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Flashcards in GB Deck (77):
1

GB - Duodenum path

Cystic Duct
Common Hepatic Duct
Common Bile Duct
Pancreatic Duct
Duodenum

2

Ampulla of vater location + fxn

between the pancreatic duct and the duodenum

`Controls the flow of bile and pancreatic juices via the sphincter of Oddi

3

- Bilirubin is formed by

breakdown of heme in hemoglobin, myoglobin

Poorly soluble in water
unbound = toxic to nervous system

4

where does bilirubin become conjugate

in liver via glucuronidation

combined with lecithin and cholesterol

5

bile composition

Detergent like substance that contains cholesterol, lecithin, bile acids, conjugated bilirubin and protein

6

bile stored + stimulus

GB

released in response to CCK and vagal stimulation when food enters duodenum

7

bile fxn (3)

Facilitate fat digestion and absorption

Alkalinize acidic gastric chyme

Facilitates absorption of fat soluble vitamins (A, D, E, K)

8

BILE ACIDS metabolism

Pass thru small intestine and are actively reabsorbed in the terminal ileum and returned to liver via enterohepatic circulation

Re-conjugated and re-excreted by hepatocytes

9

risk factors for gall stone formation

5 Fs

Female
Forty
Fat (high fat diet/obese)
Fertile (multiple pregnancies)
Family history

ALSO: crohn's/ileum resection, TPN, DM

10

pathophys of cholelithiasis

Increase biliary cholesterol saturation = estrogen, obesity and rapid weight loss

Nucleation= increased by bacterial infection of biliary system, ABX (Ceftriaxone) and TPN

Biliary stasis 2/2 TPN, pregnancy, fasting

11

Cholesterol Stones:

supersaturation of cholesterol causes cholesterol to precipitated out of solution

YELLOW cholesterol stones

12

cause of Cholesterol Stones:

GB hypomotility and diets high in cholesterol will contribute to this process

13

Bilirubin Stones:

too much bilirubin secreted,

BLACK stones

14

causes of bilirubin stones

Hemolytic anemia (G6PD, Spherocytosis, Sickle Cell anemia)

15

infected Stones: color + location

BROWN stones, infected bile, soft;

MC found in cystic and common bile ducts

16

Biliary Sludge:

thick mucous in the GB that is a precursor to gall stones


mucous + proteins +cholesterol crystals + calcium

17

biliary sludge
Associated with

TPN, rapid weight loss, starvation

18

chronic cholecystitis AKA

biliary colic

19

biliary colic path

pain when gallstone lodges in cystic duct causing increasing tension in GB that is later relieved

Causes GB hypertrophy, inflammation and eventual atrophy/fibrosis

20

biliary colic epidemiology + risk factors

65% of symptomatic gall stone dz

fatty meals, preexisting dz

21

clinical présentation chronic cholecystitis

quick, rapid onset of pain in RUQ/epigastrium

***pain free after 1-4 hrs

+/-Bloating, belching, flatulence

22

chronic cholecystitis w/u

U/S RUQ

Labs are normal

MUST consider different diagnosis IF atypical presentation

23

chronic cholecystitis tx

elective laparoscopic Cholecystectomy

24

management before sx for biliary colic + timing

Avoid fatty foods and large meals


DM should not wait long bc prone to complications

Pregnant women can undergo lap chole in 2nd trimester if diet fails

25

Acute Cholecystitis
Pathophysiology:

stone becomes lodged in cystic duct causing a significant inflammatory response and mucosal thickening with sub serosal hemorrhage of GB

26

Acute Cholecystitis
Epidemiology + RF

95% due to gallstones, 5% caused by acalculous cholecystitis

hx of biliary colic

27

Acute Cholecystitis Clinical presentation

typical colic symptoms

pain doesn’t subside after 1-5 hours and lasts several days if untx

Pain more severe than usual colic

Febrile and systemically ill with anorexia, n/v

Pain located in RUQ, Murphy’s sign positive

Guarding and rebound tenderness

28

Acute Cholecystitis Work-up:

CBC, Liver panel, RUQ u/s, HIDA scan

LEUKOCYTOSIS (12-15k, >20k suggests perforation(

Mild elevation in bilirubin, rest of liver panel is WNL

29

Acute Cholecystitis Complications:

bacterial contamination of bile, acute gangrenous cholecystitis = GB abscess or GB

30

Acute Cholecystitis tx (medical)

IVF

ABX (GN and anaerobic coverage – Rocephin + flagyl, unasyn, zosyn)

pain control

31

Acute Cholecystitis tx (sx)

Pt presents w/in first few days of illness:

Laparoscopic cholecystectomy within 24hrs

32

Acute Cholecystitis tx (sx)

Pt presents >3-4 days after onset:

IVF, ABX, pain control, lap chole in 8 weeks

33

Acute Cholecystitis tx (sx)
Pt not a surgical candidate:

percutaneous cholecystostomy to drain infected GB

34

Ascending Cholangitis
Pathophysiology:
Epidemiology:

older, female

ascending bacterial infection of bile 2/2 biliary stasis and ascending infection from duodenum

35

Ascending Cholangitis MC bacterial isolation (4)

o E. Coli
o Klebsiella
o Enterobacter
o Bacteroides

36

Ascending Cholangitis RF

choledocholithiasis

37

Ascending Cholangitis

clinical presentation

Charcot's triad --> Reynold's pentad

N/V, + murphy's, RUQ pain with guarding

V clinically ill

38

Charcot's triad

RUQ pain, fever, jaundice

associated w/Ascending Cholangitis

39

Reynold's pentad

RUQ pain, fever, jaundice, septic shock, disorientation

associated w/Ascending Cholangitis

40

Ascending Cholangitis

w/u

liver panel, ERCP

41

ERCP in Ascending Cholangitis

determines level and type of obstruction,

placement of biliary stent

culture,

removal of obstruction

42

Ascending Cholangitis

complications

: Gram negative septic shock

cardiac complications
renal failure
hepatic abscess

43

Ascending Cholangitis Treatment:

ICU placement and IVF, ERCP

ERCP for removal of obstruction


44

what if a. cholangitis pt is too sick for ERCP?

Decompression with cholesotomy and IV ABX

45

Choledocholithiasis
Pathophysiology, Risk Factors

Gallstones within common bile duct

RF: increasing age

46

Choledocholithiasis
clinical presentation

n/v, RUQ or epigastric pain and jaundice

47

Choledocholithiasis
liver panel labs

elevated alkphos, bilirubin AND transaminase

48

Choledocholithiasis test of choice

RUQ u/s

*unable to see stone due to bowel gas but can see dilated CBD

49

Choledocholithiasis confirmed w? gold standard?

MRCP to confirm

ERCP = gold standard bc can tx and diagnose

50

Choledocholithiasis Complications:

complete or incomplete CBD obstruction causing cholangitis or gallstone pancreatitis

51

Choledocholithiasis tx

ERCP + lap chole

52

Choledocholithiasis

Present and Known sx management

ERCP to remove stone followed by lap chole the next day

RF: pt could have stone that gets into different duct (retained ductal stone)

53

Choledocholithiasis found during cholangiogram sx management

explore

exploration of duct and removal of CBD stone

RF: Dye can push stone down (to pancreatic duct, causing pancreatitis) = Susceptible to surgeon damage

54

Choledocholithiasis found during cholangiogram sx management

complete

completion of cholecystectomy and ERCP to remove retained stones next day
o 2 procedures

55

Acalculous Cholecystitis
patho + epi

acute inflammation of GB w/o gallstones

Epidemiology: critically ill patients

56

Acalculous Cholecystitis w/u

liver panel u/s

57

Acalculous Cholecystitis clinical presentation

fever, elevated WBC, increased alkaline phosphatase and bilirubin

58

Acalculous Cholecystitis tx

Cholecystostomy (too ill for surgery)

59

cholangiogram

Preformed during cholecystectomy to assess for ductal stones

Injection of contrast to look for filling defects and free flow contrast

If stones are found: there will be a blockage of contrast

60

when would you do a cholangiogram

Significant change of biliary duct injury and subsequent stricture, bile leak, and need for biliary stent

61

U/S RUQ

Diagnostic study of choice to look for stones/sludge

Demonstrates thickening of GB wall, pericholecystic fluid, sonographic Murphy’s sign

Looks for acoustic shadowing (sludge has none)

62

HIDA scan

Evaluate for acute cholecystitis if RUQ u/s is non diagnostic


Injected IV and taken up selectively by hepatocytes and excreted into bile

picked up in response to CCK

63

positive HIDA =

gallbladder does not visualize (due to cystic duct obstruction (edema associated with cholecystitis or obstructing stone)


Also positive if HIDA does not enter the small intestine

64

Primary Biliary Cirrhosis

Autoimmune disorder causing immune mediated obliteration of SMALL/MEDIUM sized bile ducts in liver

Bile ducts are then destroyed and can no longer leave liver efficiently resulting in hepatitis in cirrhosis

65

PBC presentation

Women in their 40s, debilitating fatigue and severe pruritus


Early: increased ALT, AST, elevated bilirubin and alk phos

Late: development of thrombocytopenia and prolonged PT/INR

AMA is in the serum of 95% of pts w/PBC

66

PBC tx

ursodeoxycholic acid (slows progression in early phases)

liver transplant end stage dz

67

PBC prognosis

development of sicca complex (dry eyes/mouth), RUQ pain, hyperpigmentation or jaundice, signs of cirrhosis

68

Primary Sclerosing Cholangitis

Autoimmune process causing sclerosis of intra and extra-hepatic bile ducts of ALL SIZES, highly associated with IBD

69

PSC presentation

fatigue, pruritus, RUQ pain, repeated bouts of ascending cholangitis

MC in men 20s-40s

Elevated alk phos and bilirubin in cholestatic pattern

Auto-immune Abs: p-ANCA, ANA

70

tx of PSC

diagnosis confirmed with ERCP,

liver transplant, medical therapy ineffective

71

prognosis of PSC

time from diagnosis to death is 12 yrs, associated with CCC development

72

SURGICAL TREAMENT OF CHOICE

lap chole

due to reduced post op pain and LOS

73

triangle of Calot

cystic duct inferiorly

common hepatic duct medially,

inferior visceral surface of liver superiorly

used in lap chole

74

lap chole complications

increased pressure may cause internal organ injury

75

indications for open chole

complications to lap chole
pregnant

76

complications of open chole

increased infection
more pain
increased LOS

77

Cholecystostomy
Indications:

percutaneous drain place to relieve distended, inflamed, or purulent GB when surgery is contraindicated