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ABSITE > 32 Biliary > Flashcards

32 Biliary Flashcards

1
Q

Cystic artery

A

Branch off right hepatic artery

Found in triangle of calot

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2
Q

Triangle of Calot

A

Cystic duct (lateral)
Common bile duct (medial)
Edge of liver (superior)

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3
Q

Blood supply to hepatic and common bile duct

A

Right hepatic (lateral)
Retroduodenal branches of the gastroduodenal artery (medial)
Longitudinal blood supply

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4
Q

Cystic veins drain:

A

Into right branch of the portal vein

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5
Q

Lymphatics in relation to common bile duct?

A

Right side

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6
Q

Parasympathetic nervous supply to biliary tree

A

Left (anterior) trunk of vagus

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7
Q

Sympathetic nervous supply to biliary tree

A

T7-10 (splanchnic and celiac ganglion)

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8
Q

How does the gallbladder normally fill?

A

Contraction of sphincter of Oddi

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9
Q

Characteristics of the gallbladder and biliary tree

A

No submucosa
Mucosa is columnar epithelium
Ducts do NOT have periastalsis

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10
Q

Effect on sphincter of Oddi: Morphine

A

Contraction

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11
Q

Effect on sphincter of Oddi: Glucagon

A

Relaxation

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12
Q

Normal sizes:

  • Common bile duct
  • Gallbladder wall
  • Pancreatic duct
A

<8mm (<10 s/p chole)
<4mm
<4mm

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13
Q

Highest concentration of CCK and secretin cells are in:

A

The duodenum

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14
Q

Epithelial invaginations in the gallbladder wall

A

Rokitansky-Aschoff sinuses

FOrmed from increased gallbladder pressure

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15
Q

Biliary ducts that can leak after a cholecystectomy

A

Ducts of Luschka

Lie in the gallbladder fossa

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16
Q

What causes increased bile excretion?

A

CCK, secretin, vagal input

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17
Q

What causes decreased bile excretion?

A

Somatostatin, sympathetic stimulation

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18
Q

What causes gallbladder contraction?

A

CCK causes constant, steady, tonic contraction

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19
Q

Essential functions of bile?

A

Fat-soluble vitamin absorption
Essential fat absorption
Bilirubin and cholesterol excretion

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20
Q

How does the gallbladder form concentrated bile?

A

Active resoprtion of NaCl and water

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21
Q

Concentration of hepatic bile?

Concentration of gallbladder bile?

A

Na 140-170 (225-350)
Cl 50-120 (1-10)
BIle salts 1-50 (250-350)
Cholesterol 50-150 (300-700)

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22
Q

Active resorption of conjugated bile salts?

A

Terminal ileum (50%)

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23
Q

Passive resorption of nonconjugated bile salts?

A 
Small intestine (45%)
Colon (5%)
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24
Q

Postprandial gallbladder maximal emptying is at:

A

2hrs

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25
Q

Bile is secreted by:

A

Hepatocytes (80%)

Bile canalicular cells (20%)

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26
Q

Cholesterol and bile synthesis

A

HMG CoA > HMG CoA reductase > cholesterol > 7-a-hydroxylase > bile salts

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27
Q

Rate-limiting step in cholesterol synthesis?

A

HMG CoA reductase

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28
Q

Cholesterol stones

A

Nonpigmented stones
Causes: stasis, calcium nucleation, increased water reabsorption, decreased lecithin/bile salts
Found exclusively in the gallbladder

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29
Q

Black stones

A

Pigmented
Causes: hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN
Due to increased bilirubin load, decreased hepatic function and bile stasis
Form in gallbladder

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30
Q

Brown stones

A

Pigmented
Cause: infection (deconjugates bilirubin)
Check for: ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi
Primary common bile duct stones
Tx: sphincteroplasty

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31
Q

Most common organisms in cholecystitis?

A

E. coli
Klebsiella
Enterococcus

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32
Q

Risk factors for gallstones

A 
>40yo
Female
Obesity
Pregnancy
Rapid weight loss
Vagotomy
TPN (pigmented stones)
Ileal resection (pigmented stones)
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33
Q

Best initial test for jaundice or RUQ pain?

A

Ultraound

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34
Q

Ultrasound findings - Hyperechoic focus, posterior shawdoing, movement of focus with changes in position

A

Cholelithysis

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35
Q

Ultrasound findings - Gallstones, gallbladder wall thickening, pericholecystic fluid

A

Acute cholecystitis

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36
Q

Ultrasound findings - dilated CBD

A

CBD stone and obstruction

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37
Q

HIDA scan

A

Technetium taken up by liver and excreted in the biliary tract

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38
Q

Findings on cholecystokinin cholecintigraphy that indicate need for cholecystectomy?

A

Gallbladder not seen (cystic duct likely has a stone)
Takes >60 minutes to empty (chronic cholecystitis)
Ejection fraction < 40% (biliary dyskinesia)

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39
Q

Most sensitive test for cholecystitis?

A

Cholecystokinin cholescintigraphy

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40
Q

Indications for immediate ERCP?

A

Signs that a common bile duct stone is present

Jaundice, cholangitis, US show stone in CBD

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41
Q

Indications for pre-op ERCP?

A

Persistently high for >24hrs:

  • AST/ALT >200
  • Bilirubin >4
  • Amylase/lipase >1000
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42
Q

Best treatment for late common bile duct stone?

A

ERCP

Sphincerotomy allows for removal of stone

43
Q

Risks of ERCP?

A

Bleeding, pancreatitis, perforation

44
Q

MCC of air in the biliary tree?

A

Previous ERCP and sphincteretomy
Cholangitis
Erosion of the biliary system into the duodenum
Previous whipple

45
Q

Risk factors for acalculous cholecystitis?

A 
Severe burns
Prolonged TPN
Trauma
Major surgery
Bile stasis (nacotics, fasting)
46
Q

Emphysematous gallbladder disease

A

Gas in GBW
Increased risk in diabetics
Risk for perforation

47
Q

Gallstone ileus

A

Fistula between gallbladder and duodenum
Pneumobilia
Terminal ileum - site of obstruction
Tx: Cholecystectomy, fistula resection (if stable)

48
Q

Management of an intra-op CBD injury?

A

If <50% of circumference - primary repair

>50% - hepaticojejunostomy or choledochjejunostomy

49
Q

Post-op lap chole - persistent nausea, vomiting or jaundice?

A

Assess with ultrasound

Looking for a fluid collection

50
Q

Post-op lap chole - persistent nausea, vomiting or jaundice? Ultrasound shows fluid collection

A

Percutaneous drainage
If bilious > ERCP
- Cystic duct remnant leak, small injuries to hepatic or common bile duct, leak from duct of luschka - Sphincterotomy and stent
- Large lesion - hepaticojejunostomy or choledochojejunostomy

51
Q

Post-op lap chole - persistent nausea, vomiting or jaundice? Ultrasound shows no fluid collection with dilated hepatic ducts

A

Completely transected CBD

PTC tube then hepaticojejunostomy or choledochojejunostomy

52
Q

Timing of surgical intervention after CBD injury?

A 
Early symptoms (<7 days) - immediate
Late symptoms (>7 days) - wait 6-8 weeks
53
Q

Sepsis following lap chole?

A

Fluid resuscitation and stabilization

May be due to complete transection of CBD and cholangitis - get US

54
Q

Treatment of anastomotic leak following transplantation or hepaticojejunstomy?

A

Percutaneous drainage of fluid followed by ERCP with temporary stent (leak will heal)

55
Q

Most common cause of late post-op biliary stricture?

A 
Ischemia following Lap Chole
Other causes:
- Chronic pancreatitis
- Gallbladder CA
- Bile duct CA
Bile duct strictures w/o hx of pancreatitis or biliary surgery is CA until proven otherwise
56
Q

Treatment of bile duct stricture?

A

MRCP (defines anatomy - look for mass)
ERCP - brush biopsy
If due to ischemia or chronic pancreatitis - choledochojejunostomy

57
Q

MCC hemobilia

A

Fistula between bile duct and hepatic arterial system

Occurs with trauma or percutaneous instrumentation to liver

58
Q

Workup and treatment of hemobilia?

A

DX: angiogram
Tx: angioembolism, if that fails - OR

59
Q

Most common cancer of biliary tree?

A

GB adenocarcinoma

60
Q

Most common site of GBCa metastasis?

A

Liver (segments IV and V)

61
Q

Risk of GBCa with porcelain gallbladder?

A

15%

Do cholecystectomy

62
Q

Symptoms of GBCa?

A 
Jaundice first (due to bile duct invasion with obstruction)
Then RUQ pain
63
Q

Treatment of Gallbladder Cancer?

A

If muscle is not involved - open chole sufficient
Invades muscularis - Chole + wedge resection of segments IVb and V
Beyond muscle, but resectable - Formal resection of segments IVb and V

NO lap chole - tumor implants in trocar sites

64
Q

Risk factors for cholangiocarcinoma

A 
C. sinesis infection
Ulcerative colitis
Choledochal cysts
Primary sclerosing cholangitis
Chronic bile duct infection
65
Q

Symptoms/Signs of cholangiocarcinoma?

A

Painless jaundice (early)
Weight loss, pruritis (late)
Increased bilirubin and alkphos

66
Q

Diagnosis of cholangiocarinoma?

A

MRCP (defines anatomy, look for mass)

67
Q

Discovery of focal bile duct stenosis in patient w/o history of biliary surgery or pancreatitis?

A

Bile duct CA until proven otherwise

68
Q

Treatment of cholangiocarcinoma?

A

Surgery - if no distant mets or tumor is resectable
Upper 1/3 (Klatskin tumors) - lobectomy and stenting of contralateral bile duct (if localized on one duct)
Middle 1/3 - Hepaticojejunostomy
Lower 1/3 - Whipple

69
Q

Treatment of intrahepatic cholangiocarinoma?

A

Klatskin tumor - upper 1/3

Lobectomy and stenting of contralateral bile duct (if localized to one duct)

70
Q

Treatment of perihilar cholangiocarcinoma?

A

Middle 1/3

Hepaticojejunostomy

71
Q

Treatment of distal extrahepatic cholangiocarcinoma?

A

Lower 1/3

Whipple

72
Q

Cholangiocarcinoma risk with choledochal cysts?

A

15%

73
Q

Treatment of type I choledochal cysts?

A

Cyst excision with hepaticojejunostomy and cholecystectomy

74
Q

Treatment of Type IV and V choledochal cysts?

A

Partial liver resection or liver TXP

75
Q

Type I Choledochal cyst

A

Fulsiform/saccular

76
Q

Type II choledochal cyst

A

Choledochal diverticulum (periduodenal)

77
Q

Type III choledochal cyst

A

Intraduodenal diverticulus - choledochocele

78
Q

Type IVa choledochal cyst

A

Multiple intra and extra hepatic cysts

79
Q

Type IVb choledochal cyst

A

Multiple extrahepatic cysts

80
Q

Type V choledochal cysts

A

Totally intrahepatic cysts

81
Q

Primary sclerosing cholangitis

A

Men, 40-50s
Assoc: ulcerative colitis, pancreatitis, diabetes
Sx: jaundice, fatigue, pruritus, weight loss, RUQ pain
Multiple strictures through out hepatic ducts
Complications: portal HTN and hepatic failure, cirrhosis, cholangiocarinoma

82
Q

Multiple strictures through out hepatic ducts - diagnosis?

A

Primary sclerosing cholangitis

Progressive fibrosis of both intra and extra hepatic ducts

83
Q

Treatment of primary sclerosing cholangitis?

A

Liver TXP
PTC tube drainage, choledochojejunostomy or balloon dilation - symptom relief
Cholestyramine - pruritis
Ursodeoxycholic acid - improve liver enzymes, pruritis

84
Q

Primary biliary cirrhosis

A 
Women
Medium-sized hepatic ducts
Cholestasis > cirrhosis > portal HTN
Sx: jaundice, fatigue, pruritus, xanthomas
Antimitochondrial antibodies
Tx: Liver TXP
85
Q

Cirrhosis with antimitochondrial antibodies?

A

Primary biliary cirrhosis

86
Q

Charcot’s triad

A

RUQ pain
Fever
Jaundice
(Cholangitis)

87
Q

Reynold’s pentad

A 
RUQ pain
Fever
Jaundice
\+
Mental status changes
Shock
(Septic cholangitis)
88
Q

Most common organisms in cholangitis?

A

E. coli*

Klebsiella

89
Q

Why do you get systemic bacteremia with cholangitis?

A

When pressure in the biliary system gets greater than 200mmHg, you get colovenous reflux

90
Q

How do you diagnose cholangitis?

A

Increased AST/ALT, bilirubin, alkaline phosphatase, WBCs

US - dilated CBD (>8mm)

91
Q

Most serious complication of cholangitis?

A

Renal failure, secondary to sepsis

Others - structure, hepatic abscess

92
Q

MCC of cholangitis? Others?

A

Gallstones

Biliary stricture
Neoplasm
Chleodochal cyst
Duodenal diverticula

93
Q

Treatment of cholangitis?

A

Fluid resuscitation and antibiotics
Emergent ERCP with sphincterotomy and stone extraction
If ERCP fails - PTC to decompress biliary system

If due to infected PTC tube - change the tube

94
Q

Early cause of shock following lap chole?

A

First 24hrs - hemorrhagic shock from clip that fell off cystic artery

95
Q

Late cause of shock following lap chole?

A

After 24hrs - septic shock from accidental clip on CBD with subsequent cholangitis

96
Q

Adenomyomatosis

A

Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus
NOT premalignant
Can cause RUQ pain
Tx: cholecystectomy

97
Q

Granular cell myoblastoma

A

Benign neuroectoderm tumor of gallbladder
Can occur in biliary tract with signs of cholecystitis
Tx: Cholecystectomy

98
Q

Cholesterolosis

A

Speckled cholesterol deposits on the gallbladder wall

99
Q

Gallbladder polyps

A

> 1cm, concern of malignancy
Polyps in patients >60yo, more likely to be malignant
Tx: Cholecystectomy

100
Q

Delta bilirubin

A

Bound to albumin covalently
Half-life of 18 days
May take a while to clear after long-standing jaundice

101
Q

Mirizzi syndrome

A

Compression of common hepatic duct from:
a) stone in gallbladder infundibulum
b) inflammation from gallbladder or cystic duct extending to contiguous hepatic duct (causes hepatic duct stricture)
Tx: Cholecystectomy (poss hepaticojejunostomy for hepatic duct stricture)

102
Q

Complications of ceftriaxone in reference to biliary system?

A

Can cause gallbladder sludging and cholestatic jaundice

103
Q

Indications for asymptomatic cholecystectomy?

A

Liver transplant

Gastric bypass proceedure (if stones are present)

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