Flashcards in Biliary Tract Deck (132):
Which is the proximal and which is the distal bile duct?
Proximal is close to the liver
What is the name of the node in Calot's triangle?
What are the small ducts that drain bile directly into the gallbladder from the liver?
Ducts of Luschka
Which artery is susceptible to injury during cholecystectomy?
Right hepatic artery, because of its proximity to the cystic artery and Calot's triangle
What is the name of the valves of the gallbladder?
Spiral valves of Heister
Where is the infundibulum of the gallbladder?
Near the cystic duct
Where is the fundus of the gallbladder?
At the end of the gallbladder
What is Hartmann's pouch?
What are the boundaries of the triangle of Calot?
1. Cystic duct
2. Common hepatic duct
3. Cystic artery
What is the source of alkaline phosphatase?
Bile duct epithelium
What is in bile?
Cholesterol, lecithin (phospholipid), bile acids, bilirubin
What does bile do?
What is the enterohepatic circulation?
Circulation of bile acids from liver to gut and back to the liver
Where are most of the bile acids absorbed?
In the terminal ileum
What stimulates gallbladder emptying?
Cholecystokinin and vagal input
What is the source of cholecystokinin?
Duodenal mucosal cells
What stimulates the release of cholecystokinin?
Fat, protein, amino acids, and HCl in the duodenal lumen
What inhibits the release of cholecystokinin?
Trypsin and chymotrypsin
What are the actions of cholecystokinin?
1. Gallbladder emptying
2. Opening of the ampulla of Vater
3. Slowing of gastric emptying
4. Pancreas acinar cell growth and release of exocrine products
At what level of serum total bilirubin does one start to get jaundiced?
Classically, what is thought to be the anatomic location where one first finds evidence of jaundice?
Under the tongue
With good renal function, how high can the serum total bilirubin go?
Very rarely, > 20
What are the signs and symptoms of obstructive jaundice?
Jaundice, dark urine, clay-colored stools (acholic stools), pruritus, anorexia, nausea
What causes the itching in obstructive jaundice?
Bile salts in the dermis (not bilirubin)
What is cholelithiasis?
Gallstones in the gallbladder
What is choledocholithiasis?
Gallstone in the common bile duct
What is cholecystitis?
Inflammation of the gallbladder
What is cholangitis?
Bacterial infection of the biliary tract from obstruction
What is cholangiocarcinoma?
Malignancy of the extra-hepatic or intra-hepatic ducts
What is Klatskin's tumor?
Cholangiocarcinoma of bile ducts at the junction of the right and left hepatic ducts
What is biliary colic?
Pain from gallstones, usually from a stone in the cystic duct.
Pain is located in the RUQ, epigastrium, or right subscapular region of the back.
It usually lasts minutes to hours but eventually goes away.
Often postprandial, especially fatty foods.
What is the differential diagnosis of distal bile duct obstruction?
Choledocholithiasis, pancreatic carcinoma, pancreatitis, ampullary carcinoma, LAD, pseudocyst, post-surgical stricture, ampulla of Vater dysfunction, lymphoma, benign bile duct tumor, parasites
What is the initial study of choice for obstructive jaundice?
What lab results are associated with obstructive jaundice?
Elevated alkaline phosphatase, bilirubin +/- LFTs
What is the incidence of cholelithiasis?
10% of the US population
What are the big 4 risk factors for cholelithiasis?
Female, Fat, Forty, Fertile (multiparity)
What are the types of gallstones?
What are the types of pigmented gallstones?
1. Black (calcium bilirubinate)
2. Brown (biliary tract infection)
What are the causes of black-pigmented gallstones?
What is the pathogenesis of cholesterol stones?
Secretion of bile supersaturated with cholesterol (decreased lecithin, bile salts); Cholesterol precipitates out and forms solid crystals, then gallstones
Is hypercholesterolemia a risk factor for gallstone formation?
No (but hyperlipidemia is)
What are the signs and symptoms of cholelithiasis?
Symptoms of : biliary colic, cholangitis, choledocholithiasis, pancreatitis
Is biliary colic pain really "colic"?
No, symptoms usually last for hours
What percentage of patients with gallstones are asymptomatic?
What is thought to cause biliary colic?
Gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction, in the cystic duct, or passing through the cystic duct
What is Boas' sign?
Referred right subscapular pain of biliary colic
What the 5 major complications of gallstones?
1. Acute cholecystitis
3. Gallstone pancreatitis
4. Gallstone ileus
How is cholelithiasis diagnosed?
How often does U/S detect cholelithiasis?
98% of the time
How often does U/S detect choledocholithiasis?
33% of the time
How are symptomatic or complicated cases of cholelithiasis treated?
What are the possible complications of a lap chole?
Common bile duct injury, right hepatic duct or artery injury, cystic duct leak, biloma
What are the indications for cholecystectomy in the asymptomatic patient?
Sickle-cell disease, calcified gallbladder, child
What is an IOC?
Dye is injected into the bile duct via the cystic duct with fluoro/XR.
What are the 6 indications for an IOC?
3. Gallstone pancreatitis
4. Elevated alkaline phosphatase
5. Choledocholithiasis on U/S
6. Define anatomy
What is the management of choledocholithiasis?
1. ERCP with papillotomy and basket/balloon retrieval of stones
2. Laparoscopic trans-cystic duct or trans-common bile duct retrieval
3. Open common bile duct exploration
What medication may dissolve a cholesterol gallstone?
Chenodeoxycholic acid, ursodeoxycholic acid
What is the major feared complication of ERCP?
What is the pathogenesis of acute cholecystitis?
Obstruction of the cystic duct leads to inflammation of the gallbladder
What are the risk factors for cholecystitis?
What are the signs and symptoms of cholecystitis?
Unrelenting RUQ pain or tenderness, fever, N/V, painful palpable gallbladder, Murphy's sign, right subscapular pain, epigastric pain
What is Murphy's sign?
Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration
What are the complications of acute cholecystitis?
Abscess, perforation, choledocholithiasis, cholecystenteric fistula, gallstone ileus
What lab results are associated with acute cholecystitis?
Increased WBC; may have increased alkaline phosphatase, LFTs, amylase, T. Bili
What is the diagnostic test of choice for acute cholecystitis?
What are the signs of acute cholecystitis on U/S?
Thickened gallbladder wall, pericholecystic fluid, distended gallbladder, gallstones present
What is the difference between acute cholecystitis and biliary colic?
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
What is the treatment of acute cholecystitis?
IVFs, antibiotics, cholecystectomy
What are the 6 steps in lap chole?
1. Dissection of peritoneum overlying the cystic duct and artery
2. Clipping of cystic artery and transect
3. Division of cystic duct between clips
4. Dissection of gallbladder from liver bed
5. Cauterization; irrigation; suction, to obtain hemostasis of liver bed
6. Removal of the gallbladder through the umbilical trocar site
How is an IOC performed?
1. Place a clip on the cystic duct-gallbladder junction
2. Cut a small hole in the distal cystic duct to cannulate
3. Inject half-strength contrast and take an XR or fluoro
What percentage of patients has an accessory cystic artery?
Why should the gallbladder specimen be opened in the operating room?
Looking for gallbladder cancer, anatomy
What is acute acalculous cholecystitis?
Acute cholecystitis without evidence of stones
What is the pathogenesis of acute acalculous cholecystitis?
Believed to result from sludge and gallbladder disuse and biliary stasis, perhaps secondary to absence of cholecystokinin stimulation
What are the risk factors for acute acalculous cholecystitis?
Prolonged fasting, TPN, trauma, multiple transfusions, dehydration
What are the diagnostic tests of choice for acute acalculous cholecystitis?
U/S: sludge and inflammation usually present; HIDA scan
What are the findings of acute acalculous cholecystitis on HIDA scan?
Nonfilling of the gallbladder
What is the management of acute acalculous cholecystitis?
Cholecystectomy, or cholecystectomy tube if the patient is unstable
What are the common causes of cholangitis?
Choledocholithiasis, stricture, neoplasm (e.g. ampullary carcinoma), extrinsic compression (e.g. pancreatic pseudocyst, pancreatitis), instrumentation of the bile ducts (e.g. PTC/ERCP), biliary stent
What is the most common cause of cholangitis?
What are the signs and symptoms of cholangitis?
Charcot's triad, Reynold's pentad
What is Charcot's triad?
2. RUQ pain
What is Reynold's pentad?
4. Altered mental status
What lab results are associated with cholangitis?
Increased WBCs, bilirubin, alkaline phosphatase, positive blood cultures
Which organisms are most commonly isolated with cholangitis?
Gram-negatives (E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia)
Anaerobes less common (B. fragilis)
What are the diagnostic tests of choice for cholangitis?
U/S and contrast study (e.g. ERCP or IOC) after antibiotics
What is suppurative cholangitis?
Severe infection with sepsis
What is the management of non-suppurative cholangitis?
IVF, antibiotics; later, lap chole +/- ERCP
What is the management of suppurative cholangitis?
IVF, antibiotics, decompression (via ERCP with papillotomy, PTC with catheter drainage, or laparotomy with T-tube placement)
What is sclerosing cholangitis?
Multiple inflammatory fibrous thickenings of the bile duct walls resulting in biliary strictures
What is the natural history of sclerosing cholangitis?
Progressive obstruction possibly leading to cirrhosis and liver failure
What is the etiology of sclerosing cholangitis?
Unknown, probably autoimmune
What is the major risk factor for sclerosing cholangitis?
What type of IBD is the most common risk factor for sclerosing cholangitis?
What are the signs and symptoms of sclerosing cholangitis?
Same as for obstructive jaundice.
What are the complications of sclerosing cholangitis?
Cirrhosis, cholangiocarcinoma, cholangitis, obstructive jaundice
How is sclerosing cholangitis diagnosed?
Elevated alkaline phosphatase, PTC or ERCP revealing "beads on a string" appearance on contrast study
What are the management options for sclerosing cholangitis?
1. Hepatoenteric anastomosis and resection of extra-hepatic bile ducts (due to risk of cholangiocarcinoma)
2. Liver transplant
3. Endoscopic balloon dilatations
What percentage of patients with IBD develops sclerosing cholangitis?
What is gallstone ileus?
Small bowel obstruction from a large gallstone that has eroded through the gallbladder and into the small bowel
What is the classic site of obstruction in gallstone ileus?
Ileocecal valve (but may occur in duodenum, sigmoid colon)
What are the classic findings in gallstone ileus?
Air in the hepatic ducts, SBO with air fluid levels, gallstone in ileocecal valve
What is the population at risk for gallstone ileus?
Most commonly seen in women > 70yo
What are the signs and symptoms of gallstone ileus?
Distention, vomiting, hypovolemia, RUQ pain
What are the diagnostic tests of choice for gallstone ileus?
AXR: radiopaque gallstone in bowel, air in biliary tract, small bowel distention, air fluid levels; UGI: cholecystenteric fistula; Abdominal CT: air in biliary tract, SBO +/- gallstone in intestine
What is the management of gallstone ileus?
Enterotomy with removal of the stone +/- interval cholecystectomy
What are the risk factors for gallbladder cancer?
Gallstones, porcelain gallbladder, cholecystenteric fistula
What is the most common site of gallbladder cancer?
What is a porcelain gallbladder?
Calcified gallbladder resulting from chronic cholelithiasis or cholecystitis with calcified scar tissue
What percentage of patients with a porcelain gallbladder will have gallbladder cancer?
What is the incidence of gallbladder cancer?
What are the symptoms of gallbladder cancer?
Biliary colic, weight loss, anorexia; often asymptomatic until late
What are the signs of gallbladder cancer?
Jaundice, RUQ mass, palpable gallbladder
What are the diagnostic tests of choice for gallbladder cancer?
U/S, abdominal CT, ERCP
What is the route of spread of gallbladder cancer?
Contiguous spread to the liver is most common
What is the management of gallbladder cancer confined to the mucosa?
What is the management of gallbladder cancer confined to the muscularis/serosa?
Radical cholecystectomy (includes wedge resection of overlying liver, lymph node dissection +/- chemotherapy/XRT)
What is the main complication of a lap chole for gallbladder cancer?
Trocar site tumor implants
What is the prognosis for gallbladder cancer?
What is the histology of cholangiocarcinoma?
Almost all are adenocarcinomas
What is the average age at diagnosis for cholangiocarcinoma?
What are the signs and symptoms of cholangiocarcinoma?
Jaundice, pruritus, dark urine, clay-colored stools, cholangitis
What is the most common location for cholangiocarcinoma?
Proximal bile duct
What are the risk factors for cholangiocarcinoma?
Choledochal cysts, UC, thorotrast contrast dye, sclerosing cholangitis, liver flukes, toxin exposures (e.g. agent orange)
What are the diagnostic tests of choice for cholangiocarcinoma?
U/S, CT, ERCP/PTC with biopsy and brushings for cytology, MRCP
What is an MRCP?
MRI with visualization of pancreatic and bile ducts
What is the management of proximal bile duct cholangiocarcinoma?
Resection with Roux-en-Y hepaticojejunostomy +/- unilateral hepatic lobectomy
What is the management of distal common bile duct cholangiocarcinoma?
What is hydrops of the gallbladder?
Complete obstruction of the cystic duct by a gallstone, with filling of the gallbladder with fluid (not bile) from the gallbladder mucosa
What is Gilbert's syndrome?
Inborn error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia
What is Courvoisier's gallbladder?
Palpable, nontender gallbladder associated with cancer of the head of the pancreas.
Able to distend because it has not been scarred down by gallstones