Biliary System Flashcards
Types of gallstones
Cholesterol and Pigmented
Pigmented- Black and brown
Black- Hemolytic conditions, found only in GB-Calcium phosphate, carbonate- Hard, radioopaque
Brown- black+cholesterol, secondary to infection, found anywhere in biliary ducts- Calcium plamitate, stearate, bilirubinate
Stone formation- contributing factors
*Bile salts help solubilise cholesterol- less bile salts- chol precipitates out
- GB dysmotility
- Bile supersaturation- lot of cholesterol in bile
- Conc of bile- Bile conc by absorption on water and Ca. Bile gets concentrated 10x by the time it fills GB.
- Reduced GB emptying- Prolonged fasting state, somatostain analog, Vagotomy
Prophylactic cholecystectomy
Sickle cell anemia
Porcelain GB
Large gallstones >2.5cm
Long common channel
T2DM- lower threshold for opting for cholecystectomy- due to risk of gangrenous cholecystitis
Biliary Colic
No inflammation so no physical signs. Just pain.
GB stone- blocks cystic duct- GB tries to contract against a blocked CD- Pain- Constant
Onset of pain after ingesting a fatty meal- Due to release of CCK in response to high fat content in duodenum- CCK stimulates GB contraction- against a blocked cystic duct in case of GB stones obstructing the CD.
Chronic cholecystitis
Temporary block of CD by GB stone- relieves within <24hrs.
Block- TEMPORARY AND REPETITIVE.
Acute Calculous Cholecystitis
Biliary colic + fever- lasts >24 hrs.
Caused by blockage of CD that does not resolve.
Block- inflammation, stagnant bile- that gets infected. Pressure in the GB increases- ischemia of GB- Necrosis.
Acute Gangrenous cholecystitis. Acute Emphysematous Cholecystitis.
Acute cholecystitis- Clinical
Fever+ RUQ pain
Tenderness in RUQ/ epigastrium
Murphy’s Sign- Inflammation of visceral and parietal peritoneal surfaces
TOKYO Guidelines
Acute cholecystitis-Diagnosis
USG- Gallstones, pericholecystic fluid, GB wall thickening
HIDA scan- For physio study of bile flow (not to dtect GB stone)- If within 1 hr of dye inj GB not 100% visualised- Acute cholecystitis diagnosis can be made.
Acute cholecystitis- Rx
NPO
I.v fluids
Broad spectrum antibiotics
Analgesics
Cholecystectomy
Choledocholithiasis
Brown stones
Cholangitis:
1. Charcot’s triad- Fever, RUQ pain, jaundice
2. Reynold’s pentad- Charcot’s + hypotension and mental status changes
CBD>8mm dilated
LFT abnormal
ERCP with sphincterotomy with CBD stenting
Bilirubin- Symptoms
Frenulum (base of tongue)- Appears first
Sclera @ 2.5mg/dl
Skin @5 mg/dl
USG findings of GB stones/ cholecystitis
Acute cholecystitis- Pericholecystic fluid, GB wall thickening, GB stones- mobile with change in patient’s position (GB polyp- not mobile, sludge- slowly mobile), posterior acoustic shadow.
Chronic cholecystitis- GB stones may not be visualised but even sludge is suggestive of the same.
USG differentiates between medical and surgical causes of jaundice.
Porcelain GB- curvilinear posterior acoustic shadow.
HIDA scan= Biliary scintigraphy
Evaluates physiologic status of GB.
Contrast injected and filling of GB seen- if GB not visualised completely within 1 hour- Acute cholecystitis.
HIDA+CCK- Biliary dyskinesia
Gallstone pancreatitis
GB stone obstructs pancreatic duct outlet
Obstructive, reflux theory of etiology of pancreatitis
ERCP done to clear the obstructing stone
Mild pancreatitis- Lap chole in the same admission
Moderate/ severe- Lap chole within 6 weeks
Gallstone ileus
GB stone passes into the duodenum through a fistula- obstructs terminal ileum.
Intermittent obstruction features- episodic discomfort
Pneumobilia- CT abdomen.
Air fluid levels due to IO on Abdomen Xray
Enterotomy- incision proximal to the obstruction at the antimesenteric border- stone milked out- rest of the intestine palpated (?multiple stones)- enterotomy closed
The inflammation in the RUQ complicates lap chole and duodenal closure
In healthy patients- Enterotomy+ fistula closure+ lap chole done in the same sitting
Otherwise, Lap chole+ duodenal fistula repair done in a 2nd sitting.
Rigler’s triad-
Pneumobilia
Small bowel obstruction
Calcified stone (m/c in RIF)
Acute acalculous cholecystitis
Old age, burns, trauma, critically ill, diabetic, prolonged TPN use, immunosuppression
Etiology unknown
Presentation similar to calc cholecystitis
HIDA scan diagnostic
Lap chole- but cholecystostomy done due to the poor physiological status (poor GC) of most patients- interval lap chole done
Biliary dyskinesia
Functional disorder of GB
Presents similar to calc biliary disease- no radio evidence of stone
CCK+HIDA scan- EF of < 1/3rd of bile within 20 mins of contrast- diagnostic
Lap chole
Sphincter of Oddi dysfunction
Repetitive passage of GB stones/ chronic pancreatitis/ prior SOD manipulation
Sphincter manometry>40mmHg
*Milwaukee classifification of SOD dysfunction:
Biliary SOD dysfunction:
Type 1- All of:abnormal LFT >2x upper limits, biliary drainage> 45mins, CBD >12mm
Type 2- 1-2 of the above+ c/f
Type 3- C/f
Pancreatic SOD dysfunction:
Type 1- All of: Elevated serum amylase, lipase>2x of upper limits, pancreatic drainage> 49mins, PD >6 mm
Type 2- 1-2 of the above+ c/f
Type 3- C/f
Endoscopic sphincterotomy
Primary sclerosing cholangitis
Biliary strictures
Biliary cysts
Todani classification
Type 1:
Laparoscopic choecystectomy
Under GA and muscle relaxants.
Orogastric tube for decompreesing the stomach- clear surgical field (upper abdomen)
12mm post at umbilicus- for extraction
CO2 pneumoperitoneum
5mm ports at right ant axillary line, right midclavicular line, subxiphoid- for dissection
Port at right anterior axillary line- to retract GB towards right shoulder
Port at right midclavicular line- to grasp the GB infundibulum (Hartman pouch) and retract it inferolaterally- to open Calot’s triangle and to move CD away from CHD which are anatomically almost parallel
Calot node overlying cystic artery used to id cystic artery
Critical view of safety (Strassberg)- to avoid CBD injury- only two structures entering the GB and liver visualised- Lord Ganesha’s sign
CA and CD clipped
Intraop cholangiogram-
In the setting of acute cholecystitis/ if GB was entered during surgery- bag used for GB retrieval.
Bailout procedures
Subtotal cholecystectomy
Fundus first (retrograde dissection)
Conversion to open
