BILIARY Flashcards
Histologic source of choledochocyst
pancreaticobiliary duct junction - mild and reflux along common channel and cause inflammatory changes of the biliary epithelium which causes of dilatation and cyst
careful the cyst can be anywhere along the biliary tract
carcinoma in situ and T1 gallbladder cancer
do not extend into perimuscular connective tissue
Cholecystectomy alone
T2-T4 gallbladder cancer
Invade the perimuscular connective tissue or directly invade the liver
Treated with radical cholecystectomy with subsegmental resection of segments 4B and 5
Hepatic duodenal ligament lymphadenectomy
Postoperative fluorouracil-5-FU for radio sensitization post operatively
male-female ratio of sclerosing cholangitis
male 2 times risk compared to female
treatment of Klatskin tumor
this is very hilar cholangiocarcinoma
Resect entire biliary ductal system
Resect close or involved liver including possibly the caudate
5-FU and mitomycin C. and doxorubicin may help some postop
NO adjuvant radiation
common biliary pathogens associated with emphysematous cholecystitis
clostridia welchii
Escherichia coli - ( most common in regular base and cholangitis)
Enterococcus
Klebsiella
ratio of bile salt, phospholipid, cholesterol
80%, 15%, 5%
primary bile acid
colic acid
chenodeoxycholic acid
Aschoff-Rokitansky sinuses
associated with chronic cholecystitis
Atrophy of the mucosa epithelium protrudes into the muscle coat leaving the formation of the sinuses
findings of a calculus cholecystitis on HIDA scan
gallbladder not visualized
Black gallstones
hemolytic
Retrograde viscera psychosis
Sickle cell disease
Form within the gallbladder
brown gallstones
primary stones formed with in the common bile duct
related to bacteria
most common and asians
increased risk of gallbladder cancer
female
Native Americans including South America
Gallstones
Choledochal cyst
Sclerosing cholangitis
Gallbladder polyp
Nitrousamines, toluene
obesity!
Porcelain gallbladder - Unless diffuse intramural calcification - no risk ( patch other selective mucosal calcification 7% increased risk)
overall, porcelain gallbladder the removed because difficult to assess these differences
here majority of iatrogenic strictures are where
common hepatic duct distal to the confluence of the right and left hepatic ducts
Gallbladder adenomyom withatosis
hypertrophic smooth muscle bundles with ingrowth of mucosal glans into the muscular layer
causes unknown
condition is benign
treatment his observation
treatment strawberry gallbladder
observation
This is accumulation of cholesterol and macrophages of gallbladder mucosa to
bilirubin cycle
heme broken into biliVERDIN
biliVERDIN converted to a bilirubin
bilirubin down to albumin
Liver conjugate bilirubin and enters the GI tract
In the GI tract bilirubin is D. conjugate and into urobilinogen by bacteria
Urobilinogen reabsorbed by gut to go back to the liver
and
urobilinogen is excreted into urine were as converted to urobilin - yellow urine
urobilin in the gut also is oxidized to stercobilin - brown stool
biliary obstruction fracture on bilirubin cycle
bilirubin does not enter the duct
Less urobilinogen is made
Causing pale stool and decreased level urobilinogen detected in the urine
fracture of hemolysis on bilirubin cycle
increased bilirubin
Increase urobilinogen in the duct and urine
most common polypoid lesion in the gallbladder
cholesterol polyp - usually less than 10 mm, pedunculated, multiple
seen in association with cholesterolosis
Adenomyomatosic polyps
second most common polypoid lesion in the gallbladder
SESSILE
Focal thickening of gallbladder wall
Treatment observation
inflammatory polyps of the gallbladder
third most common gallbladder polyp
These are benign pseudopolyps
gallbladder adenoma
generally larger than 1 cm
is performed cholecystectomy if: Symptomatic Associated with gallstones Greater than 1 cm Age over 50?
order of workup for acalculous cholecystitis and sick burn patient
ultrasound:
Sludge, gallbladder wall thickening, pericholecystic fluid and, gallbladder dilatation
if ultrasound negative and patient is not critically ill:
HIDA scan with morphine:
Gallbladder not visualized with tracer visualized in the liver and small bowel
effective morphine on the gallbladder
causes sphincter of Oddi contraction
this increases the likelihood of filling the gallbladder with HIDA contrast when there is not cholecystitis
decreases the chance of false positive HIDA scan
factor the increase conversion rate to open cholecystectomy
Older patient!
male sex
Higher ASA
Thickened gallbladder wall
Compare findings of the left hepatic duct versus the right hepatic duct with the presence of distal obstruction
the left hepatic duct is longer
The right hepatic duct more likely to be dilated with distal obstruction
spiral valves of Heister
within cystic duct-have no true valvular function
The purpose of these mucosal folds are to frustrate the surgeon placing cystic duct catheter
relationship of the common bile duct in the main pancreatic duct an insertion with the duodenum
75% merge and unite before duodenum as a common channel - then traversing the duodenum wall as a single duct
blood supply of the common bile duct
3 and 9 o’clock positions
right hepatic artery
gastroduodenal artery
treatment of a distal common bile duct injury
choledochoduodenostomy
similar distal ureter injuries
associated signs and symptoms with gallbladder hydrops
NO Murphy’s sign!
Cholecystectomy generally recommended to avoid complications
Gallbladder may become palpable
Cystic duct becomes obstructed with impacted stone - without infection and increased mucus trapping
