32 Biliary Flashcards
Cystic artery
Branch off right hepatic artery
Found in triangle of calot
Triangle of Calot
Cystic duct (lateral)
Common bile duct (medial)
Edge of liver (superior)
Blood supply to hepatic and common bile duct
Right hepatic (lateral)
Retroduodenal branches of the gastroduodenal artery (medial)
Longitudinal blood supply
Cystic veins drain:
Into right branch of the portal vein
Lymphatics in relation to common bile duct?
Right side
Parasympathetic nervous supply to biliary tree
Left (anterior) trunk of vagus
Sympathetic nervous supply to biliary tree
T7-10 (splanchnic and celiac ganglion)
How does the gallbladder normally fill?
Contraction of sphincter of Oddi
Characteristics of the gallbladder and biliary tree
No submucosa
Mucosa is columnar epithelium
Ducts do NOT have periastalsis
Effect on sphincter of Oddi: Morphine
Contraction
Effect on sphincter of Oddi: Glucagon
Relaxation
Normal sizes:
- Common bile duct
- Gallbladder wall
- Pancreatic duct
<8mm (<10 s/p chole)
<4mm
<4mm
Highest concentration of CCK and secretin cells are in:
The duodenum
Epithelial invaginations in the gallbladder wall
Rokitansky-Aschoff sinuses
FOrmed from increased gallbladder pressure
Biliary ducts that can leak after a cholecystectomy
Ducts of Luschka
Lie in the gallbladder fossa
What causes increased bile excretion?
CCK, secretin, vagal input
What causes decreased bile excretion?
Somatostatin, sympathetic stimulation
What causes gallbladder contraction?
CCK causes constant, steady, tonic contraction
Essential functions of bile?
Fat-soluble vitamin absorption
Essential fat absorption
Bilirubin and cholesterol excretion
How does the gallbladder form concentrated bile?
Active resoprtion of NaCl and water
Concentration of hepatic bile?
Concentration of gallbladder bile?
Na 140-170 (225-350)
Cl 50-120 (1-10)
BIle salts 1-50 (250-350)
Cholesterol 50-150 (300-700)
Active resorption of conjugated bile salts?
Terminal ileum (50%)
Passive resorption of nonconjugated bile salts?
Small intestine (45%) Colon (5%)
Postprandial gallbladder maximal emptying is at:
2hrs
Bile is secreted by:
Hepatocytes (80%)
Bile canalicular cells (20%)
Cholesterol and bile synthesis
HMG CoA > HMG CoA reductase > cholesterol > 7-a-hydroxylase > bile salts
Rate-limiting step in cholesterol synthesis?
HMG CoA reductase
Cholesterol stones
Nonpigmented stones
Causes: stasis, calcium nucleation, increased water reabsorption, decreased lecithin/bile salts
Found exclusively in the gallbladder
Black stones
Pigmented
Causes: hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN
Due to increased bilirubin load, decreased hepatic function and bile stasis
Form in gallbladder
Brown stones
Pigmented
Cause: infection (deconjugates bilirubin)
Check for: ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi
Primary common bile duct stones
Tx: sphincteroplasty
Most common organisms in cholecystitis?
E. coli
Klebsiella
Enterococcus
Risk factors for gallstones
>40yo Female Obesity Pregnancy Rapid weight loss Vagotomy TPN (pigmented stones) Ileal resection (pigmented stones)
Best initial test for jaundice or RUQ pain?
Ultraound
Ultrasound findings - Hyperechoic focus, posterior shawdoing, movement of focus with changes in position
Cholelithysis
Ultrasound findings - Gallstones, gallbladder wall thickening, pericholecystic fluid
Acute cholecystitis
Ultrasound findings - dilated CBD
CBD stone and obstruction
HIDA scan
Technetium taken up by liver and excreted in the biliary tract
Findings on cholecystokinin cholecintigraphy that indicate need for cholecystectomy?
Gallbladder not seen (cystic duct likely has a stone)
Takes >60 minutes to empty (chronic cholecystitis)
Ejection fraction < 40% (biliary dyskinesia)
Most sensitive test for cholecystitis?
Cholecystokinin cholescintigraphy
Indications for immediate ERCP?
Signs that a common bile duct stone is present
Jaundice, cholangitis, US show stone in CBD
Indications for pre-op ERCP?
Persistently high for >24hrs:
- AST/ALT >200
- Bilirubin >4
- Amylase/lipase >1000
Best treatment for late common bile duct stone?
ERCP
Sphincerotomy allows for removal of stone
Risks of ERCP?
Bleeding, pancreatitis, perforation
MCC of air in the biliary tree?
Previous ERCP and sphincteretomy
Cholangitis
Erosion of the biliary system into the duodenum
Previous whipple
Risk factors for acalculous cholecystitis?
Severe burns Prolonged TPN Trauma Major surgery Bile stasis (nacotics, fasting)
Emphysematous gallbladder disease
Gas in GBW
Increased risk in diabetics
Risk for perforation
Gallstone ileus
Fistula between gallbladder and duodenum
Pneumobilia
Terminal ileum - site of obstruction
Tx: Cholecystectomy, fistula resection (if stable)
Management of an intra-op CBD injury?
If <50% of circumference - primary repair
>50% - hepaticojejunostomy or choledochjejunostomy
Post-op lap chole - persistent nausea, vomiting or jaundice?
Assess with ultrasound
Looking for a fluid collection
Post-op lap chole - persistent nausea, vomiting or jaundice? Ultrasound shows fluid collection
Percutaneous drainage
If bilious > ERCP
- Cystic duct remnant leak, small injuries to hepatic or common bile duct, leak from duct of luschka - Sphincterotomy and stent
- Large lesion - hepaticojejunostomy or choledochojejunostomy
Post-op lap chole - persistent nausea, vomiting or jaundice? Ultrasound shows no fluid collection with dilated hepatic ducts
Completely transected CBD
PTC tube then hepaticojejunostomy or choledochojejunostomy
Timing of surgical intervention after CBD injury?
Early symptoms (<7 days) - immediate Late symptoms (>7 days) - wait 6-8 weeks
Sepsis following lap chole?
Fluid resuscitation and stabilization
May be due to complete transection of CBD and cholangitis - get US
Treatment of anastomotic leak following transplantation or hepaticojejunstomy?
Percutaneous drainage of fluid followed by ERCP with temporary stent (leak will heal)
Most common cause of late post-op biliary stricture?
Ischemia following Lap Chole Other causes: - Chronic pancreatitis - Gallbladder CA - Bile duct CA Bile duct strictures w/o hx of pancreatitis or biliary surgery is CA until proven otherwise
Treatment of bile duct stricture?
MRCP (defines anatomy - look for mass)
ERCP - brush biopsy
If due to ischemia or chronic pancreatitis - choledochojejunostomy
MCC hemobilia
Fistula between bile duct and hepatic arterial system
Occurs with trauma or percutaneous instrumentation to liver
Workup and treatment of hemobilia?
DX: angiogram
Tx: angioembolism, if that fails - OR
Most common cancer of biliary tree?
GB adenocarcinoma
Most common site of GBCa metastasis?
Liver (segments IV and V)
Risk of GBCa with porcelain gallbladder?
15%
Do cholecystectomy
Symptoms of GBCa?
Jaundice first (due to bile duct invasion with obstruction) Then RUQ pain
Treatment of Gallbladder Cancer?
If muscle is not involved - open chole sufficient
Invades muscularis - Chole + wedge resection of segments IVb and V
Beyond muscle, but resectable - Formal resection of segments IVb and V
NO lap chole - tumor implants in trocar sites
Risk factors for cholangiocarcinoma
C. sinesis infection Ulcerative colitis Choledochal cysts Primary sclerosing cholangitis Chronic bile duct infection
Symptoms/Signs of cholangiocarcinoma?
Painless jaundice (early)
Weight loss, pruritis (late)
Increased bilirubin and alkphos
Diagnosis of cholangiocarinoma?
MRCP (defines anatomy, look for mass)
Discovery of focal bile duct stenosis in patient w/o history of biliary surgery or pancreatitis?
Bile duct CA until proven otherwise
Treatment of cholangiocarcinoma?
Surgery - if no distant mets or tumor is resectable
Upper 1/3 (Klatskin tumors) - lobectomy and stenting of contralateral bile duct (if localized on one duct)
Middle 1/3 - Hepaticojejunostomy
Lower 1/3 - Whipple
Treatment of intrahepatic cholangiocarinoma?
Klatskin tumor - upper 1/3
Lobectomy and stenting of contralateral bile duct (if localized to one duct)
Treatment of perihilar cholangiocarcinoma?
Middle 1/3
Hepaticojejunostomy
Treatment of distal extrahepatic cholangiocarcinoma?
Lower 1/3
Whipple
Cholangiocarcinoma risk with choledochal cysts?
15%
Treatment of type I choledochal cysts?
Cyst excision with hepaticojejunostomy and cholecystectomy
Treatment of Type IV and V choledochal cysts?
Partial liver resection or liver TXP
Type I Choledochal cyst
Fulsiform/saccular
Type II choledochal cyst
Choledochal diverticulum (periduodenal)
Type III choledochal cyst
Intraduodenal diverticulus - choledochocele
Type IVa choledochal cyst
Multiple intra and extra hepatic cysts
Type IVb choledochal cyst
Multiple extrahepatic cysts
Type V choledochal cysts
Totally intrahepatic cysts
Primary sclerosing cholangitis
Men, 40-50s
Assoc: ulcerative colitis, pancreatitis, diabetes
Sx: jaundice, fatigue, pruritus, weight loss, RUQ pain
Multiple strictures through out hepatic ducts
Complications: portal HTN and hepatic failure, cirrhosis, cholangiocarinoma
Multiple strictures through out hepatic ducts - diagnosis?
Primary sclerosing cholangitis
Progressive fibrosis of both intra and extra hepatic ducts
Treatment of primary sclerosing cholangitis?
Liver TXP
PTC tube drainage, choledochojejunostomy or balloon dilation - symptom relief
Cholestyramine - pruritis
Ursodeoxycholic acid - improve liver enzymes, pruritis
Primary biliary cirrhosis
Women Medium-sized hepatic ducts Cholestasis > cirrhosis > portal HTN Sx: jaundice, fatigue, pruritus, xanthomas Antimitochondrial antibodies Tx: Liver TXP
Cirrhosis with antimitochondrial antibodies?
Primary biliary cirrhosis
Charcot’s triad
RUQ pain
Fever
Jaundice
(Cholangitis)
Reynold’s pentad
RUQ pain Fever Jaundice \+ Mental status changes Shock (Septic cholangitis)
Most common organisms in cholangitis?
E. coli*
Klebsiella
Why do you get systemic bacteremia with cholangitis?
When pressure in the biliary system gets greater than 200mmHg, you get colovenous reflux
How do you diagnose cholangitis?
Increased AST/ALT, bilirubin, alkaline phosphatase, WBCs
US - dilated CBD (>8mm)
Most serious complication of cholangitis?
Renal failure, secondary to sepsis
Others - structure, hepatic abscess
MCC of cholangitis? Others?
Gallstones
Biliary stricture
Neoplasm
Chleodochal cyst
Duodenal diverticula
Treatment of cholangitis?
Fluid resuscitation and antibiotics
Emergent ERCP with sphincterotomy and stone extraction
If ERCP fails - PTC to decompress biliary system
If due to infected PTC tube - change the tube
Early cause of shock following lap chole?
First 24hrs - hemorrhagic shock from clip that fell off cystic artery
Late cause of shock following lap chole?
After 24hrs - septic shock from accidental clip on CBD with subsequent cholangitis
Adenomyomatosis
Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus
NOT premalignant
Can cause RUQ pain
Tx: cholecystectomy
Granular cell myoblastoma
Benign neuroectoderm tumor of gallbladder
Can occur in biliary tract with signs of cholecystitis
Tx: Cholecystectomy
Cholesterolosis
Speckled cholesterol deposits on the gallbladder wall
Gallbladder polyps
> 1cm, concern of malignancy
Polyps in patients >60yo, more likely to be malignant
Tx: Cholecystectomy
Delta bilirubin
Bound to albumin covalently
Half-life of 18 days
May take a while to clear after long-standing jaundice
Mirizzi syndrome
Compression of common hepatic duct from:
a) stone in gallbladder infundibulum
b) inflammation from gallbladder or cystic duct extending to contiguous hepatic duct (causes hepatic duct stricture)
Tx: Cholecystectomy (poss hepaticojejunostomy for hepatic duct stricture)
Complications of ceftriaxone in reference to biliary system?
Can cause gallbladder sludging and cholestatic jaundice
Indications for asymptomatic cholecystectomy?
Liver transplant
Gastric bypass proceedure (if stones are present)
