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84 Cards in this Set

  • Front
  • Back
What are the Ducts of Luschka?
drain bile directly from gall bladder to liver
Which artery is susceptible to injury during cholecystectomy?
right hepatic artery; it's close to cystic artery and Calot's triangle
What is the name of the valves of the gall bladder?
spiral valves of Heister
What is the infundibulum of the gall bladder?
the neck, which is close to the cystic duct
Where is the fundus of the gall bladder?
at the end of the gallbladder
What is "Hartmann's Pouch"?
the gallbladder infundibulum
What are the boundaries of the Triangle of Calot?
3 C's:
Cystic duct
Common hepatic duct
Cystic artery
What is the source of alkaline phosphatase?
bile duct epithelium; alk phos is elevated in bile duct obstruction
What happens to alk phos in bile duct obstruction?
What is in bile?
4 things:
1. cholesterol
2. lecithin (phospholipid)
3. bile acids
4. bilirubin
What does bile do?
emulsify fats
What is the enterohepatic circulation?
circulation of bile acids from liver to gut and back to liver
Where are most of the bile acids absorbed?
in the terminal ileum
What stimulates gall bladder emptying?
cholecystokinin and vagal input
What is the source of cholecystokinin?
duodenal mucosal cells
What stimulates release of cholecystokinin?
1. fat
2. protein/amino acids
3. HCl
What inhibits release of cholecystokinin?
trypsin and chymotrypsin
What does cholecystokinin do?
1. Gallbladder emptying
2. opening of ampulla of Vater
3. slows gastric emptying
4. growth of pancreatic acinar cells and release of exocrine products
At what serum Tbili does one get jaundiced?
greater than 2.5
Where is jaundice supposedly first discovered?
under the tongue
With good renal function, how high can serum Tbili go?
Very rarely, greater than 20
What are the signs of obstructive jaundice?
Dark urine
Clay-colored stools (acholic stools)
Loss of appetite
What causes itching in obstructive jaundice?
bile salts in the dermis
What is cholelithiasis?
gallstones in the gallbladder
What is choledocholithiasis?
gallstones in common bile duct
What is cholecystitis?
inflammation of gall bladder
What is cholangitis?
infection of biliary tract
What is cholangiocarcinoma?
adenocarcinoma of bile ducts
What is Klatskin's tumor?
cholangiocarcinoma of the bile duct at the junction of the right and left hepatic ducts
What is biliary colic?
pain from gallstones, usually from a stone at the cystic duct; pain is in the RUQ, epigastrum, or right subscapular region of the back; often postprandial, especially after fatty foods
What is a biloma?
intraperitoneal bile fluid collections
What is a choledochojejunostomy?
anastomosis between common bile duct and jejunum
What is a hepaticojejunostomy?
anastomosis of hepatic ducts or common hepatic duct to jejunum
What is initial study of choice for evaluation of biliary tract/gallbladder/cholelithiasis?
What is ERCP?
What is PTC?
What is IOC?
(done laproscopically or open to rule out choledocholithiasis)
How do you rule out choledocholithiasis?
IOC: Intra Operative Cholangiogram
What is a HIDA/PRIDA scan? What does it show?
Radioisotope study; isotope concentrated in liver and secreted into bile

will show cholecystitis, bile leak or common bile duct obstruction
How does a HIDA scan reveal cholecystitis?
non-opacification of the gallbladder from obstruction of the cystic duct
How often will you see gallstones in plain x-ray films?
10% to 15%
What is a cholecystectomy?
removal of the gallbladder done laparoscopically or through standard Kocher incision
What is the Kocher incision?
right subcostal incision
What is a sphincterotomy?
cut through sphincter of Oddi to allow passage of gallstones from the common bile duct; most often done at ERCP; also known as papillotomy
How do you treat a post-op biloma after a lap-cholecystectomy?
1. percutaneous drain bile collection
2. ERCP with placement of biliary stent past leak
How do you treat a major CBD injury from a lap-cholecystectomy?
What is the differential of PROXIMAL bile duct obstruction?
Metastatic tumor
Gallbladder carcinoma
Sclerosing cholangitis
Tumor embolus
Postsurgical stricture
Benign bile duct tumor
What lab results are associated with obstructive jaundice?
increased alk phos
elevated bilirubin
with or without elevated LFTs
What is the differential of DISTAL bile duct obstruction?
Choledocholithiasis (gallstones)
Pancreatic carcinoma
Ampullary carcinoma
Postsurgical stricture
Ampulla of Vater dysfunction
Benign bile duct tumor
What is cholelithiasis?
formation of gallstones
Incidence of gallstones?
10% of population
Risk factor for gallstones?
Fertile (multiparity)
What are the types of stones?
75% cholesterol stones
25% pigment stones
Types of pigmented stones?
black stones (calcium bilirubinate)
brown stones (biliary tract infection)
What causes the black stones?
cirrhosis, hemolysis
What causes cholesterol stones?
secretion of bile supersaturated with cholesterol, then cholesterol precipitates out and forms crystals, then gallstones
Is hypercholesterolemia a risk factor for gallstone formation?
NO. HyperLIPIDemia is.
Signs and symptoms of cholelithiasis?
RUQ pain, usually postprandial
Referred right subscapular pain
Epigastric pain

symptoms can last for hours
What is Boas' sign?
referred R subscapular pain of biliary colic
What are the complications of gallstones?
Acute cholecystitis
Gallstone pancreatitis
Gallstone ileus, cholangitis
What is thought to cause biliary colic?
gallbladder contraction against stone temporarily at gallbladder/cystic duct junction; stone in the cystic duct; stone passing through cystic duct
How do you diagnose cholelithiasis?
Lab tests
How often does u/s detect choledocholithiasis?
about 33% of time; not a good one for choledocholithiasis
How do you treat symptomatic or complicated cases of cholelithiasis?
laparoscopic cholecystectomy
Possible complications of lap chole?
1. common bile duct injury
2. R hepatic duct/artery injury
3. cystic duct leak
4. biloma
What are the indications for cholecystectomy in an asymptomatic patient?
1. sickle-cell disease
2. calcified gall bladder
3. patient is a child
Define IOC

dye in bile duct via cystic duct with fluoro/x-ray
What are indications for IOC?
when there is evidence of choledocholithiasis or questions about anatomy:
1. jaundice
2. hyperbilirubinemia
3. gallstone pancreatitis (resolved)
4. elevated alk phos
5. choledocholithiasis on u/s
6. to define anatomy
What is choledocholithiasis?
gallstones in bile ducts
How do you manage choledocholithiasis?
1. ERCP with papillotomy and basket/balloon retrieval of stones
2. laparoscopic trancystic duct or trans common bile duct retrieval
3. open common bile duct exploration
What medication can dissolve a cholesterol gallstone?
chenodeoxycholic acid
ursodeoxycholic acid (Actigall)
What is pathogenesis of acute cholecystitis?
obstruction of cystic duct leads to inflammation of gallbladder; 95% result form calculi and 5% from acalculous obstruction
What are risk factors for acute cholecystitis?
What are signs and symptoms of acute cholecystitis?
unrelenting RUQ pain or tenderness
painful, palpable gallbladder in 33%
positive Murphy's sign
right subscapular pain
epigastric discomfort
What is Murphy's sign?
acute pain and inspiratory arrest due to palpation of RUQ during inspiration
What are complications of acute cholecystitis?
Cholecystenteric fistula formation
Gallstone ileus
What lab results are associated with acute cholecystitis?
increased WBC
slight elevation in alk phos, LFTs
slight elevation in amylase, Tbili
What is the difference between acute cholecystitis and biliary colic?
1. biliary colic is temporary pain
2. acute cholecystitis has pain that doesn't resolve, elevated WBC's, fever, and signs of acute inflammation on u/s
How do you treat acute cholecystitis?
cholecystectomy early
What are the steps in a lap chole?
1. dissect peritoneum overlying cystic duct and artery
2. clip cystic artery and cannulation of cystic duct
3. intraoperative cholangiogram if necessary
4. division of cystic duct between clips
5. dissection of gallbladder from liver bed
6. cauterization; irrigation; suction, to obtain hemostasis of liver bed
7. removal of gallbladder through umbilical trocar site
What are the 3 causes of elevated indirect bilirubin?
1. defective glucuronyl transferase (newborn, Crigler-Najjar)
2. defective uptake (Gilbert's syndrome)
3. bilirubin overproduction (hemolysis)
What is going on when alk phos and GGT is mildly elevate while liver enzymes are extremely elevated?
hepatocellular disease
What is happening when alk phos and GGT jump drastically and liver enzymes rise marginally?
biliary tree obstruction
What bacteria are commonly associated with cholecystitis?
1. E. coli
2. Klebsiella pneumonia
3. Streptococcus faecalis
4. Clostridium welchii or Clostridium perfringens