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74 Cards in this Set
- Front
- Back
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Gall bladder lies between what segements of the liver?
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segments IV and V
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Cystic artery branches off what artery?
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right hepatic artery
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Describe the triangle of Calot.
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cystic duct lateral
common bile duct medial liver superior |
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Arteries that supply the hepatic and common bile duct (9- and 3-o'clock positions
when performing ERCP); considered longitudinal blood supply |
Right hepatic (lateral) Retroduodenal branches of the gastroduodenal artery
(medial) |
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Where do the cystic veins drain?
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into the right branch of the portal vein and in to the liver
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Location of lymphatic in relation to the CBD
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Lymphatics are on the right side of the common bile duct
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Parasympathetic and sympathetic fibers to the biliary system.
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Parasympathetic fibers from left (anterior) trunk of the vagus
Sympathetic fibers from T7- T10 coursing through the splanchnic and celiac ganglions |
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What layer is the gallbladder missing?
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submucosa
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What part of the billiary system has no peristalsis?
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Common bile duct
hepatic duct |
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Gallbladder normally fills by?
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contraction of sphincter of Oddi at the ampulla of Vater
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Normal sizes:
1. CBD 2. GB wall 3. Pancreatic duct |
1. CBD < 8 mm ( < 10 mm after cholecystectomy)
2. GB wall < 4 mm 3. Pancreatic duct < 4 mm |
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Location of the Highest concentration of CCK and secretin cells
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Duodenum
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Def: invagination of the epithelium of the wall of the gall bladder; formed from increased gallbladder pressure
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Rokitansky-Aschoff sinuses
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biliary ducts that can leak after a cholecystectomy
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Ducts of Luschka
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Causes Increased bile excretion
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CCK, secretin, and vagal input
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Causes decreased bile excretion
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VIP, somatostatin, sympathetic stimulation
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Essential functions of bile
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• Fat-soluble vitamin absorption
• Bilirubin excretion • Cholesterol excretion |
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How does the GB concentrate bile?
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active resorption of Na and water
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Active resorption of conjugated bile acids occurs in the ________.
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Terminal ileum (50%)
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Where is Bile secreted from?
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bile canalicular cells (20%) hepatocytes (80%)
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Def: breakdown product of conjugated bilirubin in gut; gives stool brown color
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Stercobilin
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Def: breakdown product of conjugated bilirubin in gut; yellow; some gets reabsorbed and released in urine
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Urobilin
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Rate limiting step in cholesterol synthesis
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HMG CoA reductase
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Stones in obese people
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overactive HMG CoA reductase
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Stones in thin people -
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underactive 7-alpha-hydroxylase
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Name the type of stone. increased cholesterol insolubilization, decreased lecithin and bile acids,
Increased water reabsorption, caused by stasis |
Nonpigmented stones
Most common type of stone found in the United States |
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Name the type of stone.
most common worldwide Caused by solubilization of unconjugated bilirubin with precipitation of calcium bilirubinate and insoluble salts |
Pigmented stones
Dissolution agents do not work on pigmented stones (monooctanoin) |
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Name the type of stone.
• Can be caused by hemolytic disorders or cirrhosis • Can also occur in patients on chronic TPN and in patients with ileal resection • Important factors for the development of these stones - increased bilirubin load, decreased hepatic function, and bile stasis • Almost always form in gallbladder |
Black stones
• Tx: cholecystectomy |
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Name the type of stone.
Infection causing deconjugation of bilirubin • Increased in Asians • E. coli most common - produces beta-glucuronidase, which deconjugates bilirubin, causes formation of calcium bilirubinate • Need to check for ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi • primary common bile duct stones • Almost all patients with primary stones need a biliary drainage procedure sphincteroplasty 90% successful |
Brown stones
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Define secondary
common bile duct stones |
Cholesterol stones and black stones found in the CBD are considered secondary
common bile duct stones |
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associated with frank purulence in the gallbladder can be associated with sepsis and shock
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Suppurative cholecystitis
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Most common organisms in cholecystitis
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E. coli, Klebsiella, Enterococcus
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Caused by obstruction of the cystic duct by a gallstone
• Results in gallbladder wall distention and wall inflammation |
CHOLECYSTITIS
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List Stone risk factors
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age >40, female, obesity, pregnancy, rapid weight loss,
vagotomy, TPN ( pigmented stones), ileal resection ( pigmented stones) |
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What is the usual route for Bacterial infection of bile?
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dissemination from portal system is usual route
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Type of cholecystitis
• Thickened wall, RUQ pain, increased WBCs • Occurs most commonly after severe burns, prolonged TPN, trauma, or major surgery • Primary pathology is bile stasis (narcotics, fasting), leading to distention and ischemia • Also have increased viscosity secondary to dehydration, ileus, transfusions • US shows sludge, gallbladder wall thickening, and pericholecystic fluid |
ACALCULOUS CHOLECYSTITIS
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• Can see on plain film
• Increased in diabetics; usually secondary to Clostridium perfringens • Symptoms: severe, rapid-onset abdominal pain, nausea, vomiting, and sepsis • Perforation more common in these patients |
EMPHYSEMATOUS GALLBLADDER DISEASE
• Gas in the gallbladder wall |
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Fistula between gallbladder and duodenum that releases stone, causing small bowel
obstruction; elderly • Can see pneumobilia (air in the biliary system) on plain film • Terminal ileum - most common site of obstruction |
GALLSTONE ILEUS
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When can you perform a primary repair for a CBD injury?
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if < 5O% the circumference of the common bile duct,
in all other cases, will likely need hepaticojejunostomy or choledochojejunostomy |
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most important cause of late postoperative biliary strictures
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Ischemia
• Tx: ERCP with sphincterotomy and possible stent placement to decompress; PTC tube if that fails |
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How would you Dx & Tx
• Patients classically present with UGI bleed, jaundice, and RUQ pain • Most commonly occurs with trauma ( 50% of all cases), infections, primary gallstones, aneurysms, and tumors |
HEMOBILIA
Dx angiogram Tx: resuscitation ; angiogram and embolization 1st; operation if that fails |
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most common cancer of the biliary tract
Four times more common than bile duct CA; most have stones Liver - most common site of metastasis |
GALLBLADDER ADENOCARCINOMA
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GALLBLADDER ADENOCARCINOMA first spreads to what part of the liver?
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segments IV and V; 1st nodes are the cystic duct nodes (right side)
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Risk of gallbladder CA in patients with Porcelain gallbladder these patients need
cholecystectomy |
10%-20%
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Tumor Stages of GB CA
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T1:invades lamina propria or muscular layer
T2:invades perimuscular connective tissue; no extension beyond serosa or into liver T3:Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure T4: invades main portal vein or hepatic artery or invades two or more extrahepatic organs or structures |
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What percentage of patients present with stage IV GB Ca
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90%
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Name the cancer.
Occurs in elderly; males Risk factors: C. sinensis infection, typhoid, ulcerative colitis, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection Sx: early - painless jaundice most common; can also get cholangitis; late -weight loss, anemia, pruritus Persistent increase in bilirubin and alkaline phosphatase |
BILE DUCT CANCER (CHOLANGIOCARCINOMA)
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most common type of CHOLANGIOCARCINOMA
worst prognosis, |
Klatskin tumors - Carcinoma of the hepatic duct bifurcation
Tx: can try lobectomy and stenting of contralateral bile duct if localized t o either the right or left lobe |
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CHOLANGIOCARCINOMA
Middle 1/3 - Lower 1/3 - Palliative stenting for unresectable disease • Overa l l 5-year s u rvival rate - 2 0% |
Middle 1/3- hepaticojejunostomy
Lower 1/3 - Whipple |
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Most common type of CHOLEDOCHAL CYSTS.
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type I - fusiform or saccular dilatation of extrahepatic ducts
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Treatment of CHOLEDOCHAL CYSTS
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• Tx: cyst excision with hepaticojejunostomy and cholecystectomy
• Type IV cysts are partially intrahepatic, and type V (Caroli' s disease) are totally intrahepatic will need partial liver resection |
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Name the disease
• Men in 4th-5th decade • Can be associated with retroperitoneal fibrosis, Riedel's thyroiditis, pancreatitis, ulcerative colitis, and DM • Symptoms: fatigue, fluctuating jaundice, pruritus, weight loss, RUQ pain • Pruritus caused by bile acids • Dx: ERCP - multiple strictures and dilatations |
PRIMARY SCLEROSING CHOLANGITIS
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TX for PRIMARY SCLEROSING CHOLANGITIS
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• Tx: TXP needed long term for most; PTC tube drainage, choledochojejunostomy may
be effective for some; balloon dilatation of dominant strictures may provide some symptomatic relief • Cholestyramine - can decrease pruritus symptoms (decreased bile acids) • UDCA (urodeoxycholic acid ) - can decrease symptoms ( decrease bile acids) and improve liver enzymes |
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Name the disease
• Women; medium -sized hepatic ducts • Cholestasis> cirrhosis>portal hypertension • Symptoms: fatigue, pruritus, jaundice, xanthomas • Antimitochondrial antibodies • No increased risk for cancer • Tx: TXP |
PRIMARY BILIARY CIRRHOSIS
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Charcot's triad
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RUQ pain, fever, jaundice
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Reynolds' pentad
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Charcot's triad plus mental status changes and shock (suggests sepsis)
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most common organisms in CHOLANGITIS
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E.coli and Klebsiella
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Cholovenous reflux occurs at what pressure?
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20 mmHg pressure > systemic bacteremia
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#1 serious complication; related to sepsis with CHOLANGITIS
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Renal failure
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• Asia; recurrent cholangitis from primary CBD stones
• Caused by C. sinensis, A. lumbricoides, T trichiura, and E. coli infections • Tx: hepaticojejunostomy and antiparasitic medications |
ORIENTAL CHOLANGIOHEPATITIS
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The causes of SHOCK FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY
Early (1st 24 hours) Late (after 1st 24 hours) |
Early (1st 24 hours)hemorrhagic shock from clip that fell off cystic artery
Late (after 1st 24 hours)septic shock from accidental clip on CBD with subsequent cholangitis |
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• thickened nodule of mucosa and muscle associated with
Rokitansky-Aschoff sinus • Not premalignant; does not cause stones, can cause RUQ pain • Tx: cholecystectomy |
Adenomyomatosis
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• benign neuroectoderm tumor of gallbladder
• Can occur in biliary tract with signs of cholecystitis • Tx: cholecystectomy |
Granular cell myoblastoma
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Def: speckled cholesterol deposits on the gallbladder wall
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Cholesterolosis
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Gallbladder polyps when should you worry about malignancy
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> 1 cm, worry about malignancy
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Def: bound to albumin covalently, half-life of 18 days; may take a while to clear after long-standing jaundice
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Delta bilirubin
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Def: 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
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Mirizzi syndrome
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Abx that can cause gallbladder sludging and cholestatic jaundice
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Ceftriaxone
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Indications for asymptomatic cholecystectomy
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in patients undergoing l iver TXP or gastric bypass procedure
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List the classification for CBD injuries |
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What is the MC site of obstruction for gallstone ileus? |
terminal ileum |
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Treatment of Bile Duct Ca |
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GB adenocarcinoma TX T1 and T2 |
Stage 1a- T1 confined to mucosa + lamina propria TX: Cholecystectomy Stage 1b- T2 muscle invasion only TX: Wedge resection of segments IV and V w/ 2-3 cm margins and striping of portal triad LN
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GB adenocarcinoma TX T3 and T4
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Stage 2a- beyond muscle but resectable TX: Formal resection of segments IV and V w/ 2-3 cm margins, striping of portal triad LN, possible hepatico-Jejunostomy |
