Biliary Tract Anatomy & Labs

Question 1

The RT and LT hepatic ducts join to for the ______ ______ ______.

Answer 1

Common hepatic duct

Question 2

The GB is located at the ______ end of the MLF.

Answer 2

inferior

Question 3

The GB neck tapers to form the _____ ______ which joins with the ____ _____ _____ to form the _____ _____ _____.

Answer 3

cystic duct, common hepatic duct, common bile duct

Question 4

The CHD is _____ the liver.

Answer 4

outside

Question 5

The MPV, CHD, PHA form the ______ ______ at the _____ ______. Some refer to this as the mickely mouse sign.

Answer 5

portal triad, porta hepatis

Question 6

In the portal triad, the CHD is _______ and to the ______ of the MPV and the PHA is ______ and to the ______ of the MPV.

Answer 6

anterior/right

anterior/left

Question 7

T/F - The cystic duct is commonly visualized.

Answer 7

F - it is uncommon so we use the term “common duct” to refer to the extrahepatic ductal system

Question 8

What forms the ampulla of Vater?

Answer 8

CBD and main pancreatic duct (Duct of Wirsung)

Question 9

What is the valve of Heister’s and what is its function?

Answer 9

spiral fold in the GB which controls bile flow in the cystic duct

Question 10

What is a Hartmann’s pouch?

Answer 10

abnormal sacculation (diverticulum) of the neck of the GB

Question 11

What is a phrygian cap?

Answer 11

fold between the body and fundus of the GB

Question 12

What is a junctional fold?

Answer 12

fold between the body and neck (infundibulum) of the GB

Question 13

The CBD passes _______ to the first part of the duodenum and pancreatic head, joining the duct of Wirsung at the _____ ____ _____.

Answer 13

posterior, ampulla of Vater

Question 14

The GB is divided into what 3 parts?

Answer 14

neck, body, fundus

Question 15

Muscular valve that controls the flow of digestive juices (pancreatic, bile) through the ampulla of Vater into the second part of the duodenum.

Answer 15

Sphincter of Oddi

Question 16

The ampulla of Vater empties though the _______ ______.

Answer 16

duodenal papilla

Question 17

Normal GB wall thickness.

Answer 17

<3mm

Question 18

Cholecystokinin

Answer 18

hormone released into the blood in response to ingestion of fatty foods, causing GB contraction

Question 19

Reasons for performing a fatty meal test

Answer 19

equivocal bile duct dilation
abnormal labs (conjugated bilirubin, alkaline phosphatase)
if the duct increases in size, positive result
if the duct decreases in size or is unchanged, negative result

Question 20

Where should the CHD be measured?

Answer 20

At the porta hepatis, outside the liver where the RHA courses between the MPV and CHD, lumen only

Question 21

The size of the extrahepatic bile duct is the most sensitive means of distinguishing _______ from ______ jaundice.

Answer 21

medical (pre-hepatic/hepatic)

surgical (post hepatic)

Question 22

Measurement criteria for CHD

Answer 22

Normal <5mm
Equivocal 6-7mm
Dilated >8mm (consider age and surgery)

Question 23

Upper normal value of the CHD in elderly patients

Answer 23

10mm

Question 24

The CHD diameter increases with age, _____ mm decade rule. So at age 60, _____ mm is normal and at age 80, ____mm is normal.

Answer 24

1mm
6mm
8mm

Question 25

Postcholecystectomy, the CHD acts like a reservoir for bile so it may normally increase in size up to ____mm

Answer 25

10mm

Question 26

What parts of the biliary tree dilate with a distal common bile duct obstruction?

Answer 26

entire system distends including the GB

Question 27

What parts of the biliary tree dilate with a common hepatic obstruction?

Answer 27

only the CHD and intrahepatic ducts will dilate | GB will be contracted

Question 28

What parts of the biliary tree dilate with an obstruction at the junction of the RT and LT hepatic ducts?

Answer 28

only the intrahepatic ducts, GB will be contracted

Question 29

Bilirubin

Answer 29

end product of hemoglobin breakdown

Question 30

Total bilirubin

Answer 30

conjugated + unconjugated

Question 31

Conjugation

Answer 31

process of removing protein (albumin) from unconjugated bilirubin, making it soluble

Question 32

______ is important for bilirubin disposal. It not only renders the pigment excretable by the liver, but also detoxifies the waste product.

Answer 32

conjugation

Question 33

Indirect hyperbilirubinemia

Answer 33

unconjugated

Question 34

direct hyperbilirubinemia

Answer 34

conjugated

Question 35

Unconjugated (indirect) hyperbilirubinemia results from (3)

Answer 35

impaired hepatic bilirubin uptake increased bilirubin production impaired conjugation of bilirubin

Question 36

Conjugated (direct) hyperbilirubinemia results from (1)

Answer 36

defective bile outflow

Question 37

The kidneys do not filter ______ bilirubin as they are bound to albumin.

Answer 37

unconjugated

Question 38

The presence of bilirubin in the urine indicates_______ hyperbilirubinemia.

Answer 38

conjugated, remember that the kidneys cannot filter unconjugated

Question 39

Unconjugated hyperbilirubinemia results from impaired hepatic bilirubin uptake due to (5)

Answer 39

``` CHF liver varices TIPS Drugs Contrast agents ```

Question 40

Unconjugated hyperbilirubinemia results from increased bilirubin production due to (2)

Answer 40

hemolysis - rupture or destruction of RBCs or ineffective erythropoiesis - production of RBCs

Question 41

Unconjugated hyperbilirubinemia results from impaired conjugation of bilirubin due to (2)

Answer 41

``` Gilbert syndrome (3-7% adult pop) Crigler-Najjar Syndrome Type I and II (rare, only few 100 cases) ```

Question 42

2 autosomal recessive disorders of bile metabolism resulting in underactivity of the conjugating enzyme system due to lack of the enzyme uridine diphosphate glycosyl transferase. Leads to unconjugated hyperbilirubinemia.

Answer 42

Gilbert syndrome | Crigler-Najjar Syndrome Type I and II

Question 43

Defective bile outflow from a bile duct obstruction results in reflux of ______ into plasma and direct hyperbilirubinemia.

Answer 43

conjugates

Question 44

Conjugated hyperbilirubinemia results from defective bile outflow due to (4)

Answer 44

hepatitis biliary obstruction hepatic insult due to sepsis cardiogenic shock

Question 45

High levels of ______ bilirubin may secondarily elevate the level of _____ bilirubin.

Answer 45

conjugated, unconjugated

Question 46

alkaline phosphatase

Answer 46

ALP | enzyme that is concentrated in the bile ducts and also found in bone, liver, and placenta

Question 47

_____ increases with bone growth (children) and pregnancy (liver, placenta)

Answer 47

ALP

Question 48

_____ increases in diseases that impair bile formation, specifically bile duct obstruction

Answer 48

ALP

Question 49

ALP increases with (11)

Answer 49

``` choledocholithiasis pancreatic carcinoma cholangiocarcinoma cholangitis Mirizzi syndrome choledochal cyst (Caroli's disease) GB carcinoma primary sclerosing cholangitis primary biliary cirrhosis bone growth and diseases pregnancy ```