GALLBLADDER Flashcards
(52 cards)
Length and Capacity of Gallbladder
7-10 cm long
30-50 mL capacity
lacks muscularis mucosa and submucosa
Hepatocystic triangle or Budde Triangle
cystic duct to the right
common hepatic duct to the left
margin of the R lobe of liver superiorly
Triangle of Calot
Borders
cystic duct common hepatic duct cystic artery
Calot node - located w/n the triangle; ENLARGED during cholecystitis or cholangitis
Moosman area
circular area, 30 mm in diameter that fits into the hepatocystic duct angle
Arterial Supply of Common Bile Duct
gastroduodenal artery
Right hepatic artery
Neurohormonal Regulation
VAGUS gallbladder contraction
CCK Sphincter of Oddi relaxation and GB contraction
VIP inhibits GB contraction
somatostatin inhibits GB contraction
Regulates flow of bile and pancreatic juice into the duodenum
Prevents regurgitation of duodenal contents into the biliary tree
Diverts bile into the GB
Sphincter of Oddi
Recommendations for Prophylactic Cholecystectomy
PROPHYLACTIC CHOLECYSTECTOMY INDICATED
hemoglobinopathies (SCD)
hereditary spherocytosis and thalassemia
transplant recipient (cardiac and lung)
PROPHYLACTIC CHOLECYSTECTOMY NOT INDICATED
diabetic patients
cirrhotic patients
transplant recipients (kidney and pancreas)
porcelain bladder
patients receiving prolonged TPN
spinal cord injury
PROPHYLACTIC CHOLECYSTECTOMY CONTROVERSIAL
morbid obesity
after bariatic surgery
2018 Tokyo Guidelines
LOCAL SIGNS OF INFLAMMATION
Murphy sign
RUQ mass or pain or tenderness
SYSTEMIC SIGNS OF INFLAMMATION
fever
elevated CRP
elevated WBC
IMAGING FINDINGS
characteristics of acute cholecystitis
1 item in A + 1 item in B = SUSPECTED DIAGNOSIS
1 item in A + 1 item in B + C = DEFINITE DIAGNOSIS
Diagnostic test of choice for acute cholecystitis
Ultrasound
enlarged gallbladder thickening of the gallbladder wall (>5 mm) gallbladder stones debris echo direct tenderness when probe is pushed against the gallbladder (ultrasonographic Murphy sign)
gangrenous and emphysematous cholecystitis: irregular thickening of GB wall and imaging of the ruptured GB
Involves IV injection of technetium labeled analogues of iminodiacetic acid which are excreted in the bile
Hepatobiliary Scintigraphy (Tc-HIDA scan)
failure of GB to fill w/n 60 mins after administration of tracer indicates that cystic duct is obstructed RIM SIGN - blush of increased pericholecystic radioactivity in cholecystitis
Formed in the CBD
PRIMARY STONES
Brown pigment type
biliary stasis and infection
Formed in the GB and migrate to CBD
SECONDARY STONES
more common cholesterol stones
Stones identified by cholangiography shortly after cholecystectomy
MISSED during operation
Retained Choledocholithiasis
Stones that are found later (<2 years after cholecystectomy) Same composition (black pigment or cholesterol) as the GB stones
Residual Choledocholithiasis
Assumed to be primary common duct stones (usually of brown pigment type)
Stones discovered > 2 years after choleystectomy
Recurrent Choledocholithiasis
useful for documenting stones in the gallbladder (if still present), as
well as determining the size of the common bile duct
Ultrasonography
dilated CBD (>8 mm in diameter) in patient w/ gallstones, jaundice, and biliary pain - highly suggestive of common bile duct stones
Gold standard test for acute choledocholithiasis
Provide definitive or temporary treatment of CBD stones
Endoscopic Retrograde Cholangiopancreatography (ERCP)
POSSIBLE COMPLICATION: pancreatitis
Indications for IOC during laparoscopic cholecystectomy
jaundice or history of jaundice or history of pancreatitis elevated liver function tests CBD larger than 5-7 mm in diameter cystic duct > 3 mm in diameter multiple small GB stones unclear anatomy CBD stones visualized on preoperative US palpable CBD stones intraop
Common hepatic duct obstruction caused by an exttrinsic compression from/an impacted stone in the cystic duct of Hartmann pouch of the gallbladder
Mirrizi Syndrome
Uncommon form of gallstone ileus of the duodenum characterized by gastric outlet obstruction caused by gallstone impaction in the pylorus or proximal duodenum after its passage through a cholecystoduodenal fistula
Bouveret syndrome
Rigler triad - pneumobilia, SBO, ectopic gallstoone
Ascending bacterial infection of the biliary tress in association w/ partial or complete blockage of the bile duct
Cholangitis
Diagnostic Criteria for Acute Cholangitis (2018 Tokyo Guidelines)
SYSTEMIC INFLAMMATION
(+) fever/chills
laboratory evidence of inflammatory response
CHOLESTASIS
jaundice
abnormal liver function test
IMAGING
dilated biliary system
imaging shows evidence of etiology (stricture, stone, stent etc)
At risk for developing acalculous cholecystitis
patients on parenteral nutrition
extensive burns
sepsis
major operations
multiple trauma
prolonged illness with multiple organ system failure
