Biliary Tract Anatomy & Labs Flashcards
The RT and LT hepatic ducts join to for the ______ ______ ______.
Common hepatic duct
The GB is located at the ______ end of the MLF.
inferior
The GB neck tapers to form the _____ ______ which joins with the ____ _____ _____ to form the _____ _____ _____.
cystic duct, common hepatic duct, common bile duct
The CHD is _____ the liver.
outside
The MPV, CHD, PHA form the ______ ______ at the _____ ______. Some refer to this as the mickely mouse sign.
portal triad, porta hepatis
In the portal triad, the CHD is _______ and to the ______ of the MPV and the PHA is ______ and to the ______ of the MPV.
anterior/right
anterior/left
T/F - The cystic duct is commonly visualized.
F - it is uncommon so we use the term “common duct” to refer to the extrahepatic ductal system
What forms the ampulla of Vater?
CBD and main pancreatic duct (Duct of Wirsung)
What is the valve of Heister’s and what is its function?
spiral fold in the GB which controls bile flow in the cystic duct
What is a Hartmann’s pouch?
abnormal sacculation (diverticulum) of the neck of the GB
What is a phrygian cap?
fold between the body and fundus of the GB
What is a junctional fold?
fold between the body and neck (infundibulum) of the GB
The CBD passes _______ to the first part of the duodenum and pancreatic head, joining the duct of Wirsung at the _____ ____ _____.
posterior, ampulla of Vater
The GB is divided into what 3 parts?
neck, body, fundus
Muscular valve that controls the flow of digestive juices (pancreatic, bile) through the ampulla of Vater into the second part of the duodenum.
Sphincter of Oddi
The ampulla of Vater empties though the _______ ______.
duodenal papilla
Normal GB wall thickness.
<3mm
Cholecystokinin
hormone released into the blood in response to ingestion of fatty foods, causing GB contraction
Reasons for performing a fatty meal test
equivocal bile duct dilation
abnormal labs (conjugated bilirubin, alkaline phosphatase)
if the duct increases in size, positive result
if the duct decreases in size or is unchanged, negative result
Where should the CHD be measured?
At the porta hepatis, outside the liver where the RHA courses between the MPV and CHD, lumen only
The size of the extrahepatic bile duct is the most sensitive means of distinguishing _______ from ______ jaundice.
medical (pre-hepatic/hepatic)
surgical (post hepatic)
Measurement criteria for CHD
Normal <5mm
Equivocal 6-7mm
Dilated >8mm (consider age and surgery)
Upper normal value of the CHD in elderly patients
10mm
The CHD diameter increases with age, _____ mm decade rule. So at age 60, _____ mm is normal and at age 80, ____mm is normal.
1mm
6mm
8mm
Postcholecystectomy, the CHD acts like a reservoir for bile so it may normally increase in size up to ____mm
10mm
What parts of the biliary tree dilate with a distal common bile duct obstruction?
entire system distends including the GB
What parts of the biliary tree dilate with a common hepatic obstruction?
only the CHD and intrahepatic ducts will dilate
GB will be contracted
What parts of the biliary tree dilate with an obstruction at the junction of the RT and LT hepatic ducts?
only the intrahepatic ducts, GB will be contracted
Bilirubin
end product of hemoglobin breakdown
Total bilirubin
conjugated + unconjugated
Conjugation
process of removing protein (albumin) from unconjugated bilirubin, making it soluble
______ is important for bilirubin disposal. It not only renders the pigment excretable by the liver, but also detoxifies the waste product.
conjugation
Indirect hyperbilirubinemia
unconjugated
direct hyperbilirubinemia
conjugated
Unconjugated (indirect) hyperbilirubinemia results from (3)
impaired hepatic bilirubin uptake
increased bilirubin production
impaired conjugation of bilirubin
Conjugated (direct) hyperbilirubinemia results from (1)
defective bile outflow
The kidneys do not filter ______ bilirubin as they are bound to albumin.
unconjugated
The presence of bilirubin in the urine indicates_______ hyperbilirubinemia.
conjugated, remember that the kidneys cannot filter unconjugated
Unconjugated hyperbilirubinemia results from impaired hepatic bilirubin uptake due to (5)
CHF liver varices TIPS Drugs Contrast agents
Unconjugated hyperbilirubinemia results from increased bilirubin production due to (2)
hemolysis - rupture or destruction of RBCs
or
ineffective erythropoiesis - production of RBCs
Unconjugated hyperbilirubinemia results from impaired conjugation of bilirubin due to (2)
Gilbert syndrome (3-7% adult pop) Crigler-Najjar Syndrome Type I and II (rare, only few 100 cases)
2 autosomal recessive disorders of bile metabolism resulting in underactivity of the conjugating enzyme system due to lack of the enzyme uridine diphosphate glycosyl transferase. Leads to unconjugated hyperbilirubinemia.
Gilbert syndrome
Crigler-Najjar Syndrome Type I and II
Defective bile outflow from a bile duct obstruction results in reflux of ______ into plasma and direct hyperbilirubinemia.
conjugates
Conjugated hyperbilirubinemia results from defective bile outflow due to (4)
hepatitis
biliary obstruction
hepatic insult due to sepsis
cardiogenic shock
High levels of ______ bilirubin may secondarily elevate the level of _____ bilirubin.
conjugated, unconjugated
alkaline phosphatase
ALP
enzyme that is concentrated in the bile ducts and also found in bone, liver, and placenta
_____ increases with bone growth (children) and pregnancy (liver, placenta)
ALP
_____ increases in diseases that impair bile formation, specifically bile duct obstruction
ALP
ALP increases with (11)
choledocholithiasis pancreatic carcinoma cholangiocarcinoma cholangitis Mirizzi syndrome choledochal cyst (Caroli's disease) GB carcinoma primary sclerosing cholangitis primary biliary cirrhosis bone growth and diseases pregnancy
