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170 Cards in this Set

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what is the average capacity of a functioning gallbladder?
30-50 mL
When obstructed, how much can the gallbladder contain?
up to 300 mL
What are the four anatomic areas of the gallbladder?
1. fundus
2. corpus (body)
3. infundibulum
4. neck
where in the gallbladder are most of the smooth muscles located?
the fundus
where in the gallbladder is most of the elastic tissue located?
the body (main storage area)
describe the peritoneal covering of the gallbladder
the same peritoneal lining that covers the liver covers the FUNDUS and INFERIOR SURFACE of the gallbladder
what type of epithelium lines the interior of the gallbladder?
a single layer of highly folded, tall, columnar epithelium
where in the gallbladder are the tubuloalveolar glands found and what do they secrete?
infundibulum and neck only
secrete mucous
describe the two types of musculature found in the gallbladder
1. circular longitudinal fibers
2. oblique fibers
How does the gallbladder differ histologically from the rest of the GI tract?
no submucosa and no muscularis mucosa
what is the blood supply to the gallbladder?
cystic artery
the cystic artery is a branch of what artery?
right hepatic artery
(90% of the time)
where is the cystic artery found?
in the triangle of Calot
describe the borders of the triangle of Calot
cystic duct
common hepatic duct
inferior margin of the liver
when the cystic artery reaches the gallbladder, it divides into what?
the anterior and posterior divisions of the cystic arter
what is the venous drainage of the gallbladder?
small cystic veins drain directly into the liver (most commonly)
**rarely a large cystic vein drains into the portal vein, then to the liver
describe the parasympathetic innervation of the gallbladder
from the hepatic branch of the vagus nerve
describe the sympathetic innervation TO the gallbladder
sympathetic branches from the celiac plexus
Which nerves mediate the pain of biliary colic?
splanchnic nerves
why is the left hepatic duct more likely than the right to get dilated in the case of a distal obstruction?
because it is longer
what are the spiral valves of Heister and why are they clinically important?
these are mucosal folds in the part of the cystic duct that is adjacent to the gallbladder neck.

They make cannulation of the cystic dict difficult.
on average, how long is the common bile duct (CBD)?
7 - 11 cm
on average, what is the diameter of the CBD?
5 - 10 mm
What are the three anatomical portions of the CBD?
1. supraduodenal
2. retroduodenal
3. pancreatic
describe the blood supply to the CBD
branches of the:
1. gastroduodenal artery
2. right hepatic artery

major trunks run along the medial and lateral walls (3 and 9 o'clock). these trunks anastamose freely within the duct walls
what is the nervous supply to the CBD and sphincter of Oddi?
same as the gallbladder:
parasympathetic - hepatic branch of the vagus
sympathetic - branches of the celiac trunk (efferent), splanchnics (afferent)
how often is the classic anatomical description of the biliary system and its arteries applicable to patients?
1/3 of the time
what is the clinical significance of a partial or totally intrahepatic gallbladder?
increased incidence of cholelithiasis
among all biliary anomalies, how common are anomalies of the hepatic and cystic artery?
50%
what are the ducts of Luschka and why are they important?
biliary ducts that drain from the gallbladder directly into the liver. If not recognized during a cholecystectomy can result in a bile leak and possible biloma.
earlier we stated that the cystic duct arises from the right hepatic artery 90% of the time. what about the other 10?
can arise from the:
left hepatic artery
common hepatic artery
gastroduodenal artery
superior mesenteric arteries
how much bile per day does an average adult produce?
500-1000 mL
what are the 6 major types of ingredients in bile?
1. water
2. electrolytes
3. bile salts
4. proteins
5. lipids
6. bile pigments
what is the pH of bile?
neutral or slightly alkaline
what are the two primary bile salts and where are they synthesized?
1. cholate
2. chenodeoxycholate

synthesized in the liver
what are the primary bile salts conjugated with in the liver?
taurine
glycine
once the primary bile acids are conjugated with taurine and glycine and the liver, what do they become?
bile salts
(balanced out by Na)
exactly what two types of cells within the liver is bile secreted by?
1. hepatocytes (80%)
2. bile canalicular cells (20%)
where is 80% of bile absorbed?
terminal ileum
what happens to the 20% of bile acids that are not absorbed in the terminal ileum?
they are deconjugated by gut bacteria and form secondary bile acids that can be absorbed by the colon into the enterohepatic circulation
what are the two secondary bile acids?
1. deoxycholate
2. lithocholate
overall, what % of bile is reabsorbed and recycled via the enterohepatic circulation?
95%
The color of bile is due to the presence of what pigment?
bilirubin diglucuonide

(metabolic product of hemoglobin breakdown)
why is the gallbladder so efficient at concentrating bile?
the gallbladder mucosa has the greatest absorptive power per unit area of any stucture in the body
what does the gallbladder mucosa absorb to concentrate the bile? (3)
water
sodium
chloride
what two important products do the gallbladder epithelial cells secrete?
1. glycoproteins (mucous)
2. hydrogen ions
why are the hydrogen ions so important within the gallbladder lumen?
they acidify, which increases calcium solubility, which prevents precipitation of calcium as calcium salts.
where is CCK released and what does it do?
released from the duodenal mucosa

triggers gallbladder contraction and sphincter of Oddi relaxation
what triggers CCK release?
a meal
parasympathetic stimulation
the gallbladder, when stimulated, releases 50-70% of its contents in how long?
30-40 min
defects in motility of the gallbladder are connected with what pathology?
gallstone formation
how does a vagotomy affect gallbladder response to CCK stimulation?
decreased response to CCK

size and volume of gallbladder are increased
How does VIP affect gallbladder contraction?
inhibits contraction, causes gallbladder relaxation
How does somatostatin affect gallbladder contraction?
POTENTLY inhibits gallbladder contration
patients with a somatostatinoma often have a high incidence of?
gallstones
what lab abnormality could a patient with acute cholecystitis have?
elevated WBC
what lab abnormalites could a patient with cholangitis have?
(4)
1. elevated WBC
2. elevated bilirubin
3. elevated alk phos
4. elevated aminotransferase
what lab abnormalities could a patient with cholestasis (an obstuction to bile flow) have?
(2)
1. elevated CONJUGATED bilirubin
2. elevated alk phos
what would the labs look like in a patient with biliary colic?
typically normal
ultrasound will show stones in the gallbladder with what sensitivity and specificity?
over 90%
what ultrasound findings are associated with acute cholecystitis?
* thickened gallbladder wall
* layer of edema either in the gallbladder wall or surrounding the gallbladder
* local tenderness
what ultrasound findings are associated with chronic cholecystitis?
contracted, thick gallbladder wall
what ultrasound findings suggest a stone obstructing the neck of the gallbladder?
a thin walled, large gallbladder
which portion of the common bile duct is NOT well visualized by ultrasound?
retroduodenal portion
on ultrasound, dilatation of the ducts in a patient with jaundice suggests?
extrahepatic obstruction
what findings on a HIDA scan would suggest acute cholecystitis?
a nonvisualized gallbladder with prompt filling of the CBD and duodenum.

commonly, also evidence of cystic duct obstruction.
what is the test of choice in evaluating patients with suspected malignancy of the gallbladder, extrahepatic biliary system or head of the pancreas?
CT
what is the diagnostic test of choice in a patient with obstructive jaundice, cholangitis, or gallstone pancreatitis?
ERCP
(also therapeutic: can clear stones in the CBD, perform sphincterotomy)
two MC complications of ERCP?
pancreatitis
cholangitis
what are some conditions that predispose to gallstone formation?
obesity
pregnancy
dietary
Crohn's disease
terminal ileal resection
gastric surgery
hereditary spherocytosis, sickle cell disease, thalassemia
treatment of porcelain gallbladder?
immediate cholecystectomy
(premalignant condition)
gallstones can be split into what 2 categories?
1. cholesterol stones
2. pigment stones
pigment stones can be further classified into what two types?
1. black
2. brown
what type of gallstones are MC in Western countries?
cholesterol stones
(80%)
black and brown pigment stones are more common in what part of the world?
Asia
what is the primary event in the formation of cholesterol stones?
supersaturion of bile with cholesterol
cholesterol stone formation is dependent on the relative concentrations of what three bile ingredients?
1. cholesterol
2. lecithin
3. bile salts

*usually it is cholesterol hypersecretion that causes precipitation of cholesterol forming stones*
In the bile, about 1/3 of cholesterol is transported in _________, while 2/3 is transported by ____________.
1/3 MICELLES
2/3 CHOLESTEROL PHOSPHOLIPID VESICLES (smaller, precipitate easier)
pigmented stones are caused by solubilization of unconjugated bilirubin with precipitation of ____________?
calcium bilirubinate

(this gives the pigmented stones pigment)
black stones are MC secondary to what disorders?
(2)
1. hemolytic disorders
(spherocytosis, sickle cell disease)
2. cirrhosis
which type(s) of stones are more likely to form in the gallbladder?
cholesterol stones
black stones
what is more soluble in bile: unconjugated or conjugated bilirubin?
unconjugated

*cirrhosis and hemolytic disorders both lead to increased levels of unconjugated bilirubin*
where and when do brown stones MC form?
gallbladder or bile ducts, where there is bile stasis
what are the two main components of brown stones?
1. calcium bilirubinate
2. dead bacterial cell bodies.
MC bacteria leading to brown stone formation?
E. coli
mechanism of brown stone formation?
E. coli secretes beta glucuronidase that enzymatically unconjugates bilirubin. this unconjugated bilirubin precipitates with calcium, and along with dead bacterial cell bodies forms brown stones.
what type of infection in Asian countries commonly causes bile stasis and subsequent brown stones?
parasitic infections
common cause of stasis and brown stone formation in western populations?
biliary strictures
what proportion of patients with gallstone disease present with chronic cholecystitis?
2/3
what are Rokitansky-Aschoff sinuses?
invaginations of the epithelium of the gallbladder (epithelium protrudes into the muscle layer).

*forms due to increased intraluminal pressure in chronic cholecystitis*
MC sites of pain in chronic cholecystitis?
1. epigastrum
2. RUQ

*often radiates to right upper back, between the scapulae*
typically, the pain of chronic cholecystitis is when?
after eating a fatty meal or at night
what causes hydrops of the gallbladder?
an impacted cystic duct stone

*gallbladder secretes mucous due to irritation, gets distended*
T/F: biliary sludge is an indication for cholcystectomy
True, if the patient is symptomatic and sludge is detected on 2 or more occasions
what produces the classic "strawberry gallbladder?"
cholesterolosis

(the accumulation of cholesterol in macrophages in the gallbladder mucosa)
T/F: cholecystectomy is warranted in patients with cholesterolosis or adenomyomatosis of the gallbladder.
TRUE, if they are symptomatic
What population should have cholecystectomy promptly in the setting of chronic cholecystitis?
Diabetic patients

(they are more likely to develop acute on chronic cholecystitis that is often severe)
can pregnant women with symptomatic gallstones undergo cholecystectomy?
yes.

expectant management should be tried first (diet modification); a lap chole can be done during the second trimester if necessary.
what causes acute gangrenous cholecystitis?
the gallbladder is obstructed by a stone and secondary bacterial infection occurs causing an abscess or empyema within the gallbladder
What is Mirizzi's syndrome?
obstruction of the CBD by a stone that is lodged in the infundibulum of the gallbladder which presses on the CBD.
in which two populations is there often a delay in diagnosing acute cholecystitis?
Diabetics and the elderly.

*incidence of complications is higher in these patients*
what are some of the differential diagnosises of acute cholecystitis?
*peptic ulcer (perforated or non-perf'd)
*pancreatitis
*appendicitis
*hepatitis, perihepatitis
*MI, pneumonia, pleuritis
*herpes zoster involving the intercostal nerve
three pillars of medical treatment of acute cholecystitis while waiting for the OR?
1. IVF
2. Antibiotics
3. Analgesics
what type of bugs should the antibiotics given in the treatment of acute cholecystitis cover?
gram negative aerobes
anaerobes
three MC organisms in cholecystitis?
E. coli
Klebsiella
Enterococcus
what can be done for cholecystitis patients who are unfit for surgery?
percutaneous cholecystostomy
what diameter of the CBD is suggestive of CBD stone/obstruction?
>8 mm
what % of people with gallstones also have CBD stones?
6-12%

(increases with age, so that 20-25% of people >60 have them)
what are primary vs. secondary CBD stones?
primary: formed in the CBD (usually brown stones)

secondary: formed in the gallbladder and migrate to the CBD
what is the gold standard for diagnosing CBD stones?
ERCP

(also has therapeutic option)
what should be done if a CBD stone is noted during a cholecystectomy and CBD exploration cannot be done?
a drain should be left adjacent to the cystic duct and the patient should be scheduled for endoscopic removal the next day.
what should be done if a CBD stone is noted during a cholecystectomy and an open CBD exploration was done WITHOUT retrieval of the stone?
a T-tube should be left in place
what should be done if both CBD exploration and ERCP cannot remove a CBD stone lodged in the ampulla?
choledochojejunostomy
-or-
Roux-en-Y choledochojejunostomy
what is the standard of care for paitents >70 presenting with CBD stones?
endoscopic removal, NO subsequent cholecystectomy

*only 15% become symptomatic from their gallstones)
what are the two main complications of CBD stones?
1. gallstone pancreatitis
2. cholangitis
pathogenesis of cholangitis?
bile stasis due to CBD stones facilitates bacterial contamination
what are the 4 MC organisms seen in cholangitis?
1. E. coli
2. Klebsiella
3. Streptococcus faecalis
4. Bacteroides fragilis
what is Charcot's triad?
1. fever
2. RUQ or epigastric pain
3. jaundice

(present in 2/3 of cholangitis)
what is Reynold's pentad?
Charcot's triad PLUS
1. mental status changes
2. septic shock
definitive test for cholangitis?
ERCP
initial treatment of cholangitis?
1. fluid resuscitation
2. antibiotics

*then drainage of CBD by ERCP or PTC*
what is the mortality rate of cholangitis?
5%
what is the #1 serious complication of cholangitis?
renal failure

(related to sepsis)
treatment for gallstone pancreatitis?
ERCP w/ sphincterotomy

cholecystectomy during same admission once pancreatitis resolved.
where is cholangiohepatitic endemic?
Asia
What causes cholangiohepatitis?
* biliary parasites (C. sinensis, A. lumbricoides, O. viverrini
* bacteria (E. coli, Klebsiella)
pathogenesis of cholangiohepatitis?
brown stones are formed in CBD, cause partial obstruction and repeated bouts of cholangitis. These bouts form strictures, which lead to more stones, infection, hepatic abscesses, liver failure.
treatment for severe cholangiohepatitis?
Roux-en-Y hepaticojejunostomy
two absolute contraindications to a lap chole?
1. uncontrolled coagulopathy
2. end stage liver disease
describe the port placement in a lap chole
4 ports placed.
1. epigastric (10mm)
2. umbilical (10mm)
3. midclavicular line (5mm)
4. right flank (5mm)
basic steps in a lap chole?
establish pneumoperitoneum
dissect out triangle of Calot
identification of the cystic artery
clip proximal cystic duct
clip cystic artery
removal of gallbladder through umbilical port
what are the indications for an intraoperative cholangiogram?
abnormal LFTs
pancreatitis
jaundice
dilated duct and small stones
what drug can be given to relax the sphincter or Oddi while trying to "flush" a CBD stone via choledochal exploration?
glucagon
what is Caroli's disease?
A type V choledochal cyst (intrahepatic). requires a partial liver resection.
why should choledochal cysts be removed?
15% chance of developing cholangiosarcoma
what population are choledochal cysts MC seen in?
Asia, Japan
are choledochal cysts more common in F or M?
females
what is the MC type of choledochal cyst?
Type I (fusiform or cystic dilitations)
what is the treatment for types I, II and IV choledochal cysts?
excision of the extrahepatic biliary tree along with a Roux-en-Y hepaticojejunostomy
what is the treatment for a type III choledochal cyst?
sphincterotomy

(these cysts are bile duct dilitations within the duodenal wall)
what biliary disease is associated with Riedel's thyroiditis, retroperitoneal fibrosis, pancreatitis, ulcerative colitis, and DM?
primary sclerosing cholangitis
which sex and age is primary sclerosing cholangitis MC in?
men
40s-50s
what is seen on ERCP upon diagnosing primary sclerosing cholangitis?
multiple strictures and dilitations (beaded appearance)
surgical management of primary sclerosing cholangitis?
if early: hepaticojejunostomy
if late: liver transplant
in a bile duct injury, which bile ducts can be safely ligated?
diameter <3mm
-or-
those draining a single hepatic segment
why must a transected bile duct 4 mm or larger be reimplanted?
it is likely to drain multiple hepatic segments or an entire lobe
how is lateral injury to the CBD or the common hepatic duct managed?
T-tube
two surgical options for major bile duct injuries?
1. Roux-en-Y heparticojejunostomy (MC)
2. end-to-side Roux-en-Y choledochojejunostomy
how are cystic duct leaks usually managed?
percutaneous drainage of intra-abdominal fluid collections followed by endoscopic biliary stenting
what is the overall reported 5 year survival rate for carcinoma of the gallbladder?
5%
at what age is gallbladder cancer MC?
7th decade
gallbladder cancer is more common in which sex?
females
80-90% of all gallbladder cancers are of what histologic type?
adenocarcinomas
gallbladder cancer employs which type of spread?
hematogenous, lymphatic, direct invasion
describe the following stage of gallbladder CA: T1
limited to the muscular layer of the gallbladder

(usually discovered incidentally on cholecystectomy)
describe the following stage of gallbladder CA: T2
tumor invades perimuscular connective tissue without extension beyond the serosa or into the liver
describe the following stage of gallbladder CA: T3
tumor grows beyond the serosa or invades the liver or other organs
describe the following stage of gallbladder CA: T4
distal mets
optimal surgical treatment for the following gallbladder CA types:
1. T1
2. T2
3. T3 and T4 (if no peritoneal or nodal involvement is found)
1. cholecystectomy
2. extended cholecystectomy + regional lymphadenectomy
3. complete tumor resection with extended right hepatectomy
what is an extended cholecystectomy when discussing resection of gallbladder cancer?
* cholecystectomy
* resection of liver segments IVb and V
* lymphadenectomy of the cystic duct, pericholodochal, right celiac and posterior pancreatoduodenal lymph nodes
where are 2/3 of cholangiocarcinomas located?
at the hepatic duct bifurcation (Klatskin tumor)
average age of presentation of cholangiocarcinoma?
50-70 yrs
what are some risk factors associated with cholangiocarcinoma?
primary sclerosing cholangitis
choledochal cysts
UC
hepatolithiasis
biliary-enteric anastamosis
biliary tract infections (both bacterial and parasitic)
what is the most common presentation of cholangiocarcinoma?
painless jaundice
surgical treatment of a Klatskin tumor?
most are unresectable, but can try hepatic lobectomy and stenting of contralateral bile duct if located to either R or L lobe
surgical treatment of a cholangiocarcinoma involving the middle 1/3 of the CBD?
hepaticojejunostomy
surgical treatment of cholangiocarcinoma involving the distal CBD?
Whipple (pylorus preserving pancreaticoduodenectomy)
what are the MCC of death in cholangiocarcinoma?
hepatic failure
cholangitis
carcinoma involving which section of the biliary tree has the best prognosis?
the distal CBD
carcinoma involving which section of the biliary tree has the worst prognosis?
proximal (perihilar)