Flashcards in Chapter 32 - Biliary System Deck (114):
What is the triangle of Calot?
Cystic duct, CBD, liver
What blood vessels supply the hepatic and CBD?
Right hepatic and retroduodenal branches of the GDA
What side of the CBD are the lymphatics on?
What is the mucosal of the gallbladder? Submucosa?
Columnar epithelium; NO submucosa
What will contract the sphincter of Oddi?
What will relax the sphincter of Oddi?
What is the normal size of the GB wall? Pancreatic duct? CBD?
GB wall: 2-4mm
Pancreatic duct: <10mm s/p chole
Where is the highest concentration of CCK and secretin cells?
What are Rokitansky-Aschoff sinuses?
Invagination of the epithelium of the wall of the gallbladder; formed from increased gallbladder pressure
What are the ducts of Luschka?
Biliary ducts that can leak after chole
What stimulates increased bile excretion?
CCK, secretin, vagal input
What causes decreased bile excretion?
VIP, somatostatin, sympathetic stimulation
What are the 3 essential functions of bile?
Fat-soluble vitamin absorption, bilirubin excretion, cholesterol excretion
How does the gallbladder form concentrated bile?
Active resorption of Na and H20
How many times a day does the bile salt pool cycle?
Where does active resorption of conjugated bile acids occur? Passive resorption of nonconjugated bile acids?
Active: terminal ileum (50%), passive: small intestine and colon
Where is bile secreted from?
Bile canalicular cells (20%), hepatocytes (80%)
What is the breakdown product of conjugated bilirubin that gives stool brown colon?
What is the breakdown product of conjugated bilirubin that gets reabsorbed and released in urine?
Pathway of cholesterol and bile acid synthesis?
HMG CoA --> (HMG CoA reductase) --> cholesterol --> (7-alpha-hydroxylase) --> bile acids
What is the rate-limiting step in cholesterol synthesis?
HMG CoA reductase
What causes stones in obese people? In thin people?
Obese: overactive HMG CoA reductase, thin: underactive 7-alpha-hydroxylase
What % of the population has gallstones?
What % of gallstones are radiopaque?
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
What is the most common type of stone found in the US?
What is the most common type of stone found worldwide?
What causes pigmented stones?
Solubilization of unconjugated bilirubin with precipitation of calcium bilirubinate and insoluble salts
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
What causes brown stones? Where are they found?
Infection causing deconjugation of bilirubin; found in CBD, formed in ducts
Most common bacteria causing brown stones?
What needs to be checked for in a patient with brown stones?
Ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi
Cholecystitis is caused by what?
Obstruction of the cystic duct by gallstone
What is suppurative cholecystitis?
Associated with frank purulence in the GB, can be associated with sepsis and shock
Most common organisms in acute cholecystitis?
E. coli, klebsiella, enterococcus
Risk factors for stone formation?
Age >40, female, obesity, pregnancy, rapid wt loss, vagotomy, TPN, ileal resection
Sensitivity of US in picking up stones?
What is the definition of biliary dyskinesia?
<40% of gallbladder volume excreted after CCK over 1 hour
Causes of air in the biliary system?
Previous ERCP and sphincterotomy, cholangitis, erosion of the biliary system into duodenum (gallstone ileus)
What are signs of acalculous cholecystitis? Pathology?
Thickened wall, RUQ pain, elevated WBCs; bile stasis leading to distention and ischemia
When does acalculous cholecystitis occur?
After burns, prolonged TPN, trauma, other major surgery
Diagnosis of acalculous cholecystitis?
US shows sludge, GB wall thickening, pericholecystic fluid; HIDA (+)
What is the common organism causing emphysematous gallbladder disease?
What is gallstone ileus?
Fistula between GB and duodenum that releases stone, causing SBO; elderly, can see pneumobilia on plain film
Most common site of obstruction in gallstone ileus?
Treatment for gallstone ileus?
Remove stone with enterotomy proximal to obstruction; perform chole and fistula resection
What is the benefit of interoperative cholangiography?
Does not prevent injuries; may limit severity, increases early diagnosis of injury to CBD
In what % of patients does the right posterior duct enter the CBD separately? What segment is it from?
10%, segment 6 or 7
What is the treatment if the right posterior duct is injured during lap chole?
If >2mm, need to open and perform hepaticoj
Treatment for intraop CBD injury?
If <50% of the circumference, can perform primary repair; in all other cases need hepaticoj or choledochoj
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
Treatment for anastamotic leaks following transplant or hepaticoj?
ERCP and stents
Treatment for sepsis following lap chole?
Fluid resuscitation, stabilize; concern for complete transection of CBD and cholangitis
Most common situation in which CBD or hepatic duct strictures occur?
After lap chole
What is the most important cause of late postoperative biliary strictures?
Ischemia; can also be caused by chronic pancreatitis, stricture of biliary enteric anastomosis
Diagnosis of CBD or hepatic duct stricture?
ERCP; US will show dilated ducts
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
What causes hemobilia?
Fistula between bile duct and hepatic arterial system; most commonly occurs with trauma, also infections, primary gallstones, aneurysms, tumors
Presentation of hemobilia?
UGI bleed, jaundice, RUQP
Diagnosis of hemobilia? Treatment?
Angiogram; resuscitation, angio and embolization, operation if that fails
What is the most common cancer of the biliary tract?
What is the most common site of mets from gallbladder adenocarcinoma?
Risk of cancer with porcelain gallbladder?
10-20%, need chole
What % of patients present with stage IV disease?
Symptoms of gallbladder CA?
Jaundice 1st, then RUQ pain
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
Contraindication for lap chole?
Gallbladder CA; high incidence of tumor implants in trocar sites
5-yr survival of gallbladder CA?
Risk factors for bile duct cancer (cholangiocarcinoma)?
C. sinensis infection, typhoid, UC, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection
Symptoms of cholangiocarcinoma?
Early: painless jaundice, can also get cholangitis; late: wt loss, anemia, pruritis; persistent increase in alk phos and bilirubin
Diagnosis of cholangio?
ERCP 1st, MRI may help define the lesion
What does the discovery of a focal bile duct stenosis in pts without h/o biliary surgery or pancreatitis suggest?
Bile duct ca
Where are Klatskin tumors?
In upper 1/3 of bile duct; most common type, worst prognosis
Treatment for Klatskin tumor?
Lobectomy and stenting of contralateral bile duct if localized to right or left lobe; usually unresectable
Treatment for cholangio in middle 1/3? Lower 1/3?
Middle: hepaticoj, lower: Whipple
5-yr survival for cholangio?
What % of choledochal cysts are extrahepatic?
What is the cancer risk with choledochal cysts?
Symptoms of choledochal cyst?
Episodic pain, fever, jaundice, cholangitis
Presentation in infants?
Similar to biliary atresia
Possible cause of choledochal cysts?
Abnormal reflux of pancreatic enzymes during development secondary to bad angle of insertion
Most common type of choledochal cyst?
Type I: saccular or fusiform dilation of extrahepatic ducts
Treatment for choldochal cyst?
Excision with hepaticoj and chole; type IV partially intrahepatic/type V totally intrahepatic will need liver resection
What patients have primary sclerosing cholangitis?
Men in 4-5th decade; associated with retroperitoneal fibrosis, Riedel's thyroiditis, pancreatitis, UC, DM
Symptoms of PSC?
Fatigue, fluctuating jaundice, pruritus, wt loss, RUQ pain
Does PSC get better after cholon resection for UC?
Consequences and complications of PSC?
Portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intra/extrahepatic ducts); chirrhosis, cholangio
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
Treatment for pruritus symptoms?
Primary biliary cirrhosis occurs in what size ducts?
Medium-sized hepatic ducts
Consequences of PBC?
Cholestasis --> cirrhosis --> portal HTN
Symptoms of PBC?
Fatigue, pruritus, jaundice, xanthomas
What type of antibodies are associated with PBC?
Cancer risk with PBC?
No increased risk of cancer
Treatment for PBC?
What is Charcot's triad?
RUQ pain, jaundice, fever - indicates cholangitis
What is Reynold's pentad
RUQ pain, jaundice, fever, altered mental status, shock - suggests sepsis from cholangitis
Most common organisms in cholangitis?
E. coli and Klebsiella
Late complications of cholangitis?
Stricture and hepatic abscess
#1 serious complication of cholangitis?
Renal failure; related to sepsis
Most common etiology of cholangitis? Other causes?
Gallstones; also biliary strictures, neoplasm, chronic pancreatitis, congenital choledochal cysts, duodenal diverticula
What is the cause of systemic bacteremia from cholangitis?
At >20mmHg, cholovenous reflux occurs --> systemic bacteremia
Treatment for cholangitis?
Fluid resus, abx, ERCP with sphincterotomy nd stone extraction, if fails - PTC
What is oriental cholangiohepatitis?
Recurrent cholangitis from primary CBD stones; in Asia; caused by C. sinensis, A. lumbricoides, T. trichiuria, E. coli
Treatment for oriental cholangiohepatitis?
Hepaticoj and antiparasitic medications
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
What is adenomyomatosis?
Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus; not premalignant, does not cause stones; tx: chole
What is granular cell myoblastoma?
Benign neuroectoderm tumor of the GB; can occur in biliary tract with signs of cholecystitis; tx: chole
What is cholesterolosis?
Speckled cholesterol deposits on GB wall
What size GB polyp more likely to be malignant?
What is delta bilirubin?
Bound to albumin covalently, half-life 18d, may take a while to clear after long-standing jaundice
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
What abx can cause gallbladder sludging and cholestatic jaundice?