Chapter 32 - Biliary System Flashcards Preview

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Flashcards in Chapter 32 - Biliary System Deck (114):
1

What is the triangle of Calot?

Cystic duct, CBD, liver

2

What blood vessels supply the hepatic and CBD?

Right hepatic and retroduodenal branches of the GDA

3

What side of the CBD are the lymphatics on?

Right

4

What is the mucosal of the gallbladder? Submucosa?

Columnar epithelium; NO submucosa

5

What will contract the sphincter of Oddi?

Morphine

6

What will relax the sphincter of Oddi?

Glucagon

7

What is the normal size of the GB wall? Pancreatic duct? CBD?

GB wall: 2-4mm
Pancreatic duct: <10mm s/p chole

8

Where is the highest concentration of CCK and secretin cells?

Duodenum

9

What are Rokitansky-Aschoff sinuses?

Invagination of the epithelium of the wall of the gallbladder; formed from increased gallbladder pressure

10

What are the ducts of Luschka?

Biliary ducts that can leak after chole

11

What stimulates increased bile excretion?

CCK, secretin, vagal input

12

What causes decreased bile excretion?

VIP, somatostatin, sympathetic stimulation

13

What are the 3 essential functions of bile?

Fat-soluble vitamin absorption, bilirubin excretion, cholesterol excretion

14

How does the gallbladder form concentrated bile?

Active resorption of Na and H20

15

How many times a day does the bile salt pool cycle?

4-8 times/day

16

Where does active resorption of conjugated bile acids occur? Passive resorption of nonconjugated bile acids?

Active: terminal ileum (50%), passive: small intestine and colon

17

Where is bile secreted from?

Bile canalicular cells (20%), hepatocytes (80%)

18

What is the breakdown product of conjugated bilirubin that gives stool brown colon?

Stercobilin

19

What is the breakdown product of conjugated bilirubin that gets reabsorbed and released in urine?

Urobilin

20

Pathway of cholesterol and bile acid synthesis?

HMG CoA --> (HMG CoA reductase) --> cholesterol --> (7-alpha-hydroxylase) --> bile acids

21

What is the rate-limiting step in cholesterol synthesis?

HMG CoA reductase

22

What causes stones in obese people? In thin people?

Obese: overactive HMG CoA reductase, thin: underactive 7-alpha-hydroxylase

23

What % of the population has gallstones?

10%

24

What % of gallstones are radiopaque?

10%

25

What causes nonpigmented stones?

Increase cholesterol insolubilization; caused by stasis, calcium nucleation by mucin glycoproteins, increased water reabsorption from gallbladder; decreased lecithin and bile acids

26

What is the most common type of stone found in the US?

Nonpigmented (75%)

27

What is the most common type of stone found worldwide?

Pigmented

28

What causes pigmented stones?

Solubilization of unconjugated bilirubin with precipitation of calcium bilirubinate and insoluble salts

29

What causes black stones?

Hemolytic disorders or cirrhosis; also in pts with chronic TPN, ileal resection; increased bilirubin load, decreased hepatic function and bile stasis

30

What causes brown stones? Where are they found?

Infection causing deconjugation of bilirubin; found in CBD, formed in ducts

31

Most common bacteria causing brown stones?

E. coli

32

What needs to be checked for in a patient with brown stones?

Ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi

33

Cholecystitis is caused by what?

Obstruction of the cystic duct by gallstone

34

What is suppurative cholecystitis?

Associated with frank purulence in the GB, can be associated with sepsis and shock

35

Most common organisms in acute cholecystitis?

E. coli, klebsiella, enterococcus

36

Risk factors for stone formation?

Age >40, female, obesity, pregnancy, rapid wt loss, vagotomy, TPN, ileal resection

37

Sensitivity of US in picking up stones?

95%

38

What is the definition of biliary dyskinesia?

<40% of gallbladder volume excreted after CCK over 1 hour

39

Causes of air in the biliary system?

Previous ERCP and sphincterotomy, cholangitis, erosion of the biliary system into duodenum (gallstone ileus)

40

What are signs of acalculous cholecystitis? Pathology?

Thickened wall, RUQ pain, elevated WBCs; bile stasis leading to distention and ischemia

41

When does acalculous cholecystitis occur?

After burns, prolonged TPN, trauma, other major surgery

42

Diagnosis of acalculous cholecystitis?

US shows sludge, GB wall thickening, pericholecystic fluid; HIDA (+)

43

What is the common organism causing emphysematous gallbladder disease?

C. perfringens

44

What is gallstone ileus?

Fistula between GB and duodenum that releases stone, causing SBO; elderly, can see pneumobilia on plain film

45

Most common site of obstruction in gallstone ileus?

Terminal ileum

46

Treatment for gallstone ileus?

Remove stone with enterotomy proximal to obstruction; perform chole and fistula resection

47

What is the benefit of interoperative cholangiography?

Does not prevent injuries; may limit severity, increases early diagnosis of injury to CBD

48

In what % of patients does the right posterior duct enter the CBD separately? What segment is it from?

10%, segment 6 or 7

49

What is the treatment if the right posterior duct is injured during lap chole?

If >2mm, need to open and perform hepaticoj

50

Treatment for intraop CBD injury?

If <50% of the circumference, can perform primary repair; in all other cases need hepaticoj or choledochoj

51

What is the workup for persistent nausea and vomiting or jaundice following lap chole?

US to look for fluid collection: if collection, perc drain - bilious: ERCP and stent vs repair; no fluid collection, dilated hepatic ducts - concern for transected bile duct

52

Treatment for anastamotic leaks following transplant or hepaticoj?

ERCP and stents

53

Treatment for sepsis following lap chole?

Fluid resuscitation, stabilize; concern for complete transection of CBD and cholangitis

54

Most common situation in which CBD or hepatic duct strictures occur?

After lap chole

55

What is the most important cause of late postoperative biliary strictures?

Ischemia; can also be caused by chronic pancreatitis, stricture of biliary enteric anastomosis

56

Diagnosis of CBD or hepatic duct stricture?

ERCP; US will show dilated ducts

57

Treatment of CBD or hepatic duct strictures?

ERCP with sphincterotomy and possible stent placement; PTC tube if that fails; 7d post injury: hepaticoj 6-8wks after injury

58

What causes hemobilia?

Fistula between bile duct and hepatic arterial system; most commonly occurs with trauma, also infections, primary gallstones, aneurysms, tumors

59

Presentation of hemobilia?

UGI bleed, jaundice, RUQP

60

Diagnosis of hemobilia? Treatment?

Angiogram; resuscitation, angio and embolization, operation if that fails

61

What is the most common cancer of the biliary tract?

Gallbladder adenocarcinoma

62

What is the most common site of mets from gallbladder adenocarcinoma?

Liver

63

Risk of cancer with porcelain gallbladder?

10-20%, need chole

64

What % of patients present with stage IV disease?

90%

65

Symptoms of gallbladder CA?

Jaundice 1st, then RUQ pain

66

Treatment based on stage of GB CA?

Stage I (mucosa): chole; stage II+ (into muscle): wide resection around liver bed - 2-3cm margins, regional lymphadenectomy, may need Whipple, lobectomy or resection of CBD

67

Contraindication for lap chole?

Gallbladder CA; high incidence of tumor implants in trocar sites

68

5-yr survival of gallbladder CA?

5%

69

Risk factors for bile duct cancer (cholangiocarcinoma)?

C. sinensis infection, typhoid, UC, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection

70

Symptoms of cholangiocarcinoma?

Early: painless jaundice, can also get cholangitis; late: wt loss, anemia, pruritis; persistent increase in alk phos and bilirubin

71

Diagnosis of cholangio?

ERCP 1st, MRI may help define the lesion

72

What does the discovery of a focal bile duct stenosis in pts without h/o biliary surgery or pancreatitis suggest?

Bile duct ca

73

Where are Klatskin tumors?

In upper 1/3 of bile duct; most common type, worst prognosis

74

Treatment for Klatskin tumor?

Lobectomy and stenting of contralateral bile duct if localized to right or left lobe; usually unresectable

75

Treatment for cholangio in middle 1/3? Lower 1/3?

Middle: hepaticoj, lower: Whipple

76

5-yr survival for cholangio?

20%

77

What % of choledochal cysts are extrahepatic?

90%

78

What is the cancer risk with choledochal cysts?

15%

79

Symptoms of choledochal cyst?

Episodic pain, fever, jaundice, cholangitis

80

Presentation in infants?

Similar to biliary atresia

81

Possible cause of choledochal cysts?

Abnormal reflux of pancreatic enzymes during development secondary to bad angle of insertion

82

Most common type of choledochal cyst?

Type I: saccular or fusiform dilation of extrahepatic ducts

83

Treatment for choldochal cyst?

Excision with hepaticoj and chole; type IV partially intrahepatic/type V totally intrahepatic will need liver resection

84

What patients have primary sclerosing cholangitis?

Men in 4-5th decade; associated with retroperitoneal fibrosis, Riedel's thyroiditis, pancreatitis, UC, DM

85

Symptoms of PSC?

Fatigue, fluctuating jaundice, pruritus, wt loss, RUQ pain

86

Does PSC get better after cholon resection for UC?

NO

87

Consequences and complications of PSC?

Portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intra/extrahepatic ducts); chirrhosis, cholangio

88

Diagnosis of PSC? Treatment?

ERCP showing multiple strictures and dilations; transplant needed long term, PTC drainage/choledochoj may be effective, balloon dilation for symptomatic relief

89

Treatment for pruritus symptoms?

Cholestyramine

90

Primary biliary cirrhosis occurs in what size ducts?

Medium-sized hepatic ducts

91

Consequences of PBC?

Cholestasis --> cirrhosis --> portal HTN

92

Symptoms of PBC?

Fatigue, pruritus, jaundice, xanthomas

93

What type of antibodies are associated with PBC?

Antimitochondrial antibodies

94

Cancer risk with PBC?

No increased risk of cancer

95

Treatment for PBC?

Transplant

96

What is Charcot's triad?

RUQ pain, jaundice, fever - indicates cholangitis

97

What is Reynold's pentad

RUQ pain, jaundice, fever, altered mental status, shock - suggests sepsis from cholangitis

98

Most common organisms in cholangitis?

E. coli and Klebsiella

99

Late complications of cholangitis?

Stricture and hepatic abscess

100

#1 serious complication of cholangitis?

Renal failure; related to sepsis

101

Most common etiology of cholangitis? Other causes?

Gallstones; also biliary strictures, neoplasm, chronic pancreatitis, congenital choledochal cysts, duodenal diverticula

102

What is the cause of systemic bacteremia from cholangitis?

At >20mmHg, cholovenous reflux occurs --> systemic bacteremia

103

Treatment for cholangitis?

Fluid resus, abx, ERCP with sphincterotomy nd stone extraction, if fails - PTC

104

What is oriental cholangiohepatitis?

Recurrent cholangitis from primary CBD stones; in Asia; caused by C. sinensis, A. lumbricoides, T. trichiuria, E. coli

105

Treatment for oriental cholangiohepatitis?

Hepaticoj and antiparasitic medications

106

What is the most common cause of shock following lap chole early (1st 24h)? Late (after 1st 24h)?

Early: hemorrhagic shock from clip that fell off cystic artery; late: septic shock from accidental clip on CBD with subsequent cholangitis

107

What is adenomyomatosis?

Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus; not premalignant, does not cause stones; tx: chole

108

What is granular cell myoblastoma?

Benign neuroectoderm tumor of the GB; can occur in biliary tract with signs of cholecystitis; tx: chole

109

What is cholesterolosis?

Speckled cholesterol deposits on GB wall

110

What size GB polyp more likely to be malignant?

>1cm

111

What is delta bilirubin?

Bound to albumin covalently, half-life 18d, may take a while to clear after long-standing jaundice

112

What is Mirizzi syndrome?

Compression of the common hepatic duct by a stone in the infundibulum of the GB or inflammation arising from the GB or cystic duct; causing stricture and hepatic duct obstruction

113

What abx can cause gallbladder sludging and cholestatic jaundice?

Ceftriaxone

114

What are indications for asymptomatic cholecystectomy?

Pts undergoing liver TXP or gastric bypass