Gallbladder and Extrahepatic Biliary System

Question 1

The arterial supply of the common bile duct

Answer 1

The right hepatic and gastroduodenal arteries

with major trunks running along the medial and lateral aspects of the common duct (3 oclock and 9 oclock psoitions)

Question 2

Anomalies of the hepatic artery and cystic artery are present in what percent of individuals?

Answer 2

50%

• The classical anatomy only appearing in 50 to 60%
• the cystic artery is a branch of the right hepatic artery in 90% of the individuals
• the most common arterial anomaly of the portal arterial system is a repalced right hepatic artery originating from the superior mesenteric artery in 20%

Question 3

The treatment of choice for type I choledochal cyst

Answer 3

Resection of the common bile duct, cholecystectomy, and hepatico-jejunostomy

• Choledochal cyst are rare congenital cystic dialtions of the extrahepatic and/or intrahepati biliary tree
  
  • Females
  • diagnosed in childhoof
  • jaundince and cholangitis in adults
• Type I, II, and IV = Roux-en-Y hepaticojejunostomy
• Type III = sphincterotomy

Question 4

Relaxation of the sphincter of Oddi in response to a meal is largely under the control of which hormone?

Answer 4

CCK

• Sphincter of Oddi
  
  • complex structure, independent from the duodenal musculature and creates a high pressure zone between the bile duct and the duodenum
  • 4 to 6 mm in length
  • basal resting pressure: 12 mmHg
  • phasic contractions 4/min 12 to 140 mmHg

Question 5

What percentage of the bile acid pool is reabsorbed in the ileum through the enterohepatic circulation

Answer 5

95%

Question 6

The solubility of cholesterol in bile is determined by

Answer 6

cholesterol, bile salts, lecithin

• Pure cholesterol stones are uncommon and account for <10% of all stones
• Most cholesterol stones are radiolucent <10% are radiopaque
• Supersaturation almost always caused by cholesterol hypersecretion rather than reduced cholesterol of phospholipid or bile salts

Question 7

Acute cholecystitis is considered

Answer 7

A primary inflammatory process with occasional bacterila contamination

• mediated by mucosal toxin lysolecithin, aproduct of lecithin as well as bile salts and platelt-activating factors
• Obstruction of the cystic duct by a galsstone is the initiating event that leads to gallbladder distention, inflammatory and edema of the gallbladder wall
• Secondary bacterial contamination is documented in 15 to 30% of patients undergoing cholecystectomy

Question 8

The initial treatment of patients with cholangitis

Answer 8

Intravenous fluid resucitation and antibiotics

Question 9

Risk factors for acalculous cholecystitis

Answer 9

• Sepsis
• severe burns
• prolonged parenteral nutrition
• multiple trauma
• Acute inflamamtion of the gallbladder can occur without gallstones
• develops in critically ill patients in the intensive care unit.
• Gallbladder distention with bile stasis and ischemia
• GB wall reveals edema of the serosa and muscular layers, with patchy thrombosis of arterioles and venules
• Ultrasound is the diagnostic test of choice. Percutaneous US or CT guided cholecystectomy

Question 10

Appropriate management of a patient with cirrhosis secondary to sclerosing cholangitis

Answer 10

Consideration of transplantation

• inflammatory strictures involving the intrahepatic and extrehapatic biliary tree
• It is a progressive disease which can lead to biliary cirrhosis
• Medical therapy has long been attempted with immunosuppressants, antibiotics, steroids, and ursodeoxycholic acid
• Surgical management with resection of the extraheaptic biliary tree and hepaticojejunostomy in patients with extrahepatic and bifurcation strictures but without cirrhosis or significant fibrosis

Question 11

Patients older than 70 years presenting with bile duct stones should have their ductal stones cleared ___________

Answer 11

endoscopically

Question 12

Over a 10 year period, what percentage of patients with asymptomatic gallstines will remain symptom free

Answer 12

66%

• approximately 3% of asymptomatic individuals become symptomatic per year

Question 13

Risk factors for the development of gallbladder cancer

Answer 13

• Female gener
• History of cholelithiasis
  
  • most important risk factors
  • 95% of patients with carcinoma of the gallbladder have gallstones
  • <0.5% for the overall population and 1.5% for high-risk groups
  • Larger stones (>3cm) are associated with a 10 fold increaed risk of cancer
• History of choledochal cysts
• gallbladder polyps

Question 14

The most common type of gallbladder cancer is

Answer 14

Adenocarcinoma

Question 15

The gallbladder lymphatics drain into which of the following liver segments

Answer 15

IV and V

• lymphatic flow from the gallbladder drains fiest to the cystic duct node (calot), then the pericholedochal and hilar nodes, and finally the peripancreatic, duodenal, periportal, celiac and superior mesenteric artery nodes
• tumor invasion is common

Question 16

Adequate treatment for a gallbladder lesion involving the lamina propria of the gallbladder includes

Answer 16

Cholecystectomy alone

Question 17

Morphoplogical classifications of bile duct adenocarcinoma

Answer 17

Nodular

Scirrhous

Diffusely infiltrating

serous

papillary

• over 95% of the bile duct cancers are adenocarcinoma

Question 18

Bismuth Corlette classification for perihilar cholangiocarcinoma

Answer 18

• Type I: tumors are confined to the common hepatic duct
• type II: tumors involve the bifurcation without the involvement of the secondary intraheapatic ducts
• Type IIIa and b: tumors extend into the right and left secondary intrahepatic ducts respecttively
• Type IV: involves both the right and left secondary intrahepatic ducts

Question 19

The best initial imaging test for evaluating for suspected cholagiocarcinoma

Answer 19

Ultrasound

• UTZ can establish the level of obstruction and rule out the presence of bile duct stones as the cause of obstruction and rule out the presence of bile duct stones
• Either UTZ ot spiral CT can be used to determine portal vein patency
• ERCP is used in the evaluation the biliary anatomy

Question 20

PAtients with the history of choledochal cysts are at increased risk of developing bilairy cancer

Answer 20

Throughout the biliary tree

Question 21

What percentage of bile duct injuries are identified intraoperatively?

Answer 21

25%

Intraoperatively bile leakage, recognition of the correct anatomy and an abnormal cholangiogram lead to the diagnosis of bile duct injury

Question 22

The best initial test for a suspected portoperative bile leak

Answer 22

Ultrasound

• Bile leak, most commonly from the cystic duct stup, a trnsected aberrant right heaptic duct, or a lateral injury to the main bile duct
• pain, fever, and a mild elevation of liver function test
• a CT scan or an ultrasound will show either a collection (biloma) in the gallbladder area or free fluid (bile) in the peritoneum

Question 23

What is the best initial management for an intraoperative identified minor lateral injury to the common bile duct

Answer 23

Placement of a T-tube through the site of injury in the duct

Question 24

After identification of apostoperative biliary stricture, what is the best initial managent?

Answer 24

Transhepatic catheter placement for biliart decompression

Question 25

In the early postoperative period, what is the most common presentation of apatient with biliary injury?

Answer 25

Elevated transaminases