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Surgery Clerkship - Procedures > Biliary Tract > Flashcards

Biliary Tract Flashcards

1
Q

List the components of the biliary tract.

A

Intrahepatic ducts combine to form the left and right hepatic ducts -> common hepatic duct

Gallbladder -> cystic duct

Cyst duct + hepatic duct -> common bile duct -> Ampulla of Vater

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2
Q

What is the name of the node in Calot’s triangle?

A

Calot’s node

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3
Q

What are the small ducts that drain bile directly into the gallbladder from the liver?

A

Ducts of Luschka

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4
Q

Which artery is susceptible to injury during cholecystectomy?

A

Right hepatic artery, because of its proximity to the cystic artery and Calot’s traingle

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5
Q

Where is the infundibulum of the gallbladder?

A

Near the cystic duct

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6
Q

Where is the fundus of the gallbladder?

A

At the end of the gallbladder

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7
Q

What are the boundaries of the triangle of Calot?

A
  1. Cystic duct (inferior)
  2. Common hepatic duct (medial)
  3. Cystic artery (superior)
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8
Q

What is the source of alkaline phosphatase?

A

Bile duct epithelium; expect elevation in bile duct obstruction

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9
Q

What is in bile?

A

Cholesterol
Lecitihin (phospholipid)
Bile acids
Bilirubin

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10
Q

What does bile do?

A

Emulsifies fats

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11
Q

What is the enterohepatic circulation?

A

Circulation of bile acids form liver to gut and back to th eliver

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12
Q

Where are most of the bile acids absorbed?

A

In the terminal ileum

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13
Q

What stimulates gallbladder emptying?

A

Cholecystokinin and vagal input

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14
Q

What is the source of cholecystokinin?

A

Duodenal mucosal cells

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15
Q

What are the actions of cholecystokinin?

A

Gallbladder emptying
Opening of ampulla of Vater
Slowing of gastric emptying
Pancreas acinar cell growth and release of exocrine products

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16
Q

At what level of serum total bilirubin does one start to get jaundiced?

A

2.5

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17
Q

Classically, what is thought to be the anatomic location where one first finds evidence of jaundice and why?

A

Under the tongue (UV light breaks down bilirubin at other sites)

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18
Q

What are the signs and symptoms of obstructive jaundice?

A 
Jaundice
Dark urine
Clay-colored stools (acholic stools)
Pruritis (itching)
Loss of appetite
Nausea
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19
Q

What causes the itching in obstructive jaundice?

A

Bile salts in the dermis (not bilirubin!)

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20
Q

Define cholelithiasis.

A

Gallstones in the gallbladder

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21
Q

Define choledocholithiasis.

A

Gallstone in common bile duct

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22
Q

Define cholecystitis

A

Inflammation of the gallbladder

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23
Q

Define cholangitis.

A

Infection of biliary tract

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24
Q

Define cholangiocarinoma.

A

Adenocarcinoma of bile ducts

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25
Q

Define Klatskin’s tumor.

A

Cholangiocarinoma of bile duct at the junction of the right and left hepatic ducts

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26
Q

Define biliary colic.

A

Pain from gallstones, usually from a stone at the cystic duct
Pain is located in the RUQ, epigastrium, or right subscapular region of the back
Usually lasts minutes to hours but eventually goes away; often postprandial, especially after fatty foods

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27
Q

Define biloma.

A

Intraperitoneal bile fluid collection

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28
Q

Define choledochojejunostomy

A

Anastomosis between the common bile duct and jejunum

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29
Q

Define hepaticojejunostomy

A

Anastomosis of hepatic ducts or common hepatic duct to jejunum

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30
Q

What is the initial diagnostic study of choice for evaluation fo the biliary tract/gallbladder/cholelithiasis?

A

U/S

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31
Q

Define ERCP.

A

Endoscopic Retrograde Cholangio-Pancreatography

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32
Q

Define PTC.

A

Percutaneous Transhepatic Cholangiogram

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33
Q

Define IOC.

A

IntraOperative Cholangiogram (done laparoscopically or open to rule out choledocholithiasis)

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34
Q

What is a HIDA/PRIDA scan?

A

Radioisotope study; isotope concentrated in liver and secreted into bile; will demonstrate cholecystitis, bile leak, or CBD obstruction

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35
Q

How does the HIDA scan reveal cholecystitis?

A

Non-opacification of the gallbladder from obstruction of the cystic duct

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36
Q

What is a cholecystectomy?

A

Removal of the gallbladder laparoscopically or through a standard Kocher incision

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37
Q

What is a sphincterotomy?

A

Cut through the sphincter of Oddi to allow passage of gallstones from the common bile duct; most often done at ERCP

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38
Q

How should post-operative biloma be treated after a lap chole?

A

Percutaneous drain bile collection

ERCP with placement of biliary stent past leak (usually cystic duct remnant leak)

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39
Q

What is the treatment of major CBD injury after a lap chole?

A

Choledochojejunostomy

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40
Q

What is obstructive jaundice?

A

Jaundice (hyperbilirubinemia >2.5) from obstruction of bile flow to the duodenum

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41
Q

DDx - proximal bile duct obstruction (11)

A 
Cholanigiocarcinoma
Lymphadenopathy
Metastatic tumor
Gallbladder carcinoma
Sclerosing cholangitis
Gallstones
Tumor embolus
Parasites
Post-surgical stricture
Hepatoma
Benign bile duct tumor
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42
Q

DDx - distal bile duct obstruction (11)

A 
Choledocholithiasis (gallstones)
Pancreatic carcinoma
Pancreatitis
Ampullary carcinoma
LAD
Pseudocyst
Post-surgical stricture
Ampulla of Vater dysfunction/stricture
Lymphoma
Benign bile duct tumor
Parasites
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43
Q

Initial study of choice for obstructive jaundice?

A

U/S

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44
Q

What lab results are associated with obstructive jaundice?

A

Elevated alk phos

Elevated bilirubin with or without elevated LFTs

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45
Q

Incidence of cholelithiasis?

A

~10% of the US population will develop gallstones

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46
Q

Classic 4 risk factors for cholelithiasis?

A

Female
Fat
Forty
Fertile (multiparity)

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47
Q

What are the types of gallstones?

A
  1. Cholesterol stones (75%)

2. Pigment stones (25%)

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48
Q

What are the types of pigmented stones?

A
  1. Black stones (contain calcium bilirubinate)

2. Brown stones (assc. with biliary tract infection)

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49
Q

What are the causes of black-pigmented stones?

A

Cirrhosis

Hemolysis

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50
Q

What is the pathogenesis of cholesterol stones?

A

Secretion of bile supersaturated with cholesterol (relatively decreased amounts of lecithin and bile salts); then, cholesterol precipitates out and forms solid crystals, then gallstones

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51
Q

Signs and symptoms of cholelithiasis?

A

Symptoms of biliary colic, cholangitis, choledocholithiasis, gallstone pancreatitis

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52
Q

Why is biliary colic a misnomer?

A

Symptoms usually last for hours

53
Q

What percentage of patients with gallstones are asymptomatic?

A

80%

54
Q

What is the thought to cause biliary colic?

A

Gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction; a stone in the cystic duct; or a stone passing through the cystic duct

55
Q

What are the 5 major complications of gallstones?

A 
Acute cholecystitis
Choledocholithiasis
Gallstone pancreatitis
Gallstone ileus
Cholangitis
56
Q

How is cholelithiasis diagnosed?

A

H&P

U/S

57
Q

How often does U/S detect choledocholithiasis?

A

~33% (not a very good study for choledocholithiasis)

58
Q

How are symptomatic or complicated cases of cholelithiasis treated?

A

By cholecystectomy

59
Q

What are the possible complications of a lap chole?

A

Common bile duct injury
Right hepatic duct/artery injury
Cystic duct leak
Biloma (collection of bile)

60
Q

What are the indications for cholecystectomy in the asymptomatic patient?

A

Sickle-cell disease
Calcified gallbladder (porcelain gallbladder)
Patient is a child

61
Q

Management of choledocholithiasis?

A

ERCP with papillotomy and basket/balloon retrieval of stones (pre- or post-operatively)
Laparoscopic transcystic duct or trans common bile duct retrieval
Open common bile duct exploration

62
Q

What medication may dissolve a cholesterol gallstone?

A

Chenodeoxycholic acid
Ursodeoxycholic acid

But, if meds are stopped, gallstones often recur

63
Q

What is the major feared complication of ERCP?

A

Pancreatitis

64
Q

What is the pathogenesis of acute cholecystitis?

A

Obstruction of cystic duct leads to inflammation of the gallbladder

65
Q

Causes of acute cholecystitis?

A

~95% result from calculi

~5% from acalculous obstruction

66
Q

Risk factors for acute cholecystitis?

A

Gallstones

67
Q

What are the signs and symptoms of acute cholecystitis?

A 
Unrelenting RUQ pain or tenderness
Fever
N/V
Painful palpable gallbladder in 33%
Positive Murphy's sign
Right subscapular pain (referred)
Epigastric discomfort (referred)
68
Q

What is Murphy’s sign?

A

Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

69
Q

What are the complications of acute cholecystitis?

A 
Abscess
Perforation
Choledocholithiasis
Cholecysteneteric fistula formation
Gallstone ileus
70
Q

What lab results are associated with acute cholecystitis?

A

Increased WBC

May have slight elevation in alk phos, LFTs, amylase, total bilirubin

71
Q

Dx test of choice for acute cholecystitis?

A

U/S

72
Q

Signs of acute cholecystitis on U/S?

A 
Thickened gallbladder wall (>3 mm)
Pericholecystic fluid
Distended gallbladder
Gallstones present/cystic duct stone
Sonographic Murphy's sign
73
Q

What is the difference between acute cholecystitis and biliary colic?

A

Biliary colic has temporary pain
Acute cholecystitis has pain that does not resolve, usually with elevated WBCs, fever, and signs of acute inflammation on U/S

74
Q

What is the treatment of acute cholecystitis?

A

IV fluid
ABX
Early cholecystectomy

75
Q

What is acute acalculous cholecystitis?

A

Acute cholecystitis without evidence of stones

76
Q

What is the pathogenesis of acute acalculous cholecystitis?

A

Believed to result from sludge and gallbladder disuse and biliary stasis, perhaps secondary to absence of cholecystokinin stimulation (decreased gallbladder contraction)

77
Q

What are the risk factors for acute acalculous cholecystitis?

A 
Prolonged fasting
TPN
Trauma
Multiple transfusions
Dehydration
Prolonged post-op or ICU setting
78
Q

What are the diagnostic tests of choice for acute acalculous cholecystitis?

A

U/S (sludge and inflammation usually present)

HIDA scan

79
Q

What are the findings of acalculous cholecystitis on HIDA scan?

A

Non-filling of the gallbladde

80
Q

What is the management of acute acalculous cholecystitis?

A

Cholecystectomy or cholecystectomy tube if unstable (placed percutaneously by radiology or open surgery)

81
Q

What is cholangitis?

A

Bacterial infection of the biliary tract from obstruction (either partial or complete); potentially life-threatening

82
Q

What are the common causes of cholangitis?

A

Choledocholithiasis
Stricture (usually post-operative)
Neoplasm (usually ampullary carcinoma)
Extrinsic compression (pancreatic pseudocyst/pancreatitis)
Instrumentation of the bile ducts (PTC/ERCP)
Biliary stent

83
Q

What is the most common cause of cholangitis?

A

Choledocholithiasis

84
Q

Signs and symptoms of cholangitis?

A 
Fever/chills
RUQ pain
Jaundice
(Charcot's triad)
\+Mental status changes and shock = Reynold's pentad
85
Q

Which organisms are most commonly isolated with cholangitis?

A

GN organisms (E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia)

86
Q

Dx test of choice for cholangitis?

A

U/S and contrast study (ERCP or IOC) after the patient has “cooled off” with IV ABX

87
Q

What is suppurative cholangitis?

A

Severe infection with sepsis

88
Q

Management of non-suppurative cholangitis?

A

IVF and ABX, with definitive treatment later (lap chole +/- ERCP)

89
Q

Management of suppurative cholangitis?

A

IVF
ABX
Decompression (ERCP with papillotomy, PTC with cath drainage, lap with T-tube placement)

90
Q

What is sclerosing cholangitis?

A

Multiple inflammatory fibrous thickenings of bile duct walls resulting in biliary strictures

91
Q

What is the natural history of sclerosing cholangitis?

A

Progressive obstruction possibly leading to cirrhosis and liver failure; 10% will develop cholangiocarcinoma

92
Q

Major risk factor for sclerosing cholangitis?

A

IBD (UC most common -> 66%)

93
Q

What are the signs and symptoms of sclerosing cholangitis?

A

Same as those for obstructive jaundice (many are asymptomatic as well)

94
Q

How is sclerosing cholangitis diagnosed?

A

Elevated alk phos

PTC or ERCP revealing “beads on a string” appearance on contrast study

95
Q

What are the management options for sclerosing cholangitis?

A

Hepatoenteric anastomosis (if primarily extrahepatic ducts are involved) and resection of extrahepatic bile ducts because of the risk of cholangiocarcinoma

Transplant (if primarily intrahepatic disease or cirrhosis)
Endoscopic balloon dilations

96
Q

What is gallstone ileus?

A

SBO from a large gallstone (>2.5 cm) that has eroded through the gallbladder and into the duodenum/small bowel

97
Q

Classic site of obstruction in gallstone ileus?

A

Ileocecal valve (but may cause obstruction in the duodenum, sigmoid colon)

98
Q

Classic findings of gallstone ileus on imaging?

A

Air in the hepatic bile ducts
SBO with air fluid levels
Gallstone in ileocecal valve

99
Q

Who is at risk for gallstone ileus?

A

Most common in women >70 y/o

100
Q

Signs and symptoms of gallstone ileus?

A

SBO symptoms (distention, vomiting, hypovolemia, RUQ pain)

101
Q

Gallstone ileus causes what percentage of cases of SBO?

A

<1%

102
Q

Dx test of choice for gallstone ileus?

A

Abdominal X-ray occasionally reveals radiopaque gallstone in the bowel; 40% of patients show air in the biliary tract, small bowel distention, and air fluid levels secondary to ileus

UGI: used if dx is in question, will show cholecystenteric fistula and the obstruction

Abdominal CT: air in biliary tract, SBO +/- gallstone in intestine

103
Q

Management of gallstone ileus?

A

Enterotomy with removal of the stony +/- interval cholecystectomy (interval delayed)

104
Q

What is carcinoma of the gallbladder?

A

Malignant neoplasm arising in the gallbladder, vast majority (90%) are adenocarcinoma

105
Q

Risk factors for carcinoma of the gallbladder?

A

Gallstones
Porcelain gallbladder
Cholecystenteric fistula

106
Q

What percentage of patients with a porcelain gallbladder will have gallbladder cancer?

A

~50% (20-60%)

107
Q

Incidence of gallbladder carcinoma?

A

~1% of all gallbladder specimens

108
Q

Symptoms of gallbladder cancer?

A

Biliary colic
Weight loss
Anorexia

Many asymptomatic until late
May present as acute cholecystitis

109
Q

Signs of gallbladder cancer?

A

Jaundice (from invasion of the common duct or compression by involved pericholedochal lymph nodes), RUQ mass, palpable gallbladder (advanced gisease)

110
Q

Dx tests of choice for gallbladder cancer?

A

U/S
Abdominal CT scan
ERCP

111
Q

Route of spread of gallbladder cancer?

A

Contiguous spread to the liver is most common

112
Q

Management of gallbladder cancer if confined to mucosa?

A

Cholecystectomy

113
Q

Management of gallbladder cancer if confined to muscularis/serosa?

A

Radical cholecystectomy (chole + wedge resection of overlying liver, and LN dissection +/- chemo/XRT)

114
Q

What is the main complication of a lap chole for gallbladder cancer?

A

Trocar site tumor implants (if known preoperatively, perform open chole)

115
Q

Prognosis for gallbladder cancer?

A

Dismal overall: <5% 5-year, as most are unresectable at diagnosis

T1 with cholecystectomy: 95% 5-year

116
Q

What is cholangiocarcinoma?

A

Malignancy of the extrahepatic or intrahepatic ducts (primary bile duct cancer)

117
Q

What is the histology of cholangiocarinoma?

A

Almost all are adenocarcinoms

118
Q

Average age at dx - cholangiocarcinoma?

A

~65 years (M=F)

119
Q

Most common location of cholangiocarcinoma?

A

Proximal bile duct

120
Q

Risk factors for cholangiocarcinoma?

A 
Choledochal cysts
UC
Thorotrast contrast dye (used in 1950s)
Sclerosing cholangitis
Liver flukes (clonorchiasis)
Toxin exposures (Agent orange, etc.)
121
Q

Dx tests of choice for cholangiocarinoma?

A

U/S
CT
ERCP/PTC with biopsy/brushings for cytology
MRCP (MRI with visualization of pancreatic and bile ducts)

122
Q

Management of proximal bile duct cholangiocarinoma?

A

Resection with Roux-en-Y hepaticojejunostomy (anastomose bile ducts to jejunum) +/- unilateral hepatic lobectomy

123
Q

Management of distal common bile duct cholangiocarcinoma?

A

Whipple procedure

124
Q

Cause of calcified gallbladder?

A

Chronic cholelithiasis/cholecystitis with calcified scar tissue in gallbladder wall

125
Q

What is hydrops of the gallbladder?

A

Complete obstruction of the cystic duct by a gallstone, with filling of the gallbladder with fluid (not bile) form the gallbladder mucosa

126
Q

What is Gilbert’s syndrome?

A

Inborn error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia

127
Q

What is Courvoisier’s gallbladder?

A

Palpable, non-tender gallbladder associated with cancer of the head of the pancreas; able to distend because it has not been “scarred down” by gallstones

128
Q

What is Mirizzi’s syndrome?

A

Common hepatic duct obstruction as a result of extrinsic compression from a gallstone impacted in the cystic duct

Surgery Clerkship - Procedures (17 decks)

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