Biliary Flashcards
Most common cause benign biliary stricture
Previous surgery
Cholangitis s/p liver txp, dx and tx
Anastomotic biliary stricture, ERCP stent
Meperidine metabolism and toxic metabolite
Renal, normeperidine
Asymptomatic GB polyp <1cm, tx
Surveillance US yearly
Asymptomatic GB polyp >1cm, tx
Lap chole
Asymptomatic GB polyp >2cm, tx
Cancer workup prior to sx
GB ca limited to laminate propria, tx
T1a, Simple cholecystectomy
GB ca invading muscle or perimuscular connective tissue, tx
T1b/T2, chole with en bloc IVb/V resection and portal/hepatoduodenal lig lymphadenectomy
GB ca invading visceral peritoneum/adjacent liver or 2+ adjacent organs, tx
T3 and T4, consider extended right hepatectomy
Risk factors cholangiocarcinoma
PSC, choledochal cysts, UC, bil tract infxns
Absolute contraindications to lap chole
Uncorrected coagulopathy, inability to tolerate pneumo
Recent trauma, tachy with blood from ampulla of Vater, dx and tx
Hemobilia, angioembolization
Black gallstones, dx
Sickle cell or hereditary spherocytosis
Several small gallbladder polyps with cholesterol laden macrophages, dx
Cholesterolosis
Fever, jaundice, abd pain, dx and tx
Acute cholangitis, fluids, IV abx and ERCP for decompression
Aberrant duct during lap chole, next step
IOC
Future liver remnant volume
20% healthy, 30% liver dysfunction, 40% cirrhosis
Gold standard test to determine Future Liver Remnant
CT Volumetry
Gold standard tx for inadequate future liver remanant
Portal vein embolization
Absolute contraindication portal vein embolization
Portal hypertension
Painless jaundice, elevated C19-9, CBD stricture; dx
Lower duct cholangiocarcinoma
IOC without contrast in duo; next step
1.0mg glucagon
Gallbladder Ca first metastasis
Cystic duct lymph nodes
Nonop management of gallstones
Ursodeoxycholic acid
Types choledochal cysts
I: fusiform extrahepatic
II: saccular CBD
III: distal CBD
IV: intra & extra hepatic
V: intrahepatic only
Type I choledochal cyst; tx
Resection, cholecystectomy, RYHJ
Type II choledochal cyst; tx
Cyst excision
Type III choledochal cyst; tx
Endoscopic sphincterotomy and cyst unroofing
Type IV choledochal cyst; tx
Excision extrahepatic cyst, chole, RYHJ, liver resection
Type V choledochal cyst; tx
Hepatic resection w/w/o RYHJ
Bouveret syndrome
Gastric outlet obstruction by impacted stone in pylorus or prox duo
Gallbladder Ca tx
T1a - simple chole
T1b - radical chole (segment IVB and V with portal lymphadenectomy)
Indication for radical chole
T1b GB Ca (invades muscle layer)
SAS in ICU with GB distention, elevated TB, no stones
Acalculous cholecystitis
S/p lap chole, n/v, abd pain, tachy; dx and next step
Biloma and RUQUS
Obstructive jaundice and periampullary mass; dx and tx
Likely adenoma and needs resection for risk of malignancy
Portal triad structures and their orientation
CBD lateral
Portal vein posterior
Hepatic artery medially
Gallstone pancreatitis, tx
ERCP with stone extraction, lap chole same admission
How is bile concentrated
Active secretion of NaCl
Most potent stimulator of bile secretion
Secretin
Abdominal pain and elevated LFTs/bili s/p cholecystectomy; next step
ERCP (missed bile duct injury)
Hx UC with nausea, itching and multiple biliary strictures resulting in sepsis requiring stents; dx and tx
PSC, liver txp
Resectable lower duct extrahepatic cholangiocarcinoma; tx
Pancreaticoduodenectomy
Bismuth-Strasberg Bile Duct Injury
A - cystic or luschka leak
B - aberrant right hepatic
C - leak from aberrant right hepatic
D - lateral CBD injury
E1 - 2+ cm
E2 - <2cm
E3 - bifurcation
E4 - above bifurcation
E5 - aberrant right and stricture main duct
