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Surgery M4 part 2 > Gallbladder diseases > Flashcards

Gallbladder diseases Flashcards

1
Q

Which artery supplies the gallbladder? and what is the gallbladder’s capacity?

A

CYSTIC ARTERY branch of right hepatic artery

30-45cc

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2
Q

How long is the common bile duct?

A

10-15cm

should not be more than 6mm in diameter

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3
Q

Where does the common bile duct join the major pancreatic duct?

A

the wall of the second part of the duodenum -> AMPULLA OF VATER

intraduodenal part of CBD has sphincter of ODDI to regulate bile flow

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4
Q

Where does the spiral valve of Heister exist?

A

in the neck of the gallbladder continuous with the cystic duct -> makes catheterization difficult

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5
Q

What is the lymphatic drainage of the gallbladder?

A
  • cystic lymph node of LUND by the junction of the cystic & common hepatic ducts ——> CELIAC NODES -> porta hepatis
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6
Q

Which hormone is responsible for stimulation of gallbladder contraction?

A

CHOLECYSTOKININ (CCK)

- fatty food stimulates the duodenal mucosa to secrete it

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7
Q

What are the benefits of x-ray use in case gallbladder disease?

A
  • could detect only radio-opaque stones (10-15%) —> mercedes benz
  • porcelain gallbladder -> calcified wall -> premalignant
  • emphysematous cholecystitis -> gas within wall
  • biliary fistula -> gas within biliary system after sphincterotomy or anastomosis
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8
Q

how can we differentiate between a renal & gallbladder stone in an x-ray?

A

LATERAL X-RAY

  • renal -> in spine
  • gallbladder -> anterior to spine
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9
Q

What are the functions of the gallbladder?

A
  • storage of bile until CCK is secreted -> contracts
  • concentration of bile -> absorption of water, sodium chloride, & bicarbonate by mucous membrane
  • secretion of mucus -> in complete obstruction of cystic duct could lead to mucocele
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10
Q

What is the first-line of radiological investigations used in biliary disease?

A

ultrasound abdomen shows

  • > visualizes mobile, hyperechoic, intraluminal mass with acoustic shadow
  • > cholelithiasis
  • > gallbladder wall thickening
  • > pericholecystic fluid
  • Murphy’s sign
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11
Q

What was used in adjunction with ultrasound when a patient had symptoms of cholelithiasis with a negative ultrasound?

A

ORAL CHOLECYSTOGRAM (OCG)

  • more useful in smaller stones & counting the number of stones present
  • patient should be on a fat free diet for 3 days -> take 6 tablets of TELEPAQUE the previous night -> x-ray abdomen in erect position -> fatty meal is given -> another x-ray taken to see change in size of gallbladder
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12
Q

What are the contraindications of oral cholecystogram (OCG)?

A
  • patient with serum bilirubin >3mg
  • acute cholecystitis (because cystic duct is contracted)
  • vomiting —-> use IV CHOLANGIOGRAM instead (inject biligram)
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13
Q

What are the advantages of sonography?

A
  • no ionizing radiation
  • detection of small calculi
  • no contrast medium
  • less patient preparation
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14
Q

When is CT used in case of gallbladder disease?

A
  • extent of primary tumor
  • relationship to other organs & blood vessels
  • in obese patients
  • if ultrasound is not definitive
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15
Q

What is the benefit of Magnetic Resonance CholangioPancreatography (MRCP)?

A
  • non-invasive & as diagnostic as PTC & ERCP

- demonstrates ductal obstruction, strictures, & intraductal abnormalities

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16
Q

What is the benefit of Tc99-labelled iminodiacetic acid (HIDA)?

A

diagnoses ACUTE CHOLECYSTITIS & other biliary disorders (biliary atresia)

  • non-visualization of gallbladder -> acute cholecystitis
  • delayed or reduced visualization -> chronic cholecystitis
  • biliary scintigraphy diagnoses bile leaks & iatrogenic biliary obstruction
  • evaluation of biliary dyskynesia or sphincter of Oddi dysfunction -> post-cholecystectomy syndrome
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17
Q

When is peroperative cholangiography used?

A
  • during a cholecystectomy -> catheter is placed in the cystic duct & contrast is injected directly into the biliary tree
  • defines the anatomy of the biliary tree
  • excludes the presence of stones within the bile ducts
  • when cystic duct feels dilated more than normal
  • if u feel a stone slipping into ducts after clipping the gallbladder
  • make sure the OR table is fit for x-ray or not
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18
Q

What method of investigation is used to cannulate the sphincter of Oddi, and inject dye to visualize the biliary & pancreatic tree?

A

Endoscopic Retrograde Cholangio-pancreatography (ERCP)

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19
Q

What are the diagnostic indications for ERCP?

A
  • congenital anomalies
  • stones
  • stricture in biliary tree
  • choledochal cyst
  • chronic pancreatitis -> chain of lakes
  • malignancy -> irregular filling defect
  • biopsy from tumors
  • sampling or biliary & pancreatic juices for cytology
20
Q

What are the therapeutic uses of ERCP?

A
  • extraction of stone
  • stenting of tumor in CBD or pancreas
  • dilatation of biliary strictures
  • endoscopic sphincterotomy
21
Q

What are the complications of ERCP?

A
  • pancreatitis
  • duodenal injury
  • cholangitis
  • bleeding
22
Q

What are the rules of use of Percutaneous Transhepatic Cholangiography (PTC)?

A
  • normal coagulation

- dilated biliary radicles (in long standing obstruction)

23
Q

What are the indications for PTC?

A
  • in severe obstructive jaundice -> under antibiotics & control of bleeding tendencies
  • if ERCP is inappropriate of failed
  • to drain biliary obstruction
  • used for stenting through obstruction in hepatic ducts or CBD
24
Q

Where is the Chiba or Okuda needle inserted while preforming PTC?

A

right 8th intercostal space in mid-axillary line -> aspirate bile -> inject water-soluble iodine to visualize biliary radicles

25
Q

What are the complications of PTC?

A
  • bleeding
  • biliary leak
  • biliary peritonitis
  • septicemia
26
Q

if a doctor is concerned about residual stones or strictures following a cholecystectomy, what should he preform?

A

T-tube or delayed cholangiography

- extends to the outside of the body

27
Q

What are the investigations that should be done in case of choledocholithiasis?

A

1- sonography -> enlargement or narrowing of biliary ducts due to presence of stones
2- ERCP
3- operative cholangiography

28
Q

What are the investigations that should be done in case of cholelithiasis?

A

1- ultrasound

2- scintigraphy (HIDA) -> failure of accumulation inside gallbladder

29
Q

What are the investigations that should be done in case of neoplams?

A

1- ultrasound

2- CT

30
Q

What are the investigations that should be done in case of biliary stenosis?

A

1- operative cholangiogram

2- ERCP

31
Q

What is the pathogenesis of gallstones?

A
  • metabolic abnormalities -> increased cholesterol to bile salt ratio (1:25), or ileal abnormality or resection, DM, obesity
  • infections & infestations
  • bile stasis -> estrogen therapy, VAGOTOMY, pregnancy, long term TPN
  • increased bilirubin -> haemolysis (thalassaemia & sickle cell anemia)
32
Q

What are the symptoms of gallstones?

A

Biliary Pain

  • after meals
  • RUQ
  • referred to right shoulder & back
  • recurrent
  • Murphy’s sign

Reflex retrosternal pain as angina

Fatty dyspepsia

33
Q

What are the effects of gallstones on the gallbladder?

A
  • silent stones
  • acute cholecystitis
  • chronic cholecystitis
  • obstruction of cystic duct -> mucocele
    - > empyema gallbladder
    - > perforation -> biliary peritonitis -> pericholecystitic abscess
  • carcinoma gallbladder
34
Q

What are the complications of gallstones?

A
  • obstructive jaundice
  • cholangitis
  • biliary cirrhosis
  • pancreatitis
35
Q

What are the effects of gallstones on the CBD?

A
  • obstruction of CBD
  • cholangitis & pancreatitis
  • Mirizzi syndrome -> compression of CBD by stone from cystic duct or cholecysto-choledochal fistula
36
Q

What is the effect of gallstones on the intestine?

A
  • cholecystoduodenal fistula -> gallstone ileus -> intestinal obstruction
37
Q

What is the effect of fistulation caused by a gallstone on the intestine?

A
  • to CBD -> Mirizzi syndrome
  • to duodenum -> gallstone ileus
  • to colon -> pass down
38
Q

What is the modified Mirizzi classification?

A
  • type I -> extrinsic compression on CBD by impacted gallstone -> cholecystectomy
  • type II -> cholecystobiliary fistula due to gallstone involving 1/3rd of CBD -> subtotal cholecystectomy, leave 5mm of gallbladder & put T tube
  • type III -> cholecystobiliary fistula involving 2/3rds of CBD -> subtotal cholecystectomy, leave 1cm of gallbladder & bilioenteric anastomosis OR Roux-en-Y
  • type IV -> cholecystobiliary fistula compromising the whole circumference of CBD -> subtotal cholecystectomy with Roux-en-Y hepaticojejunostomy
  • type V -> any cholecystoenteric fistula -> Va: without gallstone ileus -> division & simple suture of fistula + cholecystectomy
    - > Vb: with gallstone ileus -> treat gallstone ileus -> 3 months -> definitive surgery depending on type
39
Q

What is Rigler’s triad?

A

signs in intestinal obstruction due to gallstone ileus

  • pneumobilia
  • signs of small bowel obstruction
  • ectopic radio-opaque gallstone
40
Q

What is Forchet sign?

A

contrast passes around radiolucent calculus -> SNAKE HEAD with clear halo of the calculus

41
Q

What is Petren’s sign?

A

passage of contrast medium into biliary tract or bilioenteric fistula

42
Q

What are the indications of cholecystectomy?

A
  • complicated gallstones
  • symptomatic gallstones
  • asymptomatic GS in young age or immunocompromised
  • acute/chronic acalcular with non functioning gallbladder after conservation for 1-2 years
43
Q

When should the CBD be evaluated?

A
  • dilated CBD
  • history of jaundice in the past 6 months
  • increased GGT
44
Q

What are the borders of Calot’s triangle?

A

Superiorly -> cystic artery
Laterally -> cystic duct
Medially -> CHD & CBD

45
Q

What are the borders of the hepatocystic triangle?

A

Superiorly -> inferior border of liver
Laterally -> cystic ducts & neck of gallbladder
Medially -> CHD

Surgery M4 part 2 (36 decks)

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