chole Flashcards
(169 cards)
1
Q
Q: What is the length and diameter of the common bile duct (choledochus)?
A
A: About 7 to 11 cm in length and 5 to 10 mm in diameter.
2
Q
Q: How is the common bile duct formed?
A
A: By the junction of the cystic and common hepatic ducts.
3
Q
Q: How many parts is the common bile duct divided into, and what are they?
A
A: Four parts: supraduodenal, retroduodenal, infraduodenal, and intraduodenal.
4
Q
Q: What is the length of the supraduodenal portion of the bile duct?
A
A: About 2.5 cm long.
5
Q
Q: Where does the infraduodenal portion of the bile duct lie?
A
A: In a groove or sometimes in a tunnel on the posterior surface of the pancreas.
6
Q
Q: What surrounds the intraduodenal portion of the bile duct?
A
A: Smooth muscle fibres called the sphincter of Oddi.
7
Q
Q: Where does the common bile duct terminate?
A
A: It opens on the summit of the ampulla of Vater.
8
Q
Q: What artery supplies the gallbladder?
A
A: The cystic artery, a branch of the right hepatic artery (>90% of the time).
9
Q
Q: Where does the cystic artery usually arise?
A
A: Behind the common hepatic duct.
10
Q
Q: From which nerve does the gallbladder receive its parasympathetic supply?
A
A: From the vagus nerve.
11
Q
Q: What provides the sympathetic supply to the gallbladder?
A
A: Sympathetic branches that pass through the celiac plexus.
12
Q
Q: What is Calot’s triangle also known as?
A
A: The hepatobiliary triangle.
13
Q
Q: What are the borders of Calot’s triangle?
A
A: Cystic duct inferiorly, common hepatic artery medially, and superior border of the cystic artery.
14
Q
Q: Why is Calot’s triangle important in surgery?
A
A: It is an important surgical landmark that helps avoid damage to the extrahepatic biliary system during cholecystectomy.
15
Q
Q: What percentage of bile salts are reabsorbed in the terminal ileum?
A
A: About 95 percent.
16
Q
Q: What happens to the remaining 5 percent of bile salts?
A
A: They are excreted in the stool.
17
Q
Q: How is bilirubin processed in the bowel?
A
A: Bilirubin conjugated in the liver is converted into urobilinogen by bacteria in the bowel.
18
Q
Q: What happens to urobilinogen after it is formed in the bowel?
A
A: It gets absorbed, enters the liver for resecretion, and part of it is excreted in the urine.
19
Q
Q: What does the absence of urobilinogen in urine indicate?
A
A: It signifies obstructive jaundice.
20
Q
Q: What percentage of patients show radiopaque gallstones on a skillfully taken plain X-ray of the gallbladder?
A
A: 10 percent.
21
Q
Q: What is the percentage of gallstones that are radiopaque?
A
A: Only 10% of gallstones are radiopaque.
22
Q
Q: What percentage of gallstones are radiolucent?
A
A: 90% of gallstones are radiolucent.
23
Q
Q: What does a plain X-ray of the gallbladder sometimes show in rare cases?
A
A: Calcification of the gallbladder, known as ‘porcelain’ gallbladder.
24
Q
Q: Why is the appearance of a porcelain gallbladder significant?
A
A: It is associated with carcinoma in up to 25 percent of cases.
25
Q: What is the recommended treatment for a porcelain gallbladder?
A: Cholecystectomy.
26
Q: What can an ultrasound of the gallbladder demonstrate?
A: Biliary calculi, size of the gallbladder, thickness of the gallbladder wall, presence of inflammation around the gallbladder, size of the common bile duct, and occasionally stones within the biliary tree.
27
Q: What is the sensitivity and specificity of ultrasound for detecting stones in the gallbladder?
A: Greater than 90%.
28
Q: How do gallstones appear on ultrasound?
A: Stones are acoustically dense and reflect ultrasound waves back to the transducer.
29
Q: What effect do gallstones have on sound waves during an ultrasound?
A: They block the passage of sound waves, producing an acoustic shadow behind them.
30
Q: What imaging technique provides excellent images of the biliary tree?
A: Magnetic Resonance Cholangiopancreatography (MRCP).
31
Q: What can MRCP demonstrate in the biliary tree?
A: Ductal obstruction, strictures, or other intraductal abnormalities.
32
Q: What is the sensitivity of MRCP for detecting biliary conditions?
A: 95%.
33
Q: What is the specificity of MRCP for detecting biliary conditions?
A: 89%.
34
Q: What is the gold standard for diagnosing common bile duct stones?
A: Endoscopic Cholangiography (ERCP).
35
Q: What percentage of cases can ERCP diagnose common bile duct stones?
A: Over 90%.
36
Q: What advantage does ERCP provide at the time of diagnosis?
A: It offers a therapeutic option.
37
Q: What is the sensitivity of ERCP for detecting common bile duct stones?
A: 91%.
38
Q: What is the specificity of ERCP for detecting common bile duct stones?
A: 100%.
39
Q: What imaging indication is associated with malignancy in the biliary tree?
A: Irregular filling defect.
40
Q: What appearance is indicative of chronic pancreatitis?
A: 'Chain-of-lakes' appearance.
41
Q: What are other indications for imaging in the biliary system?
A: Congenital anomalies, stones, and stricture of the biliary tree.
42
Q: What is a choledochal cyst?
A: A cystic dilation of the common bile duct.
43
Q: What is one purpose of sampling biliary and pancreatic juices?
A: For analysis and cytology.
44
Q: What procedure is used to obtain tissue from a tumor site in the biliary system?
A: Brush biopsy.
45
Q: What is one therapeutic use of endoscopic procedures in the biliary duct?
A: Extraction of stone from the biliary duct.
46
Q: What is nasobiliary drainage?
A: A therapeutic procedure to relieve obstruction in the biliary system.
47
Q: What is stenting used for in biliary procedures?
A: For tumors in the common bile duct (CBD) or pancreas.
48
Q: What does dilatation of the biliary stricture involve?
A: Widening a narrowed segment of the biliary duct.
49
Q: What is endoscopic papillotomy?
A: A procedure to cut the papilla of Vater to facilitate bile flow.
50
Q: When is biliary surgery used?
A: When ERCP fails, in high strictures (in CHD), Klatskin tumor, catheter drainage in high blocks, and stenting high tumors.
51
Q: What is a common complication of biliary procedures?
A: Bleeding.
52
Q: What is another potential complication of biliary procedures?
A: Biliary leak and biliary peritonitis.
53
Q: What serious complication can arise from biliary procedures?
A: Septicaemia.
54
Q: What is biliary scintigraphy used for?
A: It provides a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information.
55
Q: What is the radiotracer used in biliary scintigraphy?
A: Tc99 labelled imino diacetic acid (HIDA).
56
Q: How is HIDA cleared from the body?
A: It is cleared by the Kupffer cells in the liver and excreted in the bile.
57
Q: How quickly is uptake by the liver detected after injection?
A: Within 10 minutes.
58
Q: When are the gallbladder, bile ducts, and duodenum visualized in fasting subjects?
A: Within 60 minutes.
59
Q: What is the primary use of biliary scintigraphy?
A: In the diagnosis of acute cholecystitis, indicated by a nonvisualized gallbladder due to cystic duct obstruction.
60
Q: What is the sensitivity of biliary scintigraphy for diagnosing acute cholecystitis?
A: About 95%.
61
Q: What is the specificity of biliary scintigraphy for diagnosing acute cholecystitis?
A: About 95%.
62
Q: What is placed in the common bile duct (CBD) after choledochotomy?
A: Kehr’s T-tube.
63
Q: How long is the T-tube typically left in place?
A: For 14 days.
64
Q: What is done after 14 days with the T-tube?
A: Water-soluble dye is injected into the tube, and an X-ray is taken.
65
Q: What does complete free flow of dye into the duodenum indicate?
A: There is no blockage.
66
Q: When can the T-tube be safely removed?
A: When a patent ductus cysticus is confirmed.
67
Q: What does a blockage during the dye test indicate?
A: Residual CBD stones.
68
Q: What does an elevated white blood cell (WBC) count indicate?
A: It may indicate or raise suspicion of cholecystitis.
69
Q: What should be suspected if elevated WBC is associated with bilirubin, ALP, and aminotransferase?
A: Cholangitis.
70
Q: What is a choledochal cyst?
A: It is a cystic enlargement of the common bile duct (CBD).
71
Q: Who is more commonly affected by choledochal cysts?
A: Females (4:1 ratio).
72
Q: How common are cystic diseases of the biliary system?
A: They are rare.
73
Q: What are choledochal cysts?
A: Congenital dilations of the intra- and/or extrahepatic biliary system.
74
Q: What type of choledochal cyst is the most common?
A: Type I cysts, which account for approximately 60% of cases.
75
Q: What symptoms are associated with choledochal cysts?
A: Obstructive jaundice, right hypochondrial pain, cholangitis, and a palpable abdominal mass.
76
Q: What is the classic triad of symptoms for choledochal cyst?
A: Right upper quadrant pain, jaundice, and a palpable abdominal mass.
77
Q: What imaging technique confirms the presence of a choledochal cyst?
A: Ultrasonography.
78
Q: What is the treatment of choice for a choledochal cyst?
A: Radical excision of the cyst with reconstruction using a Roux-en-Y loop of jejunum.
79
Q: Why is complete resection of the cyst important?
A: Due to the association with the development of cholangiocarcinoma.
80
81
Q: What is the most common biliary pathology?
A: Gallstones.
82
Q: What percentage of the population in western societies is estimated to be affected by gallstones?
A: 10–15 percent.
83
Q: What percentage of gallstone cases are asymptomatic?
A: More than 80 percent.
84
Q: What can cause biliary colic in symptomatic patients?
A: A stone obstructing the cystic duct.
85
Q: What percentage of asymptomatic individuals become symptomatic per year?
A: Approximately 3%.
86
Q: What percentage of symptomatic patients develop complicated gallstone disease per year?
A: 3% to 5%.
87
Q: What are the three main types of gallstones?
A: Cholesterol stones, pigment stones (brown/black), and mixed stones.
88
Q: What percentage of gallstones are cholesterol or mixed stones?
A: 80 percent.
89
Q: How much of pure cholesterol stones are there?
A: 6 percent.
90
Q: What percentage of gallstones are pigment stones?
A: 15-20 percent.
91
Q: How is cholesterol secreted in the bile?
A: From the canalicular membrane in phospholipid vesicles.
92
Q: What determines whether cholesterol remains in solution in bile?
A: The concentration and type of phospholipids and bile acids.
93
Q: What do micelles formed by phospholipids do?
A: They hold cholesterol in a stable thermodynamic state.
94
Q: What happens when bile is supersaturated with cholesterol?
A: Unstable unilamellar phospholipid vesicles form, leading to cholesterol crystal nucleation and stone formation.
95
Q: Is the process of gallstone formation simple or complex?
A: It is complex.
96
Q: What factors can increase the lithogenicity of bile?
A: Obesity, high-caloric diets, and certain medications (e.g., oral contraceptives).
97
Q: What effect does resection of the terminal ileum have on bile?
A: It depletes the bile acid pool, resulting in cholesterol supersaturation.
98
Q: What happens if gallstones are removed without removing the gallbladder?
A: It inevitably leads to gallstone recurrence.
99
Q: What defines a pigment stone?
A: Stones containing less than 30 percent cholesterol.
100
Q: How do black stones form?
A: They are composed of an insoluble bilirubin pigment polymer mixed with calcium phosphate and calcium bicarbonate.
101
Q: What percentage of gallstones are black stones?
A: 20–30 percent.
102
Q: What conditions are black stones associated with?
A: Hemolysis, usually hereditary, such as spherocytosis or sickle cell disease.
103
Q: Where are brown stones typically formed?
A: In the biliary tree as primary biliary stones.
104
Q: What conditions are brown stones related to?
A: Bile stasis and infected bile, commonly due to infections like Escherichia coli and Bacteroides.
105
Q: What foreign bodies can contribute to the formation of brown stones?
A: Endoprostheses (stents) and parasites such as Clonorchis sinensis and Ascaris lumbricoides.
106
Q: What type of bile is commonly associated with gallstones?
A: Supersaturated bile.
107
Q: What is the common gender affected by gallstones?
A: Female.
108
Q: At what age range is gallstone occurrence more common?
A: Around forty.
109
Q: What is one of the 'Four F's' associated with gallstone risk?
A: Fat.
110
Q: What is another 'F' related to gallstone risk?
A: Fertile.
111
Q: What is the last 'F' associated with gallstone risk?
A: Flatulent.
112
Q: Where is cholesterol synthesized?
A: In the liver.
113
Q: What determines the solubility of cholesterol in bile?
A: The relative concentration of cholesterol, bile salts, and lecithin.
114
Q: What happens when levels of cholesterol, lecithin, and bile salts are altered in bile?
A: It reduces micelle concentration, leading to precipitation of insoluble cholesterol and stone formation (lithogenic bile).
115
Q: What occurs when the cholesterol component in bile increases?
A: Bile becomes supersaturated, leading to inadequate micelle formation and crystallization of insoluble cholesterol.
116
Q: What type of stone forms from crystallized cholesterol?
A: Cholesterol monohydrate stones.
117
Q: What conditions can increase cholesterol secretion in bile?
O
A: Old age, oral contraceptive pills (OCP), obesity, and clofibrate.
118
Q: What factors can reduce bile salt concentration?
A: Estrogen, ileal resection, and cholestyramine.
119
Q: What is the result of increased cholesterol secretion or reduced bile salt concentration?
A: Formation of cholesterol stones.
120
Q: What bacteria are commonly associated with gallstone formation?
A: E. coli and Salmonella.
121
Q: What parasites can contribute to gallstone formation?
A: Clonorchis sinensis and Ascaris lumbricoides.
122
Q: What conditions can lead to bile stasis?
A: Estrogen therapy, pregnancy, vagotomy, and long-term intravenous fluids or TPN.
123
Q: What causes increased bilirubin production that can lead to gallstones?
A: Hemolysis due to hereditary spherocytosis, sickle cell anemia, thalassemia, malaria, or cirrhosis.
124
Q: What type of stones are common with increased bilirubin production?
A: Pigment stones.
125
Q: How are gallstones often detected?
A: Incidentally, during imaging for other symptoms.
126
Q: What type of pain do patients typically complain of with gallstones?
A: Right upper quadrant or epigastric pain, which may radiate to the back.
127
Q: How is gallstone pain often described?
A: It may be described as colicky but is more often dull and constant.
128
Q: What are other common symptoms associated with gallstones?
A: Dyspepsia, flatulence, food intolerance (especially to fats), and alteration in bowel frequency.
129
Q: What percentage of patients experience biliary colic?
A: 10–25 percent.
130
Q: How is biliary colic characterized?
A: Severe right upper quadrant pain that ebbs and flows, associated with nausea and vomiting.
131
Q: Where may the pain from biliary colic radiate?
A: It may radiate to the chest.
132
Q: How long does biliary colic pain usually last?
A: It can last for minutes or even several hours.
133
Q: When does gallstone pain often start?
A: Frequently during the night, waking the patient.
134
Q: What happens to the patient as the pain resolves?
A: The patient improves and is able to eat and drink.
135
Q: What may occur if a stone migrates and obstructs the common bile duct?
A: Jaundice may result.
136
Q: What rare complication can a gallstone lead to?
A: Bowel obstruction (gallstone ileus).
137
Q: What is a potential complication of gallstones in the gallbladder?
A: Acute cholecystitis.
138
Q: What is another complication of gallstones in the gallbladder?
A: Chronic cholecystitis.
139
Q: What condition involves pus accumulation in the gallbladder?
A: Empyema of the gallbladder.
140
Q: What serious complication can occur due to gallbladder perforation?
A: Biliary peritonitis or peri-cholecystitic abscess.
141
Q: What can localize a perforated gallbladder?
A: The inflamed gallbladder is usually localized by the omentum.
142
Q: What is a mucocele of the gallbladder?
A: An accumulation of mucus in the gallbladder.
143
Q: What cancer can develop in the gallbladder due to gallstones?
A: Carcinoma of the gallbladder.
144
Q: What complication can occur in the bile ducts due to gallstones?
A: Secondary CBD stones (occurs in 10% of gallstones).
145
Q: What condition can result from biliary obstruction?
A: Obstructive jaundice.
146
Q: What infection can occur in the bile ducts?
A: Cholangitis.
147
Q: What serious condition can gallstones cause related to the pancreas?
A: Acute pancreatitis.
148
Q: What syndrome involves compression of the CBD by a gallstone?
A: Mirizzi Syndrome.
149
Q: What intestinal complication can arise from gallstones?
A: Cholecystoduodenal fistula causing gallstone ileus.
150
Q: What is gallstone ileus?
A: Intestinal obstruction caused by gallstones.
151
COMPLICATION of gall stone in intestine in gb and in cbd
IN THE GALLBLADDER:
Acute cholecystitis
Chronic cholecystitits
Empyema gallbladder
Perforation causing biliary peritonitis or peri cholecystitic abscess.(the inflamed gall bladder is usually localised by omentum which contains the perforation)._x0000_
Mucocele of gallbladder.
Carcinoma gallbladder.
IN THE BILE DUCTS:
Secondary CBD stones: (occurs in 10% of gallstones).
Obstructive jaundice
Cholangitis
Acute pancreatitis
Mirizzi Syndrome (compression of CBD by stone from cystic duct or cholecysto-choledochal fistula).
IN THE INTESTINE:
Cholecystoduodenal fistula causing gallstone ileus and so intestinal obstruction.
152
cholecystitis classification duration and etiliology
Classification:
1. Acute calculous cholecystitis.
2. Acute acalculous cholecystitis.
153
154
Q: In which patients does acute (calculous) cholecystitis commonly occur?
A: In patients with pre-existing chronic cholecystitis, but it can also be the first presentation.
155
Q: What is the cause of acute calculous cholecystitis in 90% to 95% of cases?
A: It is secondary to gallstones.
156
Q: What is the initiating event in acute calculous cholecystitis?
A: Obstruction of the cystic duct by a gallstone.
157
Q: What are the consequences of cystic duct obstruction?
A: Gallbladder distention, inflammation, and edema of the gallbladder wall.
158
Q: What percentage of patients undergoing cholecystectomy for acute uncomplicated cholecystitis have secondary bacterial contamination?
A: 15% to 30%.
159
Q: What is the most common causative bacterium in acute calculous cholecystitis?
A: E. coli.
160
Q: Name other bacteria that can cause acute calculous cholecystitis.
A: Klebsiella, Pseudomonas, Proteus, Streptococcus faecalis, and Salmonella.
161
Q: What marks the start of the common bile duct (CBD)?
A: The union of the cystic duct and the common hepatic duct (CHD).
162
Q: What is the typical length and diameter of the CBD?
A: About 7 to 11 cm in length and 5 to 10 mm in diameter, which can increase slightly with age and after cholecystectomy.
163
Q: Describe the supraduodenal portion of the CBD.
A: The upper third passes downward in the free edge of the hepatoduodenal ligament, to the right of the hepatic artery and anterior to the portal vein.
164
Q: What is the path of the retroduodenal portion of the CBD?
A: The middle third curves behind the first portion of the duodenum and diverges laterally from the portal vein and hepatic arteries.
165
Q: How does the pancreatic portion of the CBD course?
A: It can curve behind the head of the pancreas in a groove or traverse through it to enter the wall of the second portion of the duodenum.
166
Q: Where does the CBD open?
A: It opens on a papilla of mucous membrane (ampulla of Vater), about 10 cm distal to the pylorus.
167
Q: What characterizes Grade I (Mild) acute cholecystitis?
A: No organ dysfunction, mild local inflammation, and suitable for early laparoscopic cholecystectomy.
168
Q: What are the criteria for Grade II (Moderate) acute cholecystitis?
A: Elevated WBC (>18,000/mm³), palpable tender mass in RUQ, duration of symptoms >72 hours, and marked local inflammation (gangrenous or emphysematous cholecystitis).
169
Q: What defines Grade III (Severe) acute cholecystitis?
A: Organ dysfunction in one or more systems: cardiovascular (hypotension requiring vasopressors), neurological (decreased consciousness), respiratory (PaO₂/FiO₂ <300), renal (oliguria, creatinine >2 mg/dL), hepatic (INR >1.5), and hematological (platelets <100,000/mm³).
