32: Biliary System Flashcards
Which stones, if found in the common bile duct, are considered secondary common bile duct stones?
Cholesterol stones and black stones
What is the treatment for gallbladder adenocarcinoma if there is involvement beyond muscle but it is still resectable?
Formal resection of segments IVb and V
[UpToDate: For patients with gallbladder that extends beyond the mucosa, >T1a, the benefit of more radical surgery has been controversial. Randomized trials comparing simple cholecystectomy with radical surgery for gallbladder cancer have not been performed; all available studies are retrospective series. Some of these series, but not all, link better outcomes with more radical surgery.
In another Japanese series of 1686 resected gallbladder cancers from 172 major hospitals, survival rates were significantly better for patients undergoing radical resection compared with patients with simple cholecystectomy (three-year survival: 66% vs 14%, 5-year survival: 51% vs 6%).
At the Mayo Clinic, 22 of 40 patients undergoing potentially curative resection had a simple cholecystectomy, while the remainder had a radical procedure. Although 5-year overall survival rates were similar (33% vs 32%), median survival in patients undergoing radical resection was significantly better (3.6 vs 0.8 years), and for those with transmural extension or nodal metastasis, the only 5-year survivors were those who had undergone extended cholecystectomy.
On the other hand, in a series of 104 patients treated at Memorial Sloan-Kettering over a 12-year period, major hepatectomy, resection of adjacent organs other than the liver, and common bile duct excision increased perioperative morbidity and were not associated with better survival. The authors concluded that major hepatic resection (including excision of the common bile duct) was appropriate, when necessary, to clear disease, but not mandatory in all cases.
Recommendation - Patients with a preoperative diagnosis of potentially resectable, localized gallbladder cancer should be offered definitive resection which involves en bloc resection of the gallbladder and a margin of underlying liver (nonanatomic or anatomic resection), and resection of the regional lymph nodes or extrahepatic biliary ducts depending upon the extent of disease identified intraoperatively. A right hepatic lobectomy may be appropriate in selected patients (eg, tumor of the gallbladder neck, tumor involving the right portal triad).]
What is the treatment for cholangitis?
- Fluid resuscitation
- Antibiotics
- Emergent ERCP with sphincterotomy and stone extraction (if applicable)
- If ERCP fails, place PTC tube to decompress the biliary system
[If the cause is an infected PTC tube, change the tube]
Cystic veins drain into which vein?
The right branch of the portal vein
What is caused by abnormal reflux of pancreatic enzymes during uterine development?
Choledochal cysts
What percent of gallstones are radiopaque?
Only 10%
[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.
Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.
Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]
What is the approach to intraoperative common bile duct injury that is greater than 50% of the circumference of the bile duct and cannot be primarily repaired?
Hepaticojejunostomy or choledocojejunostomy
What is the treatment for granular cell myoblastoma of the gallbladder?
Cholecystectomy
[Granular cell myoblastoma = A benign neuroectoderm tumor of the gallbladder]
What is the first symptom of gallbladder adenocarcinoma?
Jaundice (bile duct invasion with obstruction)
[RUQ pain after that]
What is the treatment for Mirizzi syndrome?
Cholecystectomy
[May need hepaticojejunostomy for hepatic duct stricture]
What type of choledochal cyst is partially intrahepatic?
Type IV
The cystic artery branches off of which artery?
Right hepatic artery
What is the most sensitive test for cholecystitis?
Cholecystokinin cholescintigraphy (CCK-CS test)
[Cholescinitgraphy is a HIDA scan. It is 97% sensitive for acute cholecystitis (U/S is 95% sensitive).]
What is the treatment for cholangiocarcinoma in the lower 1/3 of the biliary system?
Whipple
What is the treatment for choledochal cysts?
Cyst excision with hepaticojejunostomy and cholecystectomy
[UpToDate: Patients with type I, II, or IV cysts usually undergo surgical resection of the cysts due to the significant risk of malignancy, provided they are good surgical candidates. Type I and IV cysts should be completely resected with creation of a Roux-en-Y hepatojejunostomy. Serial sections from the cyst wall should be examined by the pathologist to look for any malignant changes. Type II cysts can be treated with simple cyst excision. Type III cysts (choledochoceles) require treatment if they are symptomatic and may be managed with sphincterotomy or endoscopic resection. Treatment for type V cysts is largely supportive and is aimed at dealing with problems such as recurrent cholangitis and sepsis. Type V cysts can be difficult to manage, and some patients with type V cysts eventually require liver transplantation.]
What is the overall 5-year survival of gallbladder adenocarcinoma?
5%
[UpToDate: Gallbladder cancer (GBC) is an uncommon but highly fatal malignancy; fewer than 5000 new cases are diagnosed each year in the United States. The majority are found incidentally in patients undergoing exploration for cholelithiasis; a tumor will be found in 1% to 2% of such cases. The poor prognosis associated with GBC is thought to be related to advanced stage at diagnosis, which is due both to the anatomic position of the gallbladder, and the vagueness and nonspecificity of symptoms.
Surgery is the only potentially curative treatment for gallbladder cancer. Surgical series report long-term survival rates of 85% to 100% for patients with early-stage (T1) disease. Unfortunately, fewer than 10% of symptomatic patients and only approximately 20% of patients with incidentally diagnosed gallbladder cancer have early-stage disease. The poor prognosis associated with GBC is related to the often advanced stage at diagnosis.]
What are 2 late complications of cholangitis?
- Stricture
- Hepatic abscess
What are 3 risks of ERCP?
- Bleeding
- Pancreatitis
- Perforation
What is the overall 5-year survival rate of cholangiocarcinoma?
20%
What is the treatment for gallbladder adenocarcinoma if muscle is involved but nothing beyond?
Wedge resection of segments IVb and V
[UpToDate: Patients with stage T1b disease may benefit from a more radical approach, given that T1b tumors are associated with a higher incidence of lymph node metastases compared with T1a tumors (15% versus 2.5%). Some investigators have shown a median survival advantage of over three years for extended versus cholecystectomy alone for T1b cancers (9.85 vs 6.42 years, respectively). Extended cholecystectomy (cholecystectomy including a rim of liver tissue) should be performed for medically-fit patients who have tumors that invade the muscular layer (T1b).
The optimal approach to T1b disease is more controversial. If there is no contraindication to surgery, extended resection is reasonable for T1b gallbladder cancer. At least two retrospective studies comparing cholecystectomy alone versus extended cholecystectomy for T1b tumors found no significant difference in overall survival (with up to 87% 10-year survival). Others have reported improved survival with re-resection. Furthermore, a number of studies describe high rates of residual disease upon re-resection, with lymph node metastases in 12% to 20% and 0% to 13% with liver involvement. Two reports describe up to a 50% to 60% locoregional recurrence rate after cholecystectomy alone for T1b disease. The authors of both reports concluded that gallbladder cancer is a locally aggressive disease and even early-stage disease warrants extended resection. Finally, as noted above, decision analysis showed a median survival advantage of over three years for extended versus simple cholecystectomy (9.85 vs 6.42 years).
What type of choledochal cyst is totally intrahepatic?
Type V
[Known as Caroli’s disease]
What are 5 risk factors for cholangiocarcinoma?
- C. sinensis infection
- Ulcerative colitis
- Choledochal cysts
- Primary sclerosing cholangitis
- Chronic bile duct infection
Which bacteria produces beta-glucuronidase, deconjugating bilirubin and forming calcium bilirubinate?
E. Coli
What are the 4 main causes of pigmented (black) gallstones?
- Hemolytic disorders
- Cirrhosis
- Ileal resection (loss of bile salts)
- Chronic TPN
[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.
Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.
Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]
How is hemobilia diagnosed?
Angiogram
What is the treatment for biliary strictures that are due to ischemia or pancreatitis?
Choledochojejunostomy
[Best long-term solution]
What anatomical structures form the lateral, medial, and superior borders of the Triangle of Calot (Hepatobiliary triangle)?
- Lateral border: Cystic duct
- Medial border: Common hepatic duct
- Superior border: Liver
Do dissolution agents such as monoctanoin work on pigmented stones?
No
[Monoctanoin is a monoglyceride used to dissolve gallstones that are caused by cholesterol.]
What is the risk of gallbladder cancer in a patient with porcelain gallbladder?
15%
[These patients need a cholecystectomy]
Thickened nodules of mucosa and muscle associated with Rokitansky-Aschoff sinuses in the gallbladder are called what?
Adenomyomatosis
[Not premalignant and does not cause stones but can cause RUQ pain]
[UpToDate: Adenomyomatosis is an abnormality of the gallbladder characterized by overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula. Despite the name, this condition does not involve any adenomatous changes in the gallbladder epithelium. While generally not considered to be a premalignant condition, adenomyomatosis is sometimes encountered in gallbladders resected for cancer, which has led to the suggestion that it is a premalignant condition. However, the association and its magnitude remain unclear. There is, however, a clear association of adenomyomatosis with cholelithiasis, particularly with the segmental type, which was reported in 89% of patients with segmental adenomyomatosis in one series.
Adenomyomatosis of the gallbladder is less common than cholesterolosis in most reports, with some exceptions. In one report, for example, only 103 cases of adenomyomatosis were found in over 10,000 cholecystectomies (1%). This is compared with the much higher prevalence of cholesterolosis (9% to 26%). Adenomyomatosis is more common in women.]
What is the treatment for brown (pigmented) gallstones which are primarily formed in the common bile duct?
Almost all patients with primary stones need a biliary drainage procedure
[Sphincteroplasty is 90% successful]
How does the gallbladder form concentrated bile?
Active resorption of NaCl and water
What is the most common rout of bacterial infection of bile?
Dissemination from portal system
[Not retrograde through sphincter of oddi]
What is the treatment of acalculous cholecystitis?
Cholecystectomy
What are 3 indications for immediate ERCP?
- Jaundice
- Cholangitis
- U/S shows stone in common bile duct
[Signs that a common bile duct stone is present]
What kind of bilirubin is bound to albumin covalently, has a half-life of 18 days, and may take a while to clear after long-standing jaundice?
Delta bilirubin
Which antibiotic can cause gallbladder sludging and cholestatic jaundice?
Ceftriaxone
How does the gallbladder normally fill?
Contraction of the sphincter of Oddi at the the Ampulla of Vader
Parasympathetic fibers to the biliary system come from where?
The left trunk (anterior trunk) of the vagus nerve
What is the name of the breakdown product of conjugated bilirubin in the gut that gives stool its brown color?
Stercobilin
What is the treatment for hemobilia?
Angioembolization
[Operation if that fails]
What is the approach to treating a patient with an anastomotic leak following transplantation or hepaticojejunostomy
Percutaneous drainage of fluid collection followed by ERCP with temporary stent
[Leak will heal]
Is this hepatic bile or gallbladder bile?
- Na (mEq/L): 140-170
- Cl (mEq/L): 50-120
- Bile Salts (mEq/dL): 1-50
- Cholesterol (mEq/dL): 50-150
Hepatic bile
Which hormone causes constant, steady, tonic contraction of the gallbladder?
CCK
What are the components of Reynolds’ Pentad seen in patients with cholangitis?
- Charcot’s Triad (RUQ pain, fever, jaundice)
- Mental status change
- Shock
[Suggests sepsis]
What is the only treatment that can alter the outcome for a patient with primary sclerosing cholangitis?
Liver transplant
Can a laparoscopic approach be used for the resection of gallbladder adenocarcinoma?
No
[High incidence of tumor implants in trocar sites when cancer is discovered after laparoscopic cholecystectomy]
How is cholangiocarcinoma diagnosed?
Magnetic resonance cholangiopancreatography (MRCP) defines the anatomy and looks for a mass
A gallbladder polyp of what size would be worrisome for malignancy?
Greater than 1 cm
What is the approach to a patient with evidence of an injury to the biliary system more than 7 days after laparoscopic cholecystectomy?
Hepaticojejunostomy 6-8 weeks after injury
[Tissue too friable for surgery after 7 days]
Patients undergoing which 2 procedures should have an asymptomatic cholecystectomy?
- Patient undergoing liver transplant
- Patient undergoing gastric bypass
[Also Whipple procedures should include a cholecystectomy.]
What are 3 non-iatrogenic causes of biliary strictures?
- Chronic pancreatitis
- Gallbladder cancer
- Bile duct cancer
What is the treatment for gallbladder adenocarcinoma if muscle is not involved?
Cholecystectomy
[UpToDate: Simple cholecystectomy alone is felt to be adequate for patients with tumors that are limited to the lamina propria (T1a). Cure rates following simple cholecystectomy range from 73% to 100% in case series. Patients found to have incidental T1a tumors with negative margins are generally felt to be curable with the cholecystectomy that has already been performed. Re-resection for T1a tumors does not appear to provide an overall survival benefit.]
What percent of patients undergoing cholecystectomy will have a retained common bile duct stone?
5%
[95% of these are cleared with ERCP]
Which medication or hormone causes the sphincter of Oddi to relax?
Glucagon
What are 3 findings on cholecystokinin-cholescintigraphy that are indications for cholecystectomy?
- Gallbladder not seen (cystic duct likely has a stone)
- Takes greater than 60 minutes to empty (chronic cholecystitis)
- Ejection fraction less than 40% (biliary dyskinesia)
Men in which decade of life typically get primary sclerosing cholangitis?
4th-5th decade
[UpToDate: The incidence is higher in males and the median age at diagnosis was 41.]
What is the best initial test for evaluation of jaundice or RUQ pain?
Ultrasound
Common bile duct injuries most commonly occur after which operation?
After laparoscopic cholecystectomy
What is the treatment for cholangiocarcinoma in the middle 1/3 of the biliary system?
Hepaticojejunostomy
What kind of gallbladder stone is caused by solubilization of unconjugated bilirubin with precipitation?
Pigmented (Calcium bilirubinate) stones
What kind of epithelium is the mucosa of the gallbladder?
Columnar epithelium
What are the 2 most common organisms responsible for cholangitis?
- E. Coli (most common)
- Klebsiella
Which kind of gallstones are formed in the ducts and are more common in Asians?
Brown (pigmented stones)
[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.
Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.
Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]
What is the rate-limiting enzyme in the conversion of HMG CoA to Cholesterol?
HMG CoA reductase
[HMG-CoA (or 3-hydroxy-3-methylglutaryl-coenzyme A) is an intermediate in the mevalonate and ketogenesis pathways. It is formed from acetyl CoA and acetoacetyl CoA by HMG-CoA synthase]
Emphysematous gallbladder disease is most commonly secondary to which bacteria?
Clostridium perfringens
What is the rate-limiting enzyme in the conversion of Cholesterol into bile salts (acids)?
7-alpha-hydroxylase
What is the most common type of gallstone found in the United States?
Non-pigmented (cholesterol) gallstones
[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.
Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.
Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]
What is the most common type of gallstone found worldwide?
Pigmented stones
[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.
Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.
Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]
What is the treatment for gallbladder polyps?
Cholecystectomy
Which segment(s) of the liver does gallbladder adenocarcinoma invade first?
Segments IV and V
[First nodes are the cystic duct nodes on the right side]
Which cells secrete 20% of bile?
Bile canalicular cells
[Other 80% is secreted by the hepatocytes.]
Where does active resorption of conjugated bile salts occur?
Terminal ileum
[50% of resorption occurs here]
What is the treatment for cholangiocarcinoma in the upper 1/3 of the biliary system (Klatskin tumor which occur at the confluence of the right and left hepatic bile ducts)?
Lobectomy and stenting of contralateral bile duct if localized to either the right or left lobe Palliative stenting if unresectable disease
[Upper 1/3 has worst prognosis and is usually unresectable]
What is the treatment for a type V choledochal cyst?
Partial liver resection or liver transplant
[Type V cyst is totally intrahepatic]
What type of choledochal cyst is characterized by fusiform or saccular dilatation of extrahepatic ducts?
Type I
[Most common type]
What is Mirizzi syndrome?
Compression of the common hepatic duct by a stone in the gallbladder infundibulum or from inflammation arising from the gallbladder or cystic duct and causing common hepatic duct stricture
What is characterized by multiple strictures throughout the hepatic ducts?
Primary Sclerosing Cholangitis
Fistula formation between the gallbladder and duodenum can result in what?
Gallstone ileus
[More common in elderly]
What percent of choledochal cysts are extrahepatic?
90%
What is the treatment for adenomyomatosis?
Cholecystectomy
[Adenomyomatosis = A thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus]
[UpToDate: Adenomyomatosis is an abnormality of the gallbladder characterized by overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula. Despite the name, this condition does not involve any adenomatous changes in the gallbladder epithelium. While generally not considered to be a premalignant condition, adenomyomatosis is sometimes encountered in gallbladders resected for cancer, which has led to the suggestion that it is a premalignant condition. However, the association and its magnitude remain unclear. There is, however, a clear association of adenomyomatosis with cholelithiasis, particularly with the segmental type, which was reported in 89% of patients with segmental adenomyomatosis in one series.
Adenomyomatosis of the gallbladder is less common than cholesterolosis in most reports, with some exceptions. In one report, for example, only 103 cases of adenomyomatosis were found in over 10,000 cholecystectomies (1%). This is compared with the much higher prevalence of cholesterolosis (9% to 26%). Adenomyomatosis is more common in women.]
What are speckled cholesterol deposits on the gallbladder wall called?
Cholesterolosis
Is this hepatic bile or gallbladder bile?
- Na (mEq/L): 225-350
- Cl (mEq/L): 1-10
- Bile Salts (mEq/dL): 250-350
- Cholesterol (mEq/dL): 300-700
Gallbladder bile
What is the associated risk of cholangiocarcinoma in a patient with a choledochal cyst?
15% cancer risk
What is the most common site of obstruction in gallstone ileus?
Terminal ileum
Epithelial invaginations in the gallbladder wall that are formed from increased gallbladder pressures are called what?
Rokitansky-Aschoff sinuses
What is the name of the breakdown product of conjugated bilirubin that gets released in the urine and gives urine its yellow color?
Urobilin
[Conjugated bilirubin is broken down in gut -> Reabsorbed -> Converted to urobilinogen -> converted to urobilin]
What is the treatment for emphysematous gallbladder disease?
Emergent cholecystectomy
Which cells secrete 80% of bile?
Hepatocytes
[Other 20% is secreted by the bile canalicular cells.]
Which tissue layer is absent in the gallbladder?
Submucosa
Which 3 signals increase bile excretion?
- CCK
- Secretin
- Acetylcholine (vagal input)
Where does passive resorption of nonconjugated bile salts occur?
- Small intestine (45% of resorption)
- Colon (5% of resorption)
[The other 50% of resorption is actively resorbed in the terminal ileum.]
Sympathetic fibers to the biliary system come from where?
T7-T10 (splanchnic and celiac ganglions)
Which anatomical triangle contains the cystic artery?
The triangle of Calot (Hepatobiliary triangle)
Progressive fibrosis of intrahepatic and extrahepatic bile ducts in a patient with primary sclerosing cholangitis eventually results in what?
Portal hypertension and hepatic failure
In which portion of the biliary system does cholangiocarcinoma most commonly occur?
Upper 1/3
[Worst prognosis and usually unresectable]
[UpToDate: Biliary tract cancers were traditionally divided into cancers of the gallbladder, the extrahepatic ducts, and the ampulla of Vater, while intrahepatic tumors of the bile system were classified as primary liver cancers. More recently, the term cholangiocarcinoma has been used to refer to bile duct cancers arising in the intrahepatic, perihilar, or distal (extrahepatic) biliary tree, exclusive of the gallbladder or ampulla of Vater.
Intrahepatic cholangiocarcinomas originate from small intrahepatic ductules (termed peripheral cholangiocarcinomas) or large intrahepatic ducts proximal to the bifurcation of the right and left hepatic ducts. The extrahepatic bile ducts are divided into perihilar (including the confluence itself) and distal segments, with the transition occurring at the point where the common bile duct lies posterior to the duodenum distal to the insertion of the cystic duct into the common bile duct.
In general, perihilar disease represents about 50%; distal disease, 40%; and intrahepatic disease, less than 10% of cholangiocarcinoma cases.]
Patients with primary biliary cirrhosis test positive for which antibody?
Antimitochondrial antibodies
[UpToDate: Antimitochondrial antibodies (AMA) are the serologic hallmark of PBC. They are present in approximately 95% of patients with PBC. Occasionally, AMA are detected in patients with no other features suggestive of PBC. Many of these patients will eventually go on to develop features of PBC.
Antinuclear antibodies (ANA) are found in up to 70% of patients with PBC. A variety of staining patterns may be present. Two immunofluorescence patterns are considered “PBC-specific”: the multiple nuclear dots pattern (target antigen, Sp100) and the rim-like/membranous pattern (target antigens, gp210, nucleoporin p62, and the lamin B receptor). Other antibodies such as anticentromere, anti-SSA/Ro, and anti-dsDNA antibodies can be also found in PBC.
ANA have clinical significance in PBC for two reasons. First, their presence can cause confusion with autoimmune hepatitis or autoimmune hepatitis/PBC overlap. Second, some suggest that ANA may be associated with more rapid progression of disease and a poorer prognosis. However, the strength of this association and the implications for management are uncertain. For example, patients with PBC who are AMA-negative and have a positive ANA, a disease often called autoimmune cholangitis but more appropriately AMA-negative PBC, have the same outcomes as those who are AMA-positive and ANA-negative.]
What is the normal thickness of the gallbladder wall?
Less than 4mm
[UpToDate: Gallbladder wall thickening (greater than 4 to 5 mm) is indicative of cholecystitis.
Measurements of components of the hepatobiliary tree depend upon the skill of the ultrasonographer obtaining the measurements, and there is variability in terms of what is considered “normal.” However, some general estimates are available regarding the expected sizes of structures in the hepatobiliary tree:
Gallbladder: The gallbladder wall should be less than or equal to 2 mm (in a distended or fasting gallbladder). Collapsed gallbladders, seen when the subject has eaten, typically appear slightly more thickened. Typically, the maximum “normal” dimension of the gallbladder is 5 X 10 cm.
Common hepatic duct: The common hepatic duct (inner wall to inner wall) is usually measured at the level of the hepatic artery. In the normal fasting state, it should be <7 mm in patients <60 years, and <10 mm in patients older than 60.
Common bile duct (CBD): The normal CBD diameter increases with age and in patients who have had a cholecystectomy. In patients in their 40s, the normal mean diameter is 4 mm. The normal mean diameter then increases by 1 mm every decade, and authors have proposed that in older patients the normal upper limit of normal be set at 8.5 mm. The CBD is commonly up to 10 mm in patients who have undergone a cholecystectomy.
Liver: The span of the liver in the right midclavicular line should be less than 16 cm.]
What is the approach to a patient with evidence of an injury to the biliary system within 7 days of laparoscopic cholecystectomy?
Take back to the OR for hepaticojejunostomy
[After 7 days, must wait 6-8 weeks before takeback for hepaticojejunostomy.]
