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Flashcards in Fiser Chapter 32 BILIARY SYSTEM Deck (69):
1

Gallbladder function

Stores bile

Concentrates bile by active resorption of NaCl and water (has more sodium, bile salts, and cholesterol than hepatic bile; hepatic bile has more chloride)

Postprandial emptying (maximum at 2 hours)

Cholecystectomy -> decreased total bile salt pools

2

45yo man with UC presents with jaundice, fatigue, pruritis, weight loss, and RUQ pain

Primary sclerosing cholangitis: associated with UC, pancreatitis, DM

Multiple strictures throughout hepatic ducts (string of beads)

Leads to portal HTN, hepatic failure (progressive fibrosis of intrahepatic and extrahepatic ducts) -> cirrhosis, cholangiocarcinoma

Tx: PTC tube drainage, choledochojejunostomy or balloon dilatation of dominant strictures may provide symptomatic relief, cholestyramine to decrease bile acids and pruritis, UDCA (ursodiol) to decrease bile acids and improve liver enzyms; LIVER TXP EVENTUALLY NEEDED FOR MOST; Colon resection does NOT help PSC

3

Cholangitis dx

Elevated AST/ALT, bilirubin, alk phos, WBC

US shows dilated CBD (> 8 mm, > 10 mm after cholecystectomy) if d/t biliary obstruction

4

GB wall normal size

< 4 mm

5

Pigmentes stones

Most common worldwide

1. Calcium bilirubinate stones: from increased bilirubin load, decreased hepatic function, and bile stasis -> solubilization of unconjugated bilirubin with precipitation; dissolution agents (monooctanoin) do NOT work

2. Black stones: Hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN; tx cholecystectomy if symptomatic

6

Cholecystitis most common organisms

E coli (#1), Klebsiella, Enterocococcus

7

Biliary colic

Transient cystic duct obstruction caused by passage of gallstone

RESOLVES IN 4-6 HOURS

8

Patient with sepsis following lap chole

1. Fluid resuscitation, stabilize
2. US to look for dilated intrahepatic ducts or fluid collection (cystic duct leak versus transection)
3. Could also be cholangitis

9

Charcot's triad

RUQ pain, fever, jaundice

Reynaud's pentad: altered mental status and shock

10

Diabetic with severe rapid-onset abdominal pain, nausea, vomiting, sepsis, gas in gallbladder wall on plain film

Emphysematous gallbladder disease: risk of perforation

Usually d/t clostridium perfringens
Tx: emergent cholecystectomy, percutaneous drainage if unstable

11

Enterohepatic circulation

1. Bile secreted by hepatocytes (80%) and bile canalicular cells (20%); broken down in gut to stercobilin (makes stool brown); reabsorbed

2. Terminal ileum: active resorption of conjugated bile salts; Small intestine (45%) and colon (5%): passive resorption of non-conjugated bile salts

3. Absorbed bile gets converted to urobilinogen and eventually urobilin, which is released in urine (yellow color)

12

Drugs that affect sphincter of Oddi

Morphine: contracts (why meperidine used to be used)

Glucagon: relaxes

13

Cholesterol and bile acid synthesis

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

HMG CoA reductase is rate limiting step in cholesterol synthesis

14

Shock after lap chole causes

First 24 hours: hemorrhagic shock from clip that fell off cystic artery

After 24 hours: septic shock from accidental clip on CBD with subsequent cholangitis

15

Gallstone risk factors

>40yo

Female

Obesity

Pregnancy

Rapid weight loss

Vagotomy

TPN (pigmented stones)

Ileal resection (pigmented stones)

16

Most sensitive test for cholecystitis

CCK-CS test (cholecystokinin cholescintigraphy), also uses HIDA scan (technetium taken up by liver and excreted in biliary tract)

Indications for cholecystectomy afterward:
-GB not seen (stone in cystic duct)
-Take >60 min to empty (chronic cholecystitis)
-EF < 40% (biliary dyskinesia)

17

Cystic vein

Drain into R branch of portal vein

18

Best treatment for late CBD stone

ERCP (sphincterotomy allows for removal of stone)

Risks: bleeding, pancreatitis, perforation

19

Most common cause of positive bile cultures

Postoperative strictures, usually E coli, or polymicrobial

20

Longitudinal blood supply of hepatic and common bile ducts

Right hepatic artery (9 oclock on ERCP), gastroduodenal artery retroduodenal branches (3 oclock on ERCP)

21

Pancreatic duct normal size

< 4 mm

22

Rokitansky-Aschoff sinuses

Epithelial invaginations in GB wall, formed from increased gallbladder pressure

23

Patient with sepsis, cholangitis, and jaundice

Bile duct stricture: cancer until proven otherwise (unless history of pancreatitis or biliary surgery)

Dx: MRCP to define anatomy, look for mass -> ERCP with brush biopies

Tx: if d/t ischemia or chronic pancreatitis -> choledochojejunostomy (best long-term solution), otherwise if cancer then appropriate workup

24

Todani classification of choledochal cysts

I: saccular or fusiform dilatation of a portion or whole CBD

II: isolated diverticulum from CBD

III: right by duodenum

IV: multiple (extrehepatic +/- intrahepatic)

V: intrahepatic (if multiple intrahepatic, is Carroli's disease)

25

Cystic artery anatomy

Branches off right hepatic artery

Found in triangle of Calot (cystic duct latera, CBD medial, liver superior)

26

Most common route of bacterial infection of bile

Dissemination from portal system (NOT retrograde through sphincter of ODD)

27

Benign neuroectoderm tumor of gallbladder

Granular cell myoblastoma: can occur in biliary tract with signs of cholecystitis

Tx: cholecystectomy

28

CBD normal size

< 8 mm (< 10 mm after chole)

29

Causes of bile duct strictures

-Ischemia after lap chole (most important cause)

-Chronic pancreatitis

-Gallbladder cancer

-Bile duct cancer

30

Indications for asymptomatic cholecystectomy

Patients undergoing liver transplant, or gastric bypass procedure (if stones are present)

31

Cystic lymphatics are where

Right side of common bile duct

32

Galbladder wall layers

Mucosa (columnar epithelium)

(No submucosa)

33

Speckled cholesterol deposits on gallbladder wall

Cholesterolosis

34

Patient with persistent nausea, emesis, jaundice after lap chole: first step

Get US to look for fluid collection

1. Fluid collection (bile leak): percutaneous drainage -> if bilious get ERCP
-> if cystic duct remnant leak, small injuries to hepatic or common bile duct, or leak from duct of Luschka -> sphincterotomy

2. Dilated hepatic ducts and no fluid collection (completely transected CBD): PTC tube initially, then hepaticojejunostomy or choledochojejunostomy

35

Old Asian woman with episodic RUQ pain, fever, jaundice, and cholangitis

Choledochal cyst: 90% are extrahepatic, most type 1, 15% risk of cholangiocarcinoma

In infant can present like biliary atresia; caused by abnormal reflux of pancreatic enzymes during uterine development

36

Patient after PTC tube presents with UGI bleed, jaundice, and RUQ pain

Hemobilia: fistula between bile duct and hepatic arterial system (most commonly)

Most commonly occurs with trauma or percutaneous instrumentation to liver (PTC tube)

Dx: angiogram

Tx: angioembolization; operation if that fails

37

Bile essential functions

Fat-soluble vitamin absorption

Essential fat absorption

Bilirubin and cholesterol excretion

38

Nerve fibers of gallbladder

Parasympathetic fivers from Left (anterior) vagus trunk

Sympathetic fibers from T7-T10 (splanchnic and celiac ganglions)

39

Old patient with SBO and pneumobilia on plain film

Gallstone ileus: fistula between gallbladder and duodenum that releases stone, causing SBO

TI most common site of obstruction

Tx: Remove stone through enterotomy proximal to obstruction; perform cholecystectomy and fistula resection if patient can tolerate it

40

Cholesterol stones

Caused by stasis, calcium nucleation, and increased water reabsorption from GB; also by decreased lecithin and bile salts

Most common type in US

41

Bacteria causes cholecystitis, pneumobilia bile infection, emphysematous gallbladder disease

Cholangitis: E coli (#1) and kleb

Cholecystitis: E coli (#1), kleb, enterococcus

Pneumobilia bile infection from postop stricture: E coli, or often polymicrobial

Emphysematous GB disease: Clostridium perfringens

42

Most common biliary tract cancer

Gallbladder adenocarcinoma (rare but most common cancer of biliary tract), 4x more common than bile duct cancer; most have stones

Most common met site is liver: first to segments IV and V

First nodes are cystic duct nodes (right side)

15% risk in patients with porcelain GB (they need cholecystectomy if found)

High incidence of tumor implants in trocar sites when discovered after lap chole

5% 5-year survival

43

hormones that increase and decrease bile excretion

Increase: CCK, secretin, vagal input (CCK and secretin cells highest concentration in duodenum)
-CCK causes constant, steady, tonic GB contraction

Decrease: somatostatin, sympathetic stimulation

44

Gallbladder polyp tx

If > 1 cm or < 60yo, worry about malignancy

Tx: cholecystectomy

45

Indications for immediate and pre-op ERCP

Immediate:
-Jaundice, cholangitis, US shows stone in CBD (signs that CBD stone is present)

Pre-op ERCP: Any of following for > 24 hours
-AST or ALT > 200, bilirubin > 4, amylase or lipase > 1,000

46

Causes of cholangitis; complications

Causes:
-Bile duct obstruction (most commonly gallstones; also indwelling PTC tube)
-Stricture, neoplasm, choledochal cysts, duodenal diverticula

Complications:
-Systemic bacteremia: colovenous reflux (occurs at > 200 mm Hg)
-Renal failure (#1 serious complication; related to sepsis)
-Stricture and hepatic abscess are late complications

47

Location of gallbladder relevant to liver

Beneath segments IV and V

48

Cholecystitis tx

Cholecystectomy

Very ill: cholecystostomy tube

49

Thickened nodule of mucosa and muscle on gallbladder wall

Adenomyomatosis: associated with Rokitansky-Aschoff sinus, NOT premalignant, does NOT cause stones but can cause RUQ pain

Tx: cholecystectomy

50

CBD transection tx

Symptoms 7 days or sooner: hepaticojejunostomy immediately

Late symptoms after 7 days: hepaticojejunostomy 6-8 weeks after injury (tissue too friable at this time point)

51

RUQ pain, leukocytosis, US shows thickened wall, sludge, and pericholecystic fluid but no stones, HIDA scan positive: diagnosis, etiology, tx

-Acalculous cholecystitis: bile stasis (narcotic, fasting) -> distention and ischemia; also increased viscosity d/t/ dehydration, ileus, transfusion

-Most commonly burns, prolonged TPN, trauma, or major surgery

-Cholecystectomy, percutaneous drainage if unstable

52

Best initial test for RUQ pain and jaundice

US: 95% sensitive for stones

Stones: Hyperechoic focus, posterior shadowing, movement of focus with changes in position

Cholecystitis: stones, wall thickening (> 4 mm), pericholecystic fluid

Obstruction: dilated CBD (> 8 mm)

53

Cholangitis tx

1. Fluid resuscitation
2. Antibiotics
3. Emergent ERCP with sphincterotomy and stone extraction
4. PTC tube to decompress biliary system if ERCP fails
5. If d/t infected PTC tube, change the tube

54

Elderly male with UC, PSC, presents with pain jaundice, weight loss, pruritis, found to have high bilirubin and alk phos, and on MRCP focal bile duct stenosis (but no history of biliary surgery or pancreatitis)

Cholangiocarcinoma, risk factors: C sinensis, UC, choledochal cysts, PSC, chronic bile duct infection; invades contiguous structures early

Dx: MRCP to define anatomy and look for mass; focal bile duct stenosis in patients without a history of biliary surgery or pancreatitis is highly suggestive of bile duct CA

55

Pnuemobilia causes

Most commonly occurs with previous ERCP and sphincterotomy

Can also occur with cholangitis or erosion of biliary system into duodenum (gallstone ileus)

56

Mirizzi syndrome

Compression of common hepatic duct by 1) stone in GB infundibulum, or 2) inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causing common hepatic duct stricture

Tx: cholecystectomy, may need hepaticojejunostomy for hepatic duct stricture

57

Antibiotic that can cause gallbladder sludging and cholestatic jaundice

Ceftriaxone

58

Ducts of Luschka

Biliary ducts in the GB fossa that can leak after chole

59

Percentage of patients undergoing cholecystectomy who will have a reained CBD stone

< 5%

and 95% of these are cleared with ERCP

60

Patient with jaundice and then RUQ pain, found to have gallbladder adenocarcinoma, what is tx?

Open cholecystectomy (sufficient if muscle not involved; lap chole contraindicated)

Wedge resection of segements IVb and V (if in muscle)

Formal resection of segments IVb and V (if beyond muscle and still resectable)

61

How does the gallbladder normally fill?

Contraction of sphincter of Oddi at ampulla of Vater

CBD and CHD do NOT have peristalsis

62

Cholangiocarcinoma tx

Upper 1/3 bile duct (Klatskin tumors): most common type, worst prognosis, usually unresectable
-Can try lobectomy and stenting of contralateral bile duct if localized to either R or L lobe

Middle 1/3: hepaticojejunostomy

Lower 1/3: Whipple

Unresectable: palliative stenting

20% 5-year survival

63

Gallstone types

Nonpigmented (cholesterol)

Pigmented (calcium bilirubinate and black stones)

Brown stones

64

Treatment of anastomotic leak after transplant or hepaticojejunostomy

Perc drainage of fluid collection, followed by ERCP with temporary stent (leak will heal)

65

Delta bilirubin

Bound covalently to albumin, t 1/2 18 days, may take a while to clear after long-standing jaundice

66

Brown stones

-Primary CBD stones, most commonly formed in ducts, Asians (brown and cholesterol stones found in CBD are secondary stones)

-Infection (E coli most common) -> beta-glucuronidase production -> deconjugation of bilirubin -> calcium bilirubinate formation

-Need to check for ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi

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

67

Patient with persistent RUQ pain, referred to R shoulder and scapula, nausea, vomiting, anorexia, frequently after a fatty meal, positive Murphy's sign, elevated WBC and alk phos

Cholecystitis: cystic duct obstruction -> wall distension and inflammation

Suppurative cholecystitis: frank purulence in GB, associated with sepsis and shock

68

Woman with jaundice, fatigue, pruritis, xanthomas, positive antimitochondrial antibodies

Primary biliary cirrhosis: cholestasis -> cirrhosis -> portal hypertension

NO increased risk of cancer

Tx: Liver transplant

69

Tx of intraoperative CBD injury

< 50 % circumference: probably primary repair; otherwise need hepaticojejunostomy or choledocho jejunostomy