General Surgery Biliary System

Front 1

what is the average capacity of a functioning gallbladder?

Back 1

30-50 mL

Front 2

When obstructed, how much can the gallbladder contain?

Back 2

up to 300 mL

Front 3

What are the four anatomic areas of the gallbladder?

Back 3

1. fundus
2. corpus (body)
3. infundibulum
4. neck

Front 4

where in the gallbladder are most of the smooth muscles located?

Back 4

the fundus

Front 5

where in the gallbladder is most of the elastic tissue located?

Back 5

the body (main storage area)

Front 6

describe the peritoneal covering of the gallbladder

Back 6

the same peritoneal lining that covers the liver covers the FUNDUS and INFERIOR SURFACE of the gallbladder

Front 7

what type of epithelium lines the interior of the gallbladder?

Back 7

a single layer of highly folded, tall, columnar epithelium

Front 8

where in the gallbladder are the tubuloalveolar glands found and what do they secrete?

Back 8

infundibulum and neck only
secrete mucous

Front 9

describe the two types of musculature found in the gallbladder

Back 9

1. circular longitudinal fibers
2. oblique fibers

Front 10

How does the gallbladder differ histologically from the rest of the GI tract?

Back 10

no submucosa and no muscularis mucosa

Front 11

what is the blood supply to the gallbladder?

Back 11

cystic artery

Front 12

the cystic artery is a branch of what artery?

Back 12

right hepatic artery
(90% of the time)

Front 13

where is the cystic artery found?

Back 13

in the triangle of Calot

Front 14

describe the borders of the triangle of Calot

Back 14

cystic duct
common hepatic duct
inferior margin of the liver

Front 15

when the cystic artery reaches the gallbladder, it divides into what?

Back 15

the anterior and posterior divisions of the cystic arter

Front 16

what is the venous drainage of the gallbladder?

Back 16

small cystic veins drain directly into the liver (most commonly)
**rarely a large cystic vein drains into the portal vein, then to the liver

Front 17

describe the parasympathetic innervation of the gallbladder

Back 17

from the hepatic branch of the vagus nerve

Front 18

describe the sympathetic innervation TO the gallbladder

Back 18

sympathetic branches from the celiac plexus

Front 19

Which nerves mediate the pain of biliary colic?

Back 19

splanchnic nerves

Front 20

why is the left hepatic duct more likely than the right to get dilated in the case of a distal obstruction?

Back 20

because it is longer

Front 21

what are the spiral valves of Heister and why are they clinically important?

Back 21

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.

Front 22

on average, how long is the common bile duct (CBD)?

Back 22

7 - 11 cm

Front 23

on average, what is the diameter of the CBD?

Back 23

5 - 10 mm

Front 24

What are the three anatomical portions of the CBD?

Back 24

1. supraduodenal
2. retroduodenal
3. pancreatic

Front 25

describe the blood supply to the CBD

Back 25

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

Front 26

what is the nervous supply to the CBD and sphincter of Oddi?

Back 26

same as the gallbladder:
parasympathetic - hepatic branch of the vagus
sympathetic - branches of the celiac trunk (efferent), splanchnics (afferent)

Front 27

how often is the classic anatomical description of the biliary system and its arteries applicable to patients?

Back 27

1/3 of the time

Front 28

what is the clinical significance of a partial or totally intrahepatic gallbladder?

Back 28

increased incidence of cholelithiasis

Front 29

among all biliary anomalies, how common are anomalies of the hepatic and cystic artery?

Back 29

50%

Front 30

what are the ducts of Luschka and why are they important?

Back 30

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.

Front 31

earlier we stated that the cystic duct arises from the right hepatic artery 90% of the time. what about the other 10?

Back 31

can arise from the:
left hepatic artery
common hepatic artery
gastroduodenal artery
superior mesenteric arteries

Front 32

how much bile per day does an average adult produce?

Back 32

500-1000 mL

Front 33

what are the 6 major types of ingredients in bile?

Back 33

1. water
2. electrolytes
3. bile salts
4. proteins
5. lipids
6. bile pigments

Front 34

what is the pH of bile?

Back 34

neutral or slightly alkaline

Front 35

what are the two primary bile salts and where are they synthesized?

Back 35

1. cholate
2. chenodeoxycholate

synthesized in the liver

Front 36

what are the primary bile salts conjugated with in the liver?

Back 36

taurine
glycine

Front 37

once the primary bile acids are conjugated with taurine and glycine and the liver, what do they become?

Back 37

bile salts
(balanced out by Na)

Front 38

exactly what two types of cells within the liver is bile secreted by?

Back 38

1. hepatocytes (80%)
2. bile canalicular cells (20%)

Front 39

where is 80% of bile absorbed?

Back 39

terminal ileum

Front 40

what happens to the 20% of bile acids that are not absorbed in the terminal ileum?

Back 40

they are deconjugated by gut bacteria and form secondary bile acids that can be absorbed by the colon into the enterohepatic circulation

Front 41

what are the two secondary bile acids?

Back 41

1. deoxycholate
2. lithocholate

Front 42

overall, what % of bile is reabsorbed and recycled via the enterohepatic circulation?

Back 42

95%

Front 43

The color of bile is due to the presence of what pigment?

Back 43

bilirubin diglucuonide

(metabolic product of hemoglobin breakdown)

Front 44

why is the gallbladder so efficient at concentrating bile?

Back 44

the gallbladder mucosa has the greatest absorptive power per unit area of any stucture in the body

Front 45

what does the gallbladder mucosa absorb to concentrate the bile? (3)

Back 45

water
sodium
chloride

Front 46

what two important products do the gallbladder epithelial cells secrete?

Back 46

1. glycoproteins (mucous)
2. hydrogen ions

Front 47

why are the hydrogen ions so important within the gallbladder lumen?

Back 47

they acidify, which increases calcium solubility, which prevents precipitation of calcium as calcium salts.

Front 48

where is CCK released and what does it do?

Back 48

released from the duodenal mucosa

triggers gallbladder contraction and sphincter of Oddi relaxation

Front 49

what triggers CCK release?

Back 49

a meal
parasympathetic stimulation

Front 50

the gallbladder, when stimulated, releases 50-70% of its contents in how long?

Back 50

30-40 min

Front 51

defects in motility of the gallbladder are connected with what pathology?

Back 51

gallstone formation

Front 52

how does a vagotomy affect gallbladder response to CCK stimulation?

Back 52

decreased response to CCK

size and volume of gallbladder are increased

Front 53

How does VIP affect gallbladder contraction?

Back 53

inhibits contraction, causes gallbladder relaxation

Front 54

How does somatostatin affect gallbladder contraction?

Back 54

POTENTLY inhibits gallbladder contration

Front 55

patients with a somatostatinoma often have a high incidence of?

Back 55

gallstones

Front 56

what lab abnormality could a patient with acute cholecystitis have?

Back 56

elevated WBC

Front 57

what lab abnormalites could a patient with cholangitis have?
(4)

Back 57

1. elevated WBC
2. elevated bilirubin
3. elevated alk phos
4. elevated aminotransferase

Front 58

what lab abnormalities could a patient with cholestasis (an obstuction to bile flow) have?
(2)

Back 58

1. elevated CONJUGATED bilirubin
2. elevated alk phos

Front 59

what would the labs look like in a patient with biliary colic?

Back 59

typically normal

Front 60

ultrasound will show stones in the gallbladder with what sensitivity and specificity?

Back 60

over 90%

Front 61

what ultrasound findings are associated with acute cholecystitis?

Back 61

* thickened gallbladder wall
* layer of edema either in the gallbladder wall or surrounding the gallbladder
* local tenderness

Front 62

what ultrasound findings are associated with chronic cholecystitis?

Back 62

contracted, thick gallbladder wall

Front 63

what ultrasound findings suggest a stone obstructing the neck of the gallbladder?

Back 63

a thin walled, large gallbladder

Front 64

which portion of the common bile duct is NOT well visualized by ultrasound?

Back 64

retroduodenal portion

Front 65

on ultrasound, dilatation of the ducts in a patient with jaundice suggests?

Back 65

extrahepatic obstruction

Front 66

what findings on a HIDA scan would suggest acute cholecystitis?

Back 66

a nonvisualized gallbladder with prompt filling of the CBD and duodenum.

commonly, also evidence of cystic duct obstruction.

Front 67

what is the test of choice in evaluating patients with suspected malignancy of the gallbladder, extrahepatic biliary system or head of the pancreas?

Back 67

CT

Front 68

what is the diagnostic test of choice in a patient with obstructive jaundice, cholangitis, or gallstone pancreatitis?

Back 68

ERCP
(also therapeutic: can clear stones in the CBD, perform sphincterotomy)

Front 69

two MC complications of ERCP?

Back 69

pancreatitis
cholangitis

Front 70

what are some conditions that predispose to gallstone formation?

Back 70

obesity
pregnancy
dietary
Crohn's disease
terminal ileal resection
gastric surgery
hereditary spherocytosis, sickle cell disease, thalassemia

Front 71

treatment of porcelain gallbladder?

Back 71

immediate cholecystectomy
(premalignant condition)

Front 72

gallstones can be split into what 2 categories?

Back 72

1. cholesterol stones
2. pigment stones

Front 73

pigment stones can be further classified into what two types?

Back 73

1. black
2. brown

Front 74

what type of gallstones are MC in Western countries?

Back 74

cholesterol stones
(80%)

Front 75

black and brown pigment stones are more common in what part of the world?

Back 75

Asia

Front 76

what is the primary event in the formation of cholesterol stones?

Back 76

supersaturion of bile with cholesterol

Front 77

cholesterol stone formation is dependent on the relative concentrations of what three bile ingredients?

Back 77

1. cholesterol
2. lecithin
3. bile salts

*usually it is cholesterol hypersecretion that causes precipitation of cholesterol forming stones*

Front 78

In the bile, about 1/3 of cholesterol is transported in _________, while 2/3 is transported by ____________.

Back 78

1/3 MICELLES
2/3 CHOLESTEROL PHOSPHOLIPID VESICLES (smaller, precipitate easier)

Front 79

pigmented stones are caused by solubilization of unconjugated bilirubin with precipitation of ____________?

Back 79

calcium bilirubinate

(this gives the pigmented stones pigment)

Front 80

black stones are MC secondary to what disorders?
(2)

Back 80

1. hemolytic disorders
(spherocytosis, sickle cell disease)
2. cirrhosis

Front 81

which type(s) of stones are more likely to form in the gallbladder?

Back 81

cholesterol stones
black stones

Front 82

what is more soluble in bile: unconjugated or conjugated bilirubin?

Back 82

unconjugated

*cirrhosis and hemolytic disorders both lead to increased levels of unconjugated bilirubin*

Front 83

where and when do brown stones MC form?

Back 83

gallbladder or bile ducts, where there is bile stasis

Front 84

what are the two main components of brown stones?

Back 84

1. calcium bilirubinate
2. dead bacterial cell bodies.

Front 85

MC bacteria leading to brown stone formation?

Back 85

E. coli

Front 86

mechanism of brown stone formation?

Back 86

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.

Front 87

what type of infection in Asian countries commonly causes bile stasis and subsequent brown stones?

Back 87

parasitic infections

Front 88

common cause of stasis and brown stone formation in western populations?

Back 88

biliary strictures

Front 89

what proportion of patients with gallstone disease present with chronic cholecystitis?

Back 89

2/3

Front 90

what are Rokitansky-Aschoff sinuses?

Back 90

invaginations of the epithelium of the gallbladder (epithelium protrudes into the muscle layer).

*forms due to increased intraluminal pressure in chronic cholecystitis*

Front 91

MC sites of pain in chronic cholecystitis?

Back 91

1. epigastrum
2. RUQ

*often radiates to right upper back, between the scapulae*

Front 92

typically, the pain of chronic cholecystitis is when?

Back 92

after eating a fatty meal or at night

Front 93

what causes hydrops of the gallbladder?

Back 93

an impacted cystic duct stone

*gallbladder secretes mucous due to irritation, gets distended*

Front 94

T/F: biliary sludge is an indication for cholcystectomy

Back 94

True, if the patient is symptomatic and sludge is detected on 2 or more occasions

Front 95

what produces the classic "strawberry gallbladder?"

Back 95

cholesterolosis

(the accumulation of cholesterol in macrophages in the gallbladder mucosa)

Front 96

T/F: cholecystectomy is warranted in patients with cholesterolosis or adenomyomatosis of the gallbladder.

Back 96

TRUE, if they are symptomatic

Front 97

What population should have cholecystectomy promptly in the setting of chronic cholecystitis?

Back 97

Diabetic patients

(they are more likely to develop acute on chronic cholecystitis that is often severe)

Front 98

can pregnant women with symptomatic gallstones undergo cholecystectomy?

Back 98

yes.

expectant management should be tried first (diet modification); a lap chole can be done during the second trimester if necessary.

Front 99

what causes acute gangrenous cholecystitis?

Back 99

the gallbladder is obstructed by a stone and secondary bacterial infection occurs causing an abscess or empyema within the gallbladder

Front 100

What is Mirizzi's syndrome?

Back 100

obstruction of the CBD by a stone that is lodged in the infundibulum of the gallbladder which presses on the CBD.

Front 101

in which two populations is there often a delay in diagnosing acute cholecystitis?

Back 101

Diabetics and the elderly.

*incidence of complications is higher in these patients*

Front 102

what are some of the differential diagnosises of acute cholecystitis?

Back 102

*peptic ulcer (perforated or non-perf'd)
*pancreatitis
*appendicitis
*hepatitis, perihepatitis
*MI, pneumonia, pleuritis
*herpes zoster involving the intercostal nerve

Front 103

three pillars of medical treatment of acute cholecystitis while waiting for the OR?

Back 103

1. IVF
2. Antibiotics
3. Analgesics

Front 104

what type of bugs should the antibiotics given in the treatment of acute cholecystitis cover?

Back 104

gram negative aerobes
anaerobes

Front 105

three MC organisms in cholecystitis?

Back 105

E. coli
Klebsiella
Enterococcus

Front 106

what can be done for cholecystitis patients who are unfit for surgery?

Back 106

percutaneous cholecystostomy

Front 107

what diameter of the CBD is suggestive of CBD stone/obstruction?

Back 107

>8 mm

Front 108

what % of people with gallstones also have CBD stones?

Back 108

6-12%

(increases with age, so that 20-25% of people >60 have them)

Front 109

what are primary vs. secondary CBD stones?

Back 109

primary: formed in the CBD (usually brown stones)

secondary: formed in the gallbladder and migrate to the CBD

Front 110

what is the gold standard for diagnosing CBD stones?

Back 110

ERCP

(also has therapeutic option)

Front 111

what should be done if a CBD stone is noted during a cholecystectomy and CBD exploration cannot be done?

Back 111

a drain should be left adjacent to the cystic duct and the patient should be scheduled for endoscopic removal the next day.

Front 112

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?

Back 112

a T-tube should be left in place

Front 113

what should be done if both CBD exploration and ERCP cannot remove a CBD stone lodged in the ampulla?

Back 113

choledochojejunostomy
-or-
Roux-en-Y choledochojejunostomy

Front 114

what is the standard of care for paitents >70 presenting with CBD stones?

Back 114

endoscopic removal, NO subsequent cholecystectomy

*only 15% become symptomatic from their gallstones)

Front 115

what are the two main complications of CBD stones?

Back 115

1. gallstone pancreatitis
2. cholangitis

Front 116

pathogenesis of cholangitis?

Back 116

bile stasis due to CBD stones facilitates bacterial contamination

Front 117

what are the 4 MC organisms seen in cholangitis?

Back 117

1. E. coli
2. Klebsiella
3. Streptococcus faecalis
4. Bacteroides fragilis

Front 118

what is Charcot's triad?

Back 118

1. fever
2. RUQ or epigastric pain
3. jaundice

(present in 2/3 of cholangitis)

Front 119

what is Reynold's pentad?

Back 119

Charcot's triad PLUS
1. mental status changes
2. septic shock

Front 120

definitive test for cholangitis?

Back 120

ERCP

Front 121

initial treatment of cholangitis?

Back 121

1. fluid resuscitation
2. antibiotics

*then drainage of CBD by ERCP or PTC*

Front 122

what is the mortality rate of cholangitis?

Back 122

5%

Front 123

what is the #1 serious complication of cholangitis?

Back 123

renal failure

(related to sepsis)

Front 124

treatment for gallstone pancreatitis?

Back 124

ERCP w/ sphincterotomy

cholecystectomy during same admission once pancreatitis resolved.

Front 125

where is cholangiohepatitic endemic?

Back 125

Asia

Front 126

What causes cholangiohepatitis?

Back 126

* biliary parasites (C. sinensis, A. lumbricoides, O. viverrini
* bacteria (E. coli, Klebsiella)

Front 127

pathogenesis of cholangiohepatitis?

Back 127

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.

Front 128

treatment for severe cholangiohepatitis?

Back 128

Roux-en-Y hepaticojejunostomy

Front 129

two absolute contraindications to a lap chole?

Back 129

1. uncontrolled coagulopathy
2. end stage liver disease

Front 130

describe the port placement in a lap chole

Back 130

4 ports placed.
1. epigastric (10mm)
2. umbilical (10mm)
3. midclavicular line (5mm)
4. right flank (5mm)

Front 131

basic steps in a lap chole?

Back 131

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

Front 132

what are the indications for an intraoperative cholangiogram?

Back 132

abnormal LFTs
pancreatitis
jaundice
dilated duct and small stones

Front 133

what drug can be given to relax the sphincter or Oddi while trying to "flush" a CBD stone via choledochal exploration?

Back 133

glucagon

Front 134

what is Caroli's disease?

Back 134

A type V choledochal cyst (intrahepatic). requires a partial liver resection.

Front 135

why should choledochal cysts be removed?

Back 135

15% chance of developing cholangiosarcoma

Front 136

what population are choledochal cysts MC seen in?

Back 136

Asia, Japan

Front 137

are choledochal cysts more common in F or M?

Back 137

females

Front 138

what is the MC type of choledochal cyst?

Back 138

Type I (fusiform or cystic dilitations)

Front 139

what is the treatment for types I, II and IV choledochal cysts?

Back 139

excision of the extrahepatic biliary tree along with a Roux-en-Y hepaticojejunostomy

Front 140

what is the treatment for a type III choledochal cyst?

Back 140

sphincterotomy

(these cysts are bile duct dilitations within the duodenal wall)

Front 141

what biliary disease is associated with Riedel's thyroiditis, retroperitoneal fibrosis, pancreatitis, ulcerative colitis, and DM?

Back 141

primary sclerosing cholangitis

Front 142

which sex and age is primary sclerosing cholangitis MC in?

Back 142

men
40s-50s

Front 143

what is seen on ERCP upon diagnosing primary sclerosing cholangitis?

Back 143

multiple strictures and dilitations (beaded appearance)

Front 144

surgical management of primary sclerosing cholangitis?

Back 144

if early: hepaticojejunostomy
if late: liver transplant

Front 145

in a bile duct injury, which bile ducts can be safely ligated?

Back 145

diameter <3mm
-or-
those draining a single hepatic segment

Front 146

why must a transected bile duct 4 mm or larger be reimplanted?

Back 146

it is likely to drain multiple hepatic segments or an entire lobe

Front 147

how is lateral injury to the CBD or the common hepatic duct managed?

Back 147

T-tube

Front 148

two surgical options for major bile duct injuries?

Back 148

1. Roux-en-Y heparticojejunostomy (MC)
2. end-to-side Roux-en-Y choledochojejunostomy

Front 149

how are cystic duct leaks usually managed?

Back 149

percutaneous drainage of intra-abdominal fluid collections followed by endoscopic biliary stenting

Front 150

what is the overall reported 5 year survival rate for carcinoma of the gallbladder?

Back 150

5%

Front 151

at what age is gallbladder cancer MC?

Back 151

7th decade

Front 152

gallbladder cancer is more common in which sex?

Back 152

females

Front 153

80-90% of all gallbladder cancers are of what histologic type?

Back 153

adenocarcinomas

Front 154

gallbladder cancer employs which type of spread?

Back 154

hematogenous, lymphatic, direct invasion

Front 155

describe the following stage of gallbladder CA: T1

Back 155

limited to the muscular layer of the gallbladder

(usually discovered incidentally on cholecystectomy)

Front 156

describe the following stage of gallbladder CA: T2

Back 156

tumor invades perimuscular connective tissue without extension beyond the serosa or into the liver

Front 157

describe the following stage of gallbladder CA: T3

Back 157

tumor grows beyond the serosa or invades the liver or other organs

Front 158

describe the following stage of gallbladder CA: T4

Back 158

distal mets

Front 159

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)

Back 159

1. cholecystectomy
2. extended cholecystectomy + regional lymphadenectomy
3. complete tumor resection with extended right hepatectomy

Front 160

what is an extended cholecystectomy when discussing resection of gallbladder cancer?

Back 160

* cholecystectomy
* resection of liver segments IVb and V
* lymphadenectomy of the cystic duct, pericholodochal, right celiac and posterior pancreatoduodenal lymph nodes

Front 161

where are 2/3 of cholangiocarcinomas located?

Back 161

at the hepatic duct bifurcation (Klatskin tumor)

Front 162

average age of presentation of cholangiocarcinoma?

Back 162

50-70 yrs

Front 163

what are some risk factors associated with cholangiocarcinoma?

Back 163

primary sclerosing cholangitis
choledochal cysts
UC
hepatolithiasis
biliary-enteric anastamosis
biliary tract infections (both bacterial and parasitic)

Front 164

what is the most common presentation of cholangiocarcinoma?

Back 164

painless jaundice

Front 165

surgical treatment of a Klatskin tumor?

Back 165

most are unresectable, but can try hepatic lobectomy and stenting of contralateral bile duct if located to either R or L lobe

Front 166

surgical treatment of a cholangiocarcinoma involving the middle 1/3 of the CBD?

Back 166

hepaticojejunostomy

Front 167

surgical treatment of cholangiocarcinoma involving the distal CBD?

Back 167

Whipple (pylorus preserving pancreaticoduodenectomy)

Front 168

what are the MCC of death in cholangiocarcinoma?

Back 168

hepatic failure
cholangitis

Front 169

carcinoma involving which section of the biliary tree has the best prognosis?

Back 169

the distal CBD

Front 170

carcinoma involving which section of the biliary tree has the worst prognosis?

Back 170

proximal (perihilar)