BILIARY

Question 1

Histologic source of choledochocyst

Answer 1

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

Question 2

carcinoma in situ and T1 gallbladder cancer

Answer 2

do not extend into perimuscular connective tissue

Cholecystectomy alone

Question 3

T2-T4 gallbladder cancer

Answer 3

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

Question 4

male-female ratio of sclerosing cholangitis

Answer 4

male 2 times risk compared to female

Question 5

treatment of Klatskin tumor

Answer 5

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

Question 6

common biliary pathogens associated with emphysematous cholecystitis

Answer 6

clostridia welchii
Escherichia coli - ( most common in regular base and cholangitis)
Enterococcus
Klebsiella

Question 7

ratio of bile salt, phospholipid, cholesterol

Answer 7

80%, 15%, 5%

Question 8

primary bile acid

Answer 8

colic acid

chenodeoxycholic acid

Question 9

Aschoff-Rokitansky sinuses

Answer 9

associated with chronic cholecystitis

Atrophy of the mucosa epithelium protrudes into the muscle coat leaving the formation of the sinuses

Question 10

findings of a calculus cholecystitis on HIDA scan

Answer 10

gallbladder not visualized

Question 11

Black gallstones

Answer 11

hemolytic
Retrograde viscera psychosis
Sickle cell disease

Form within the gallbladder

Question 12

brown gallstones

Answer 12

primary stones formed with in the common bile duct
related to bacteria

most common and asians

Question 13

increased risk of gallbladder cancer

Answer 13

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

Question 14

here majority of iatrogenic strictures are where

Answer 14

common hepatic duct distal to the confluence of the right and left hepatic ducts

Question 15

Gallbladder adenomyom withatosis

Answer 15

hypertrophic smooth muscle bundles with ingrowth of mucosal glans into the muscular layer

causes unknown

condition is benign

treatment his observation

Question 16

treatment strawberry gallbladder

Answer 16

observation

This is accumulation of cholesterol and macrophages of gallbladder mucosa to

Question 17

bilirubin cycle

Answer 17

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

Question 18

biliary obstruction fracture on bilirubin cycle

Answer 18

bilirubin does not enter the duct

Less urobilinogen is made

Causing pale stool and decreased level urobilinogen detected in the urine

Question 19

fracture of hemolysis on bilirubin cycle

Answer 19

increased bilirubin

Increase urobilinogen in the duct and urine

Question 20

most common polypoid lesion in the gallbladder

Answer 20

cholesterol polyp - usually less than 10 mm, pedunculated, multiple

seen in association with cholesterolosis

Question 21

Adenomyomatosic polyps

Answer 21

second most common polypoid lesion in the gallbladder

SESSILE

Focal thickening of gallbladder wall

Treatment observation

Question 22

inflammatory polyps of the gallbladder

Answer 22

third most common gallbladder polyp

These are benign pseudopolyps

Question 23

gallbladder adenoma

Answer 23

generally larger than 1 cm

  is performed cholecystectomy if:
Symptomatic
Associated with gallstones
Greater than 1 cm
Age over 50?

Question 24

order of workup for acalculous cholecystitis and sick burn patient

Answer 24

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

Question 25

effective morphine on the gallbladder

Answer 25

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

Question 26

factor the increase conversion rate to open cholecystectomy

Answer 26

Older patient!
male sex
Higher ASA
Thickened gallbladder wall

Question 27

Compare findings of the left hepatic duct versus the right hepatic duct with the presence of distal obstruction

Answer 27

the left hepatic duct is longer

The right hepatic duct more likely to be dilated with distal obstruction

Question 28

spiral valves of Heister

Answer 28

within cystic duct-have no true valvular function

The purpose of these mucosal folds are to frustrate the surgeon placing cystic duct catheter

Question 29

relationship of the common bile duct in the main pancreatic duct an insertion with the duodenum

Answer 29

75% merge and unite before duodenum as a common channel - then traversing the duodenum wall as a single duct

Question 30

blood supply of the common bile duct

Answer 30

3 and 9 o’clock positions

right hepatic artery

gastroduodenal artery

Question 31

treatment of a distal common bile duct injury

Answer 31

choledochoduodenostomy

similar distal ureter injuries

Question 32

associated signs and symptoms with gallbladder hydrops

Answer 32

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