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Surgical Recall > SR 54 - Biliary Tract > Flashcards

SR 54 - Biliary Tract Flashcards

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1
Q

Which is the proximal and which is the distal bile duct?

A

Proximal is close to the liver

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2
Q

What is in Calot’s triangle?

A

Calot’s nodes

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3
Q

What are the small ducts that drain bile directly into the gallbladder from the liver?

A

Ducts of Luschka

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4
Q

What artery is at risk during cholecystectomy?

A

Right hepatic artery

close to cystic artery and Calot’s triangle

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5
Q

What is the name of the valves of the gallbladder?

A

Spiral valves of Heister

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6
Q

Where is the infundibulum of the gallbladder?

A

Near the cystic duct

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7
Q

Where is the fundus of the gallblader?

A

At the top end of the gallbladder

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8
Q

What are the boundaires of the triangle of Calot?

A

Cystic duct
Common hepatic duct
Cystic artery (newer - liver edge)

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9
Q

What is the source of alkaline phosphatase?

A

Bile duct epithelium

Thus, elevated in duct obstruction

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10
Q

What is in bile?

A

Cholesterol
Lecithin (phospholipid)
Bile acids
Bilirubin

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11
Q

What does bile do?

A

Emulsifies fats

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12
Q

Where is bile absorbed?

A

Terminal ileum

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13
Q

What stimulates gallbladder emptying?

A

CCK

Vagal input

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14
Q

What is the source of CCK?

A

Duodenal mucosal cells

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15
Q

What stimulates the release of CCK?

A

Fat, protein, AA and HCl in duodenum

and antral stretch

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16
Q

What inhibits release of CCK?

A

Trypsin

Chymotrypsin

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17
Q

What are the actions of CCK?

A

Gallbladder emptying
Opening of ampulla of Vater
Slowing of gastric emptying
Pancrease acinar cell growth and release of exocrine products

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18
Q

What level of bilirubin does a patient become jaundiced?

A

> 2.5

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19
Q

Where is the first anatomical location that you see evidence of jaundice?

A

Under the tongue

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20
Q

With good renal function, how high can bilirubin go?

A

Rarely >20

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21
Q

Signs and symptoms of obstructive jaundice?

A 
Jaundice
Dark urine
Clay-color stools (acholic stools)
Pruritis
Loss of appetite
Nausea
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22
Q

What causes itching in obstructive jaundice?

A

Bile salts in teh dermis

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23
Q

Define Klastkin’s tumor

A

Cholangiocarcionma of bile duct at the junction of the right and left hepatic ducts

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24
Q

Define Biliary colic

A

Pain from gallstones
RUQ, epigastrum or right subscapular region
Lasts minutes to hours
Often postprandial, especially with fatty foods

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25
Define Biloma
Intraperitoneal bile fluid collection
26
Initial diagnostic studry for evaluation of billary tract?
US
27
Define ERCP
Endoscopic retrograde cholangiopancreatography
28
Define PTC
Percutaneous transhepatic cholangiogram
29
Define IOC
Intraoperative cholangiogram (to rule out choledocholithiasis)
30
Define HIDA/PRIDA scan
Radioisotope study Isotope is concentrated in the liver and secreted into bile Demonstrates cholecystitis, bile leak or CBD obstruction
31
How often will plain x-ray film see gallstones?
10-15%
32
What is the Kocher incision?
Right subcostal incision
33
What is a sphincterotomy?
Cut through the sphinchter of Oddi to allow passage of gallstones from the CBD AKA papillotomy
34
How do you treat post-op biloma after a lap-chole?
Percutaneous drain bile collection | ERC with placement of biliary stent
35
What is the treatment of major CBD injury after lap chole?
Choledochoejunostomy
36
DDx of proximal bile duct obstruction?
``` Cholangiocarcinoma Lymphadenopathy Metastatic tumor Gallbladder carcinoma Sclerosing cholangitis Gallstones Tumor embolus Parasites Postsurgical stricture Hepatoma Benign bile duct tumor ```
37
DDx of distal bile duct obstruction?
``` Choledocholithiasis (gallstones) Pancreatic carcinoma Pancreatitis Ampullary carcinoma Lymphadenopathy Pseudocyst Postsurgical stricture Ampulla of Vater dysfunction/stricture Lyphoma Benign bile duct tumor Parasites ```
38
Initial study of choice for obstructive jaundcce?
US
39
Labs associated with obstructive jaundice?
Elevated alk-phos Elevated bilirubin +/- elevated LFTs
40
Risk factors for cholelithiasis?
``` Female, fat, forty, fertile Oral contraceptives Bile stasis Chronic hemolysis Cirrhosis Infection Native American Rapid weight loss/gastric bypass Obesity IBD Terminal ileal resection TPN Vagotomy Advanced age Hyperlipidemia Somatostatin therapy ```
41
What are black stones made of?
Calcium bilirubinate | Cirrhosis, hemolysis
42
What are brown stones made from?
Biliary tract infections
43
Complications of gallstones?
``` Acute cholecystitis Choledocholithiasis Gallstone pancreatitis Gallstone ileus Cholangitis ```
44
Possible complications of lap-chole?
Common bile duct injury Right hepatic duct/artery injury Cystic duct leak Biloma
45
Indications for cholecystectomy in asymptomatic patient?
Sickle-cell disease Calcified gallbladder* Child
46
What are indications for IOC?
``` Jaundice Hyperbilirubinemia Gallstone pancreatitis (Resolved) Elevated alkaline phosphatase Choledocholithiasis on ultrasound To define anatomy ```
47
How do you manage choledocholithiasis?
ERCP with papillotomy and basket/balloon retrieval of stones Laparoscopic trancystic duct or trans common bile duct retrieval Open common bile duct exploration
48
What medication may dissolve cholesterol gallstones?
Chenodeoxycholic acid | Ursodeoxycholic acid
49
Major feared complication of ERCP?
Pancreatitis
50
Signs and symptoms of acute cholecystitis?
``` Unrelenting RUQ pain/tenderness Fever Nausea/vomiting Painful, palpable gallbladder (33%) Postiive MUrphy's signs Right subscapular pain Epigastric discomfort ```
51
Complications of acute cholecystitis?
``` Abscess Perforation Choledocholithiasis Cholecysteneric fistula formation Gallstone ileus ```
52
Labs associated with acute cholecystitis?
Increased WBC Slight elevation in alk-phos Slight elevation in LFTs, amylase, T. bili
53
Signs of acute cholecystitis on US?
``` Thickened gallbladder wall (>3mm) Pericholecystic fluid Distended gallbladder Gallstones present/cystic duct stone Sonographic Murphy's sign ```
54
Treatment of acute cholecystitis?
IVF Antibiotics Cholecystectomy
55
What percentage of patients have an accessory cystic artery?
10%
56
Why would you open the gallbladder in the operating room?
Looking for cancer | To determine anatomy
57
What is acute acalculous cholecystitis?
Acute cholecystitis without gallstones | Due to bile stasis
58
Risk factors for acalculous cholecystitis?
``` Prolonged fasting TPN Trauma Multiple transfusions Dehydration Prolonged post-op or ICU setting ```
59
Diagnostic tests for acalculus cholecystitis?
US | HIDA (non-filling)
60
Management of acalculus cholecystitis?
``` Cholecystectomy Cholecystomy tube (if unstable) ```
61
What is cholangitis?
Bacterial infection of the biliary tract | Associated with obstruction
62
What are common causes of cholangitis?
``` Choledocholithiasis Stricture (post-op) Neoplasm (ampullary carcinoma) Extrinsic compression (pseudocyst, pancreatitis) Instrumentation of the bile ducts Biliary stent ```
63
Most common cause of cholangitis?
Gallstones in the CBD
64
Signs and symptoms of cholangitis?
Charcot's triad - Fever/chills, RUQ pain, jaundice | Reynold's pentad - Alterted mental status, Shock
65
Labs associated with cholangitis?
Increased WBCs, bilirubin, alk-[hos | Positive blood cultures
66
Most common organisms with cholangitis?
G- (E. coli, Klebsiella, Psuedomonas, Enterobacter, Proteus, serratia) G+ (enterococci) Anarobes - less common (B. fragilis) Fungi - rare (Candida)
67
Management of nonsuppurative cholangitis?
IVF Antibiotics Definitive treatment treatment later (lap-chole, ERCP)
68
Managment of suppurative cholangitis?
IVF Antibiotics Decompression - ERCP with papillotomy; PTC with catheter drainage; laparotomy with T-tube placement
69
What is sclerosing cholangitis?
Mulitple inflammatory fibrou thickening of bile duct walls resulting in biliary strictures
70
What is the natural history of sclerosing cholangitis?
Progressive obstruction leading to eventual cirrhosis and liver failure 10% develop cholangiocarcinoma
71
Major risk factor for sclerosing cholangitis?
IBD - 66% ulcerative colitis
72
Signs and symptoms of sclerosing cholangitis?
Obstructive jaundice
73
Complications of sclerosing cholangitis?
Cirrhosis Cholangiocarcinoma Cholangitis Obstructive jaundice
74
How do you diagnose sclerosing cholangitis?
Elevated Alk-phos | PTC/ERCP revealing ‘beads on a string’ appearance on contrast study
75
How do you manage sclerosing cholangitis?
``` Hepatoenteric anastomosis (if extrahepatic ducts are pimarily involved) and resection of extrahepatic ducts due to risk of cholangiocarcinoma Transplant (primarily intrahepatic or cirrhosis) Endoscopic ballon dilation ```
76
What is gallstone ileus?
Small bowel obstruction from large gallstone (>2.5cm) that has eroded through the gallbladder and into the duodenum/small bowel
77
What is the classic site of obstruction in gallstone ileus?
Ileocecal valve | Flextures, brim of the pelvis
78
Classic findings of gallstone ileus?
Air in hepatic bile ducts SBO with air fluid levels Gallstone in ileocecal valve
79
Signs/symptoms of gallstone ileus?
SBO - distention, vomiting, hypovolemia, RUQ pain
80
What is carcinoma of the gallbladder?
Malignant neoplasm | Most are adenocarcinoma
81
Risk factors for gallbladder carcinoma?
Gallstones Porcelain gallbladder Cholecysenteric fistula
82
What percentage of patients with a porcelain gallbladder have gallbladder cancer?
50%
83
Symptoms of gallbladder cancer?
``` Biliary colic Weight loss Anorexia Asymptomatic until late May present as acute cholecysitis ```
84
What are the signs of gallbladder cancer?
Jaundice (invasion of CBD compression by LNs) RUQ mass Palpable gallbladder (late)
85
Management of gallbladder cancer that is confined to the mucousa?
Cholecystectomy
86
Managment of gallbladder cancer confided to muscularis/serosa?
Radial cholecystectomy
87
Main complicatio of a lap chole for gallbladder cancer?
Trocar site tumor implants | if the diagnosis is know presurgery - do an open approach
88
What is cholangiocarcinoma?
Malignancy of extrahepatic or intrahepatic ducts | Adenocarcinoma
89
Signs and symptoms of cholangiocarcinoma?
Biliary obstruction (aundice, pruritis, dark urine, clay-colored stools, cholangitis)
90
Most common location for cholangiocarcinoma?
Proximal bile duct
91
What are the risk factors for cholangiocarcinoma?
``` Choledochal cysts UC Thorotrast contrast dye (1950s) Sclerosing cholangitis Liver flukes (clonorchiasis) Toxin exposures (i.e. Agent orange) ```
92
What is hydrops of the gallbladder?
Complete obstruction fo teh cystic duct | Filling of the gallblader with fluid from gallbladder mucosa
93
What is Gilbert's syndrome?
Error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia
94
What is Courvoisier's gallbladder?
Palpable, nontender gallbladder Associated with cancer of the head of teh pancreas Able to distend due to lack of scaring (versus obstruction associated with gallstones)
95
What is Mirizzi's syndrome?
Common hepatic duct ostruction due to extrinsic compression from a gallstone impacted in the cystic duct

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