Chapter 32: Gallbladder Flashcards Preview

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Flashcards in Chapter 32: Gallbladder Deck (176):
1

Where does gallbladder lie?

Beneath segments 4 and 5

2

Where does gallbladder lie?

Beneath segments 4 and 5

3

What is the cystic artery a branch of?

The right hepatic artery

4

Where is the cystic artery found?

Triangle of Calot

5

Where is the triangle of calot?

Lateral - cystic duct
Medial - Common bile duct
Superior - liver

6

What is the longitudinal blood supply of the hepatic and common bile duct?

Right hepatic (lateral) and retroduodenal branches of the gastroduodenal artery (medial_

7

Where do the cystic veins drains?

Right branch of the portal vein

8

Where are lymphatics in relation to the common bile duct?

Lymphatics are on the right side of the common bile duct

9

Where do parasympathetic fibers come from to gallbladder?

Parasympathetic fibers come from the left (anterior) trunk of the vagus.

10

Where do sympathetic fibers come from?

T7-T10 (splanchnic and celiac ganglions)

11

Mucosa for gallbladder

Gallbladder has no submucosa; mucosa is columnar epithelium

12

Peristalsis of common bile duct and common hepatic duct

Do not have peristalsis

13

How does the gallbladder fill?

Gallbladder normally fills by contraction of sphincter of Oddi at the ampulla of Vater

14

Medication: contracts the sphincter of Oddi

Morphine

15

Medication: relaxes the sphincter of Oddi

Glucagon

16

Normal size: common bile duct (CBD)

17

Normal size: gallbladder wall

18

What happens to total bile salt pools after cholecystectomy?

Total bile salt pools decrease

19

What happens to total bile salt pools after cholecystectomy?

Total bile salt pools decrease

20

What is the cystic artery a branch of?

The right hepatic artery

21

Biliary ducts that can leak after a cholecystectomy, lie in the gallbladder fossa

Ducts of Luschka

22

Where is the triangle of calot?

Lateral - cystic duct
Medial - Common bile duct
Superior - liver

23

What is the longitudinal blood supply of the hepatic and common bile duct?

Right hepatic (lateral) and retroduodenal branches of the gastroduodenal artery (medial_

24

Where do the cystic veins drains?

Right branch of the portal vein

25

Where are lymphatics in relation to the common bile duct?

Lymphatics are on the right side of the common bile duct

26

Where do parasympathetic fibers come from to gallbladder?

Parasympathetic fibers come from the left (anterior) trunk of the vagus.

27

Where do sympathetic fibers come from?

T7-T10 (splanchnic and celiac ganglions)

28

Mucosa for gallbladder

Gallbladder has no submucosa; mucosa is columnar epithelium

29

Peristalsis of common bile duct and common hepatic duct

Do not have peristalsis

30

How does the gallbladder fill?

Gallbladder normally fills by contraction of sphincter of Oddi at the ampulla of Vater

31

Medication: contracts the sphincter of Oddi

Morphine

32

Medication: relaxes the sphincter of Oddi

Glucagon

33

Normal size: common bile duct (CBD)

34

Normal size: gallbladder wall

35

Rate limiting step in cholesterol synthesis

HMG CoA reductase

36

What happens to total bile salt pools after cholecystectomy?

Total bile salt pools decrease

37

Where are the highest concentration of CCK and secretin cells?

Duodenum

38

Epithelial invaginations in the gallbladder wall; formed from increased gallbladder pressure

Rokitansky-Aschoff sinuses

39

Biliary ducts that can leak after a cholecystectomy, lie in the gallbladder fossa

Ducts of Luschka

40

Increases bile excretion

CCK, secretin, and vagal input

41

Decreases bile excretion

Somatostatin, sympathetic stimulation

42

What causes gallbladder contraction?

CCK causes constant, steady, tonic contraction

43

Essential functions of bile

Fat-soluble vitamin absorption, essential fat absorption, bilirubin and cholesterol excretion

44

How does gallbladder form concentrated bile?

Active resorption of NaCl and water

45

Where does active resorption of conjugated bile salts occur?

Terminal ileum (50%)

46

Where does passive resorption of non conjugated bile salts occur?

Small intestine (45%) and colon (5%)

47

Time: postprandial gallbladder emptying

Maximum at 2 hours (80%)

48

What secretes bile?

Hepatocytes (80%) and bile canalicular cells (20%)

49

What causes color of bile?

Mostly due to conjugated bilirubin

50

Breakdown product of conjugated bilirubin in gut; gives stool brown color

Stercobilin

51

Conjugated bilirubin is broken down in the gut and reabsorbed; gets converted to urobilinogen and eventually urobilin, which is released in the urine (yellow color)

Urobilinogen

52

Pathway of bile salts (acids) formation

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

53

Rate limiting step in cholesterol synthesis

HMG CoA reductase

54

occurs in 10% of the population; vast majority are asymptomatic
- only 10% of gallstones are radiopague

gallstones

55

What causes cholesterol stones?

Stasis, calcium nucleation, and increased water reabsorption form gallbladder. Also caused by decreased lecithin and bile salts

56

- found almost exclusively in the gallbladder
- most common type of stone found in the united state (75%)

Nonpigmented stones - cholesterol stones

57

- most common type of stone found in the united states
- most common type of stone found worldwide

- US: nonpigmented (cholesterol)
- World: pigmented (calcium bilirubinate, black, brown)

58

Caused by solubilization of unconjugated bilirubin with precipitation

Calcium bilirubinate stones (pigmented stones)

59

Do not work on pigmented stones

Dissolution agents (monoctanoin)

60

What causes black stones?

Hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN

61

Factors for development of black stones

Increased bilirubin load.
Decreased hepatic function.
Bile stasis -> all get calcium bilirubinate stones.

62

Can be caused by hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN.
- Almost always form in gallbladder.
- Tx: cholecystectomy if symptomatic

Black stones (pigmented stones)

63

- primary CBD stones, formed in ducts, Asians
- Infection causing deconjugation of bilirbuin

Brown stones

64

Most common organism causing brown stones

E coli

65

How does E coli cause brown stones?

Produces beta-glucuronidase, which deconjugates bilirubin with formation of calcium bilirubinate

66

What do you need to check for with brown stones?

Ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi

67

Where are brown stones most commonly formed?

Most commonly form in the bile ducts (are primary common bile duct stones)

68

Tx: brown stones

Almost all patients with primary stones need a biliary drainage procedure - sphincteroplasty (90% successful)

69

What are considered secondary common bile duct stones?

Cholesterol stones and black stones found in the CBD

70

- Primary common bile duct stones
- Secondary common bile duct stones

- Primary: brown stones
- Secondary: cholesterol and black stones

71

- Caused by obstruction of the cystic duct by a gallstone
- Results in gallbladder wall distention and wall inflammation
- RUQ pain, referred pain to the right shoulder and scapula, n/v, loss of appetite.
- attacks frequently occur after a fatty meal; pain is persistent (unlike biliary colic)

Cholecystitis

72

Patient resists deep inspiration with deep palpation to the RUQ secondary to pain

Murphy's sign

73

Lab tests likely to be elevated in cholecystitits

Alkaline phosphatase and WBCs

74

Associated with frank purulence in the gallbladder -> can be associated with sepsis and shock

Suppurative cholecystitis

75

Most common organisms in cholecystitis

E. coli (#1), Klebsiella, Enterococcus

76

Risk factors for stone development

Age > 40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)

77

Is ultrasound effective in cholecystitis?

95% sensitive for picking up stones.
- Hyperechoic focus, posterior shadowing, movement of focus with changes in position.

78

Best initial evaluation test for jaundice of RUQ pain.

Ultrasound

79

What are ultrasound findings suggestive of acute cholecystitis?

Gallstones, gall bladder wall thickening (>4mm), pericholecystic fluid

80

Size of common bile duct suggesting CBD stone and obstruction

> 8 mm

81

Technetium taken up by liver and excreted in the biliary tract

HIDA scan

82

Most sensitive test for cholecystitis (also uses HIDA)

CCK-CS test (cholecystokinin cholescntigraphy)

83

Indications for cholecystectomy after CCK-CS test

- If gallbladder not seen (the cystic duct likely has a stone in it)
- Takes > 60 minutes to empty (chronic cholecystitis)
- Ejection fraction

84

Indications for immediate ERCP

Signs that a common bile duct stone is present -> jaundice, cholangitis, US shows stones in CBD

85

Indications for pre-op ERCP

Any of the following needs to be persistently high for > 24 hours to justify pre-op ERCP
- AST or ALT ( > 200)
- Bilirubin > 4
- Amylase or lipase (> 1000)

86

How many patients undergoing cholecystectomy will have a retained CBD stone?

87

Treatment for cholecystitis

Cholecystectomy; cholecystostomy tube can be placed in patients who are very ill and cannot tolerate surgery

88

Best treatment for late common bile duct stone

ERCP. Spincterotomy allows for removal of stone.

89

Risks: ERCP

bleeding, pancreatitis, perforation

90

Transient cystic duct obstruction caused by passage of a gallstone

Biliary colic; resolves within 4-6 hours

91

When does air in the biliary system occur?

Most commonly occurs with previous ERCP and sphincterotomy
- Can also occur with cholangitis or erosion of the biliary system into the duodenum (i.e. gallstone ileus)

92

How does bacterial infection of bile occur?

Dissemination form portal system is the most common route (not retrograde through sphincter of Oddi)

93

Highest incidence of positive bile cultures

Occurs with postoperative strictures (usually E. coli, often polymicrobial)

94

thickened wall, RUQ pain, increased WBCs, no stones

Acalculous cholecystitis

95

What causes acalculous cholecystitis?

Severe burns, prolonged TPN, trauma, or major surgery

96

Primary pathology: acalculous cholecystitis

Bile stasis (narcotic fasting), leading to distention and ischemia
- Also have increased viscosity secondary to dehydration, ileus, transfusions

97

Ultrasound/HIDA: acalculous cholecystitis

- US: Sludge, gallbladder wall thickening, and pericholecystic fluid
- HIDA: positive

98

Tx: acalculous cholecystitis

Cholecystectomy; percutaneous drainage if patient too unstable

99

- Gas in the gallbladder wall -> can see on plain film
- Symptoms: severe, rapid-onset abdominal pina, nausea, vomiting, and sepsis
- perforation more common in these patients

Emphysematous gallbladder disease

100

Patient population associated with emphysematous gallbladder disease

Increased in diabetes; usually secondary to Clostridium perfringens

101

Tx: emphysematous gallbladder disease

Emergent cholecystectomy; percutaneous drainage if patient is too unstable

102

Fistula between gallbladder and duodenum that releases stone, causing small bowel obstruction; elderly.
- can see pneumobilia (air in the biliary system) on plain film

Gallstone ileus

103

Most common site of obstruction in gallstone ileus

Terminal ileum

104

Tx: gallstone ileus

Remove stone through enterotomy proximal to obstruction
- perform cholecystectomy and fistula resection if patient can tolerate it (if old and frail, just leave the fistula)

105

When do common bile duct injuries most commonly occur?

After laparoscopic cholecystectomy

106

Management of intraoperative CBD injury

If

107

Persistent nausea and vomiting or jaundice following lap chole..

Get ultrasound to look for fluid collection

108

Ultrasound shows fluid collection after lap chole

May be bile leak -> percutaneous drain into the collection.
- bilious fluid: get ERCP -> sphincterotomy & stent if due to cystic duct remnant leak, small injuries to hepatic or CBD, leak of DOL
- Large lesions: hepaticojejunostomy or choledochojejunostomy

109

N/V/jaundice s/p lap chole:
- US shows fluid collection with dilated hepatic ducts

Likely have a completely transected common bile duct (PTC tube initially, then hepaticojejunostomy or choledochojejunostomy)
- Early symptoms (7d): hepaticojejunostomy 6-8wks after injury (tissue too friably for surgery after 7 days)

110

Management: sepsis following lap chole

Fluid resuscitation and stabilize. May be due to complete transection of the CBD and cholangitis -> get U/S to look for dilated intrahepatic ducts or fluid collections

111

Management of anastomotic leaks following transplantation or hepaticojejunostomy

Usually handled with percutaneous drainage of fluid collection followed by ERCP with temporary stent (leak will heal)

112

Lap chole: most important cause of late postoperative bile duct strictures

Ischemia

113

Causes of bile duct strictures

Ischemia following lap chole, chronic pancreatitis, gallbladder CA, bile duct CA

114

Symptoms: bile duct strictures

Sepsis, cholangitis, jaundice

115

Dx: bile duct strictures without a history of pancreatitis or biliary surgery

CA until proven otherwise

116

Dx: Bile duct strictures

MRCP defines anatomy, look for mass -> if CA not rule out with MRCP, need ERCP with brush biopsies

117

Tx: bile duct strictures

If due to ischemia or chronic pancreatitis -> choledochojejunostomy (best long-term solution).
- If due to cancer, follow appropriate workup

118

Pathophys: hemobilia

Fistula between bile duct and hepatic arterial system (most commonly)

119

UGIB, jaundice, RUQ pain

Hemobilia

120

What is the insult causing hemobilia?

Trauma or percutaneous instrumentation to liver (eg, PTC tube)

121

Dx: hemobilia

Angiogram

122

Tx: hemobilia

Angioembolization; operation if that fails.

123

Rare, although MC CA of the biliary tract

Gallbladder adenocarcinoma
- Four times more common than bile duct CA; most have stones

124

Most common site of metastasis of gallbladder adenocarcinoma

liver

125

Risk of gallbladder CA in porcelain gallbladder

15%

126

Tx: porcelain gallbladder

Cholecystectomy

127

How does gallbladder adenocarcinoma spread?

1st spreads to segments 4 and 5; 1st nodes are the cystic duct nodes (right side)

128

Symptoms: jaundice 1st (bile duct invasion with obstruction) then RUQ pain

Gallbladder adenocarcinoma

129

Tx: gallbladder adenocarcinoma

If muscle not involved -> cholecystectomy sufficient
- If in muscle but not beyond -> need wedge resection of segments 4b and 5
- if beyond muscle and still resectable -> need formal resection of segments IVb and V

130

Why is the laparoscopic approach contraindicated for gallbladder cancer?

High incidence of tumor implants in trocar sites when discovered after laparoscopic cholecystectomy

131

Overall 5 year survival in bladder adenocarcinoma

5%

132

- Occurs in elderly; males
- risk factors: C sinensis infection, ulcerative colitis, choledochal cysts, primary sclerosing cholangitis, chronic bile duct infection

Bile duct cancer (cholangiocarcinoma)

133

Symptoms:
early - painless jaundice;
late - weight loss, pruritus

Bile duct cancer (cholangiocarcioma)

134

Persistent increase in bilirubin and alkaline phosphatase
- Dx: MRCP (defines anatomy, looks for mass)
- Invades contiguous structures early

Bile duct cancer (cholangiocarcinoma)

135

What is highly suggestive of bile duct cancer?

Discovery of a focal bile duct stenosis in patients without a history of biliary surgery or pancreatitis

136

Tx: bile duct cancer (cholangiocarcinoma)

- Upper 1/3 (Klatskin tumors): can try lobectomy and stenting of contralateral bile duct if localized to either the right or left lobes
- Middle 1/3: hepaticojejunostomy
- Lower 1/3: Whipple

137

Treatment: unresectable bile duct cancer (cholangiocarcinoma)

Palliative stenting for unresectable disease

138

5-year survival rate bile duct cancer (cholangiocarcinoma)

20%

139

- Female gender; Asians; 90% are extrahepatic; 15% CA risk (cholangiocarcinoma)
- older patients have episodic pain, fever, jaundice, cholangitis

Choledochal cysts

140

How do choledochal cysts present in children?

Infants can have symptoms similar to biliary atresia

141

Most common types of choledochal cysts

Most are type I: fusiform or saccular dilatation of extra hepatic ducts (very dilated)

142

What causes choledochal cysts?

Caused by abnormal reflux of pancreatic enzymes during uterine development

143

Tx: choledochal cysts

Cyst excision with hepaticojejunostomy and cholecystectomy usual

144

Choledochal cysts: partially intrahepatic

Type 4 cysts

145

Choledochal cysts: totally intrahepatic

Type 5 (Caroli's disease)

146

Management: type 4 and type 5 choledochal cysts

Will need partial liver resection or liver TXP

147

- Men in 4th-5th decade
- Can be associated with ulcerative colitis, pancreatitis, diabetes
- Symptoms: jaundice, fatigue, pruritus (from bile acids), weight loss, RUQ pain

Primary sclerosing cholangitis

148

Pathophysiology: primary sclerosing cholangitis

- Get multiple strictures throughout the hepatic ducts
- Leads to portal HTN and hepatic failure (progressive fibrosis of intrahepatic and extra hepatic ducts)

149

Relationship of primary sclerosing cholangitis to colon resection for ulcerative colitis

Does not get better after colon resection for ulcerative colitis

150

Complications: primary sclerosing cholangitis

Cirrhosis, cholangiocarcinoma

151

Tx: primary sclerosing cholangitis

- Liver TXP needed long term for most; PTC tube drainage, choledochojejunostomy or balloon dilatation of dominant strictures may provide symptomatic relief
- Cholestyramine: can decrease pruritus symptoms (decrease bile acids)
- UDCA (ursodeoxycholic acid) - can decrease symptoms (decrease bile acids) and improve liver enzymes

152

- women; medium-sized hepatic ducts
- cholestasis -> cirrhosis -> portal hypertension
- Symptoms: jaundice, fatigue, pruritus, xanthomas

Primary biliary cirrhosis

153

Antibodies for primary biliary cirrhosis

Antimitochrondrial antibiodies

154

Risk for cancer in primary sclerosing cholangitis

No increased risk for cancer

155

Tx: primary biliary cirrhosis

Liver TXP

156

- usually caused by obstruction of the bile duct (most commonly due to gallstones)
- can also be caused by indwelling tubes (Eg PTC tube)

Cholangitis

157

RUQ pain.
Fever.
Jaundice.

Charcot's triad - cholangitis

158

Charcot's triad plus mental status changes and shock (suggests sepsis)

Reynold's pentad - cholangitis

159

MC organisms causing cholangitis

E. coli (#1) and Klebsiella

160

What causes colovenous reflux?

> 200 mmHg pressure -> systemic bacteremia

161

Dx: cholangitis

Increased AST/ALT, bilirubin, alkaline phosphatase, and WBCs.
- US: dilated CBD (>8 mm, > 10mm after cholecystectomy) if due to obstruction of the biliary system

162

Late complications of cholangitis

Stricture and hepatic abscess

163

#1 serious complication cholangitis; related to sepsis

Renal failure

164

Causes of cholangitis

Infection, biliary strictures, neoplasm, choledochal cysts, duodenal diverticula

165

Tx: cholangitis

Fluid resuscitation and antibiotics intially.
- Emergent ERCP with sphincterotomy and stone extraction; if ERCP fails, place PTC tube to decompress the biliary system.
- If the patient has cholangitis due to infected PTC tube, change the PTC tube

166

Cause of shock following lap chole: early (1st 24 hours)

Hemorrhagic shock from clip that fell off cystic artery

167

Cause of shock following lap chole: late (after 1st 24 hours)

Septic shock from accidental clip on CBD with subsequent cholangitis

168

Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus
- Not premalignant; does not cause stones, can cause RUQ pain
- Tx: cholecystectomy

Adenomyomatosis

169

Benign neuroectoderm tumor of gallbladder
- Can occur in biliary tract with signs of cholecystitis
- Tx: cholecystectomy

Granular cell myoblastoma

170

Speckled cholesterol deposits on the gallbladder wall

Cholesterolosis

171

if > 1 cm, need to worry about malignancy
- polyps in patients > 60 years more likely malignant
- TX: cholecystectomy

Gallbladder polyps

172

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

Delta bilirubin

173

Compression of the common hepatic duct
- Tx: cholecystectomy; may need hepaticojejunostomy for hepatic duct stricture

Mirrizzi syndrome

174

What causes Mirizzi syndrome (compression of the common hepatic duct)?

1) stone in the gallbladder infundibulum
2) inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causes common hepatic duct stricture

175

Antibiotic: can cause gallbladder slugging and cholestatic jaundice

Ceftriaxone

176

Indications for asymptomatic cholecystectomy

In patients undergoing liver TXP or gastric bypass procedure (if stones are present)