytosis), the incidence increasing with each decade.

  • 4. In which sex are gallstones more common?

    Correct answer:

    They are twice as common in women.

  • 5. In which races are gallstones particularly common?

    Correct answer:

    They are particularly common in the Mediterranean races, and the highest incidence is found among the Indians of New Mexico.

  • 6. In which race is the incidence of gallstones most common?

    Correct answer:

    Indians of New Mexico.

  • 7. What is cholelithiasis?

    Correct answer:

    Gallstones.

  • 8. What is bile composed of?

    Correct answer:

    Bile is composed of cholesterol, phospholipids (principally lecithin), bile salts (chenodeoxycholic acid and cholic acid) and water. Bile also contains conjugated bilirubin, the breakdown product of haemoglobin, which is quite distinct from bile salts. Cholesterol is not water soluble and is carried in the bile in water-soluble micelles, in which the hydrophobic cholesterol is carried within a ‘shell’ of phospholipid and bile salts.

  • 9. What is the principal phospholipid in bile?

    Correct answer:

    Lecithin.

  • 10. What are the principal bile salts in bile?

    Correct answer:

    Chenodeoxycholic acid and cholic acid.

  • 11. What type of bilirubin is found in bile?

    Correct answer:

    Conjugated bilirubin.

  • 12. How is cholesterol carried in bile?

    Correct answer:

    Cholesterol is not water soluble and is carried in the bile in water-soluble micelles, in which the hydrophobic cholesterol is carried within a ‘shell’ of phospholipid and bile salts.

  • 13. What does bile do in the gut?

    Correct answer:

    Once in the gut, bile salts act as a detergent, breaking up and emulsifying fats to facilitate their absorption.

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