Anatomy and Physiology

Question 1

Bile ducts Location

Answer 1

either intrahepatic or extrahepatic
lie superior to the corresponding portal vein
which in turn are lateral and inferior to the arterial supply

Question 2

Which is longer rt or lt duct ?

Answer 2

The left hepatic duct retains a longer transverse extrahepatic portion and travels under the edge of segment IV

Question 3

Lt duct drains which segments ?

Answer 3

left duct drains segments I, II, III, and IV, with the most distal branch draining segment IVA

Question 4

Rt Duct drains which segments ?

Answer 4

drainage of the right duct system includes segments V, VI, VII, and VIII

Question 5

Cystic Duct Length

Answer 5

The cystic duct can range from 1 to 5 cm in length

Question 6

valves of Heister Function

Answer 6

> > folds of mucosa oriented in spiral pattern within the neck of gallbladder

> > function to retain bile in the gallbladder until contraction in response to enteric stimulation.

Question 7

The CBD is divided into three portions:

Answer 7

supraduodenal
retroduodenal
the pancreatic portion

Question 8

Where dose the CBD starts and Ends ?

Answer 8

The insertion of cystic duct marks the separation of the CBD (below) from the common hepatic duct (above)

The CBD ends in the second portion of duodenum at the ampulla of Vater. The pancreatic duct also joins the ampulla

Question 9

exposure of the bifurcation ?

Answer 9

> > incision at the base of segment IV and lifting the liver off these structures.
This technique, called lowering hilar plate, is used to expose the proximal extrahepatic biliary tree.

(Hilar Plate is an extension of Glissons capsule)

Question 10

Cystic Artrey comes from where?

Answer 10

• from the right hepatic artery
• may arise :
  » left hepatic
  » proper hepatic
  » common hepatic
  » gastroduodenal
  » superior mesenteric artery

Question 11

Cystic artery Location

Answer 11

• can pass posterior or anterior to the CBD to supply the gallbladder.
• Although variable, the cystic artery generally lies superior to the cystic duct and is usually associated with a lymph node, known as Calot node

Question 12

right hepatic artery passes .. ?

Answer 12

posterior to the common hepatic duct to supply the right lobe of the liver.

Question 13

triangle of Calot

Answer 13

bordered by the cystic duct
common hepatic duct
and edge of the liver

Question 14

Importance of this triangle ?

Answer 14

The cystic artery takes off from the right hepatic artery in this triangle, which is at risk for injury during cholecystectomy

Question 15

accessory or replaced right hepatic artery location

Answer 15

• 20% of the population, there is an accessory or replaced right hepatic artery passing through the portacaval space and ascending to the right lobe along the lateral aspect of the CBD.
• A pulsatile structure palpated on the most lateral aspect of the porta during a Pringle maneuver identifies this anomaly

Question 16

On ct, where to see the replaced or accessory artery ?

Answer 16

a vessel passing transversely between the portal vein and inferior vena cava behind the head of the pancreas.

Question 17

perfusion to the inferior bile duct, below the duodenal bulb

Answer 17

• from tributaries of the postero-superior pancreatico-duodenal and gastro-duodenal arteries.
• The small branches coalesce to form the two vessels that run along the CBD at the 3- and 9-o’clock positions.
• These vessels can be damaged and leave the bile duct at risk for ischemic injury with close dissection of the areolar tissue surrounding the bile duct.

Question 18

Patterns of biliary duct–pancreatic duct junction and insertion into the duodenal wall

Answer 18

(A) Separate common bile duct (CBD) and pancreatic duct (PD) entry
(B) Joining ducts at the ampula
(C) Joining ducts before the ampula
(D) PD entering the CBD

Question 19

Bile salts examples , made of What ?

Answer 19

such as cholic acid and deoxycholic acid

are originally created from cholesterol

Question 20

What is the rate-limiting step in bile salt excretion.

Answer 20

• The transport of bile salts across the canalicular membrane

Question 21

Diarrhea after Cholecystectomy ?

Answer 21

When sufficient quantities of bile salts reach the colonic lumen, the powerful detergent activity of the bile salts can cause inflammation and diarrhea.

> > This can sometimes be seen after a cholecystectomy when the speed of the enterohepatic circulation of bile increases and may overwhelm the ability of the terminal ileum to absorb bile salts

Question 22

The major lipid components of bile are

Answer 22

phospholipids and cholesterol.

Question 23

Some info about Bile

Answer 23

Bile pigments such as bilirubin are breakdown products of hemoglobin and myoglobin.

These products are transported in the blood, bound to albumin, to hepatocytes.

Inside hepatocytes, they will be transferred into the endoplasmic reticulum and conjugated to form bilirubin glucuronides, known as conjugated or “direct” bilirubin.

Bile pigment gives the color of bile and, when converted to urobilinogen by bacterial enzymes, gives stool its characteristic color.

Question 24

What stimulate Bile Secretion?

Answer 24

• Vagal activity induces bile secretion as does the gastrointestinal hormone secretin.
• Cholecystokinin (CCK), secreted by the intestinal mucosa, serves to induce biliary tree secretion and gallbladder wall contraction, thereby augmenting excretion of bile into the intestines

Question 25

Why Stones Forms ?

Answer 25

Increases in cholesterol and calcium concentration calcium lead to decreased stability of phospholipid cholesterol vesicles. The reduced vesicle stability predisposes to nucleation of this stagnant pool of cholesterol and, thus, to cholesterol stone formation.

Question 26

What makes the GB increase Its Filling ?

Answer 26

An increase in the activity of the sphincter of Oddi in the fasting state whose musculature is independent from the duodenal intestinal wall, increases pressure in the CBD, filling the gallbladder, which is capable of storing up to 300 mL of daily bile production, through a retrograde mechanism

Question 27

What prevents Duodenal Contents to go in the biliary System ?

Answer 27

During the fasting state >> The oblique passage of the bile duct through the duodenal wall and the tonic activity of the sphincter prevent duodenal contents from refluxing into the biliary tree.

Question 28

Elevation in serum bilirubin caused by obstruction of the biliary system will be identifiable in the

Answer 28

- frenulum of the tongue - sclera - skin. - check the frenulum first >> level of bilirubin must reach to 2.5 mg/dL to be seen in sclera >> above 5 mg/dL to be manifested in skin.

Question 29

Stone Vs polyp Vs Sludge on US

Answer 29

Most gallstones, unless impacted, will move with positional changes in the patient. This feature allows their differentiation from gallbladder polyps, which are fixed and from sludge, which will move more slowly and does not have the sharp echogenic pattern of gallstones.

Question 30

Porcelain gallbladder appearance on US

Answer 30

>> calcified wall, will appear as a curvilinear echogenic focus along the entire gallbladder wall, with posterior shadowing

Question 31

hepatic iminodiacetic acid (HIDA) scan importance ?

Answer 31

- evaluate the physiologic secretion of bile - injection of an iminodiacetic acid, which is processed in the liver and secreted with bile - injection of CCK during a scan will document physiologic ejection of the gallbladder - failure to fill the gallbladder 2 hours after injection demonstrates obstruction of the cystic duct, as seen in acute cholecystitis >> the scan will identify obstruction of the biliary tree and bile leaks, which may be useful in the postoperative setting. >> useful in patients with biliary tract pain but without stones because some patients have pain from impaired emptying, known as biliary dyskinesia

Question 32

CT ?

Answer 32

- CT provides superior anatomic information - CT can be used to identify the cause and site of biliary obstruction ( hepatic or pancreatic parenchyma or possible neoplastic processes )

Question 33

ERCP ?

Answer 33

- using endoscopy and fluoroscopy to inject contrast material through the ampulla to image the biliary tree - complication rate of up to 10%

Question 34

Percutaneous Transhepatic Cholangiography

Answer 34

- A needle is passed directly into the liver to access one of the biliary radicals, and the tract is then used for contrast imaging and can serve to allow insertion of transhepatic catheters for drainage and sometimes biopsy. - useful for patients with intrahepatic biliary disease or in whom ERCP is not technically feasible - PTC can decompress biliary obstruction and stent obstructions nonoperatively and can provide anatomic information for biliary reconstruction

Question 35

Indications for IOC

Answer 35

- pain on the day of operation - abnormal hepatic function panel - anomalous or confusing biliary anatomy - alteration in anatomy that precludes the ability to perform ERCP after cholecystectomy, such as Roux-en-Y gastric bypass, dilated biliary tree, or any preoperative suspicion of choledocholithiasis

Question 36

EUS ?

Answer 36

- most useful in assessing tumors for invasion into vascular structures.

Question 37

EUS : Radial Vs Linear Endoscopes ?

Answer 37

Radial echoendoscopes are most useful for providing a tomographic evaluation linear echoendoscopes can guide interventions such as needle biopsies under real-time ultrasound guidance

Question 38

PET CT ?

Answer 38

FDG PET scans can differentiate benign and malignant lesions, detect recurrence, and identify metastatic disease. - Incapable of demonstrating carcinomatosis and, given the high metabolism of the immune system >> Limited value in infection or inflammation

Question 39

Biliary Tree is Sterile ?

Answer 39

The biliary tree inserts into the duodenum and therefore cannot be considered truly sterile

Question 40

MC organisms in Biliary infections ?

Answer 40

Enterobacteriaceae ( Gram Negative ) such as : Escherichia coli Klebsiella Enterobacter followed by Enterococcus spp.

Question 41

Prophylactic Abx before Intervention ?

Answer 41

- Prophylactic antibiotics >> ERCP or PTC. - first- or second-generation cephalosporin or fluoroquinolone - elective laparoscopic cholecystectomy for biliary colic, no antibiotic prophylaxis is necessary. - Abx If suspected or documented infection of the biliary tree, such as acute cholecystitis or ascending cholangitis,