Absite 32: Biliary System

Front 1

the gallbladder lies between these 2 liver segments

Back 1

segment 4 and 5

Front 2

cystic artery is a branch off of this

Back 2

right hepatic artery

Front 3

name the boundaries of callot triangle

Back 3

cystic duct laterally
Common bile duct medially
Liver superior

Front 4

these arteries were considered longitudinal blood supply to the hepatic and common bile duct, lies in a 3 and 9:00 position

Back 4

right hepatic
Retroduodenal
(branches of gastroduodenal artery)

Front 5

where the cystic veins drain

Back 5

right branch of the portal vein and into the liver

Front 6

where the biliary lymphatics located with respect to the common bile duct

Back 6

right side

Front 7

name the parasympathetic and sympathetic innervation to gallbladder

Back 7

parasympathetic: Left (anterior) the trunk of the vagus
Sympathetic from T7-T10

Front 8

which epithelial layer as the gallbladder lack compared to the rest of the GI tract

Back 8

no submucosa

Front 9

this hormone relaxes the sphincter of oddi

Back 9

glucagon

Front 10

give the normal size for:
common bile duct
Gallbladder wall
pancreatic duct

Back 10

common bile duct -less than 8 mm
Gallbladder wall - less than 4 mm
pancreatic duct - less than 4 mm

Front 11

where is the highest concentration of CCK and secretin cells

Back 11

duodenum

Front 12

these are invagination of the epithelium of the wall of the gallbladder, formed by increased gallbladder pressure

Back 12

Rokitansky-Aschoff sinuses

Front 13

name 3 things that increase bile excretion

Back 13

CCK
Secretin
vagal input

Front 14

name 3 things that decrease bile excretion

Back 14

VIP
Somatostatin
Sympathetics

Front 15

name 3 essential functions of bile

Back 15

fat-soluble vitamin absorption
bilirubin excretion
Cholesterol excretion

Front 16

where does bile become concentrated and how

Back 16

in the gallbladder
Resorption of sodium and water

Front 17

where does the active resorption of conjugated bile acids occur

Back 17

terminal ileum

Front 18

name the 2 cells which secrete bile

Back 18

bilateral canalicular cells, 20%
Hepatic sites, 80%

Front 19

we gives bile its green color

Back 19

conjugated bilirubin

Front 20

this is a breakdown product of conjugated bilirubin in the gut, it gives stool a brown color

Back 20

stercobilin

Front 21

breakdown product of conjugated bilirubin, gives urine its yellow color

Back 21

urobilin

Front 22

this is the rate limiting step in cholesterol synthesis

Back 22

HMG coA reductase

Front 23

name the 2 enzymes in bile acids synthesis

Back 23

HMG coA reductase
7-alpha- hydroxylase

Front 24

give cause of cholesterol stone formation in thin versus overweight people

Back 24

thin, underactive 7-alpha- hydroxylase

Overweight, overactive HMG coA reductase

Front 25

name 4 factors that increased cholesterol insoluabilization

Back 25

stasis
Calcium nucleation
increased water absorption in the gallbladder
decreased lecithin and bile acids

Front 26

which gallstone is more common in United States

Back 26

nonpigmented, cholesterol

Front 27

black pigmented gallstones:
4 common causes

Back 27

hemolytic disorders
Cirrhosis
Chronic TPN
Status post ileal resection

Front 28

black pigmented gallstones:
3 key factors for development

Back 28

increased bilirubin load
Decreased hepatic function
Bile stasis

Front 29

black pigmented gallstones:
where do they form
treatment

Back 29

within the gallbladder
Cholecystectomy

Front 30

brown pigmented gallstones:
pathophysiology of formation

Back 30

infection causing deconjugation of bilirubin

Front 31

brown pigmented gallstones:
most common cause,
Commonly seen in this population

Back 31

E. coli
Asian

Front 32

brown pigmented gallstones:
where do they form

Back 32

common bile duct

Front 33

these 2 gallstones are considered secondary common bile duct stones. (formed in the gallbladder)

Back 33

cholesterol stones
Black stones

Front 34

3 most common bacteria in cholecystitis

Back 34

E. coli
Klebsiella
Enterococcus

Front 35

name 4 preemptive conditions which increased risk for acalculus cholecystitis

Back 35

severe burns
Prolonged TPN
Trauma
Major surgery

Front 36

emphysematous gallbladder disease
Describe
Seen in this population
Most common etiology

Back 36

gas within the gallbladder wall
diabetics
Clostridium perfringens

Front 37

emphysematous gallbladder disease
Signs and symptoms
Treatment

Back 37

severe, rapid onset abdominal pain, nausea, vomiting and sepsis
Emergency cholecystectomy or percutaneous drainage if unstable

Front 38

pathophysiology of gallstone ileus

Back 38

fistula between the gallbladder and duodenum, releases stone causing small bowel obstruction... seen in the elderly

Front 39

gallstone ileus:
Common finding on plain film
Most common site of obstruction

Back 39

pneumobilia
Terminal ileum

Front 40

gallstone ileus:
Treatment

Back 40

enterotomy and possible resection to remove stone, cholecystectomy with fistula resection

Front 41

pelvis common bile duct injury treatment differentiated

Back 41

if greater than 2 mm will need hepaticojejunostomy

Front 42

this is the most important cause of the leak postoperative biliary stricture,

Back 42

ischemia

Front 43

name 2 treatments for common bile duct or hepatic duct strictures

Back 43

ERCP with sphincterotomy and stent placement
PTC tube

Front 44

most common cancer of the biliary tract
First site of metastasis
Typical symptoms

Back 44

gallbladder adenocarcinoma
Segments 4 and 5 of the liver
Jaundice first then right upper quadrant pain

Front 45

differentiate stage I versus stage II gallbladder adenocarcinoma
Treatment for each

Back 45

1-limited to the gallbladder mucosa; cholecystectomy
2-into the muscle; wide resection around liver bed with possible Whipple

Front 46

choledochal cyst
common etiology
Signs and symptoms

Back 46

female, Asian, 90% extrahepatic, 15% cancer risk
Episodic pain, fever, jaundice, cholangitis

Front 47

choledochal cyst
most common type, described

Back 47

1, fusiform or saccular dilation of extrahepatic ducts

Front 48

give treatment for type one choledochal cyst

Back 48

cyst excision with hepaticojejunostomy and cholecystectomy

Front 49

described type 4 and type V choledochal cysts

Back 49

4-partially intrahepatic
5-caroli's disease, total he intrahepatic requiring partial liver resection

Front 50

30-40-year-old male patient presents with fatigue, fluctuating jaundice, pruritis, weight loss, right upper quadrant pain

Back 50

primary sclerosing cholangitis

Front 51

in 2 complications of primary sclerosing cholangitis

Back 51

cirrhosis
Cholangiocarcinoma

Front 52

2 medications which can be used in primary sclerosing cholangitis, give affect of each

Back 52

cholestyramine -- decreased pruritis symptoms by decreasing bile acids
UDCA: decrease symptoms and improve liver function

Front 53

primary biliary cirrhosis
Most common in
Symptoms
Key lab value

Back 53

women
Fatigue, itching, jaundice, xanthomas
Positive antimitochondrial antibodies

Front 54

Charcot's triad

Back 54

right upper quadrant pain
Fever
Jaundice

Front 55

reynolds Pentad

Back 55

right upper quadrant pain
Fever
Jaundice
Altered mental status
Shock

Front 56

2 most common pathogens associated with cholangitis

Back 56

Escherichia coli
Klebsiella

Front 57

give differential diagnoses for shock following laparoscopic cholecystectomy:
Early-first 24 hours
Late-after 24 hours

Back 57

early hemorrhagic shock from clip falling off the cystic artery
Late-septic shock from accidental clip the common bile duct with subsequent cholangitis

Front 58

thickened nodule the mucosa and muscle associated with Rokitansky Ashcroft sinuses
Not premalignant,
Give treatment

Back 58

adenomyomatosis

Cholecystectomy

Front 59

benign neuroectoderm tumor of gallbladder
Can occur in biliary tract with signs of cholecystitis
Give treatment

Back 59

granular cell myoblastoma
Cholecystectomy

Front 60

speckled cholesterol deposits on the gallbladder wall

Back 60

cholesterolosis

Front 61

2 signs concerning for malignancy and gallbladder polyps

Back 61

greater than 1 cm
Patient greater than 60 years old

Front 62

type of bilirubin down to albumin covalently, half-life of 18 days

Back 62

delta bilirubin

Front 63

compression of the common hepatic duct by a stone in the infundibulum of the gallbladder or inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct causing stricture and hepatic duct obstruction

Back 63

mirizzi syndrome

Front 64

this antibiotic can cause gallbladder sludge and cholestatic jaundice

Back 64

ceftriaxone