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Section II General Surgery P203Surgical Recall Sixth > Biliary Tract, C54 P364-381 > Flashcards

Biliary Tract, C54 P364-381 Flashcards

1
Q

ANATOMY
Name structures 1 through
8 (below) of the biliary tract:
P364 (picture)

A
  1. Intrahepatic ducts
  2. Left hepatic duct
  3. Right hepatic duct
  4. Common hepatic duct
  5. Gallbladder
  6. Cystic duct
  7. Common bile duct
  8. Ampulla of Vater
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2
Q

ANATOMY
Which is the proximal and
which is the distal bile duct?
P364

A

Proximal is close to the liver (bile and the
liver is analogous to blood and the heart;
they both flow distally)

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3
Q

ANATOMY
What is the name of the
node in Calot’s triangle?
P364

A

Calot’s node

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4
Q 
ANATOMY
What are the small ducts that
drain bile directly into the
gallbladder from the liver?
P364
A

Ducts of Luschka

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5
Q 
ANATOMY
Which artery is susceptible
to injury during
cholecystectomy?
P364
A

Right hepatic artery, because of its
proximity to the cystic artery and Calot’s
triangle

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6
Q

ANATOMY
What is the name of the
valves of the gallbladder?
P364

A

Spiral valves of Heister

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7
Q

ANATOMY
Where is the infundibulum
of the gallbladder?
P364

A

Near the cystic duct

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8
Q

ANATOMY
Where is the fundus of the
gallbladder?
P364

A

At the end of the gallbladder

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9
Q

ANATOMY
What is “Hartmann’s pouch”?
P365

A

Gallbladder infundibulum

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10
Q

ANATOMY
What are the boundaries of
the triangle of Calot?
P365 (picture)

A

The 3 C’s:

  1. Cystic duct
  2. Common hepatic duct
  3. Cystic artery
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11
Q 
ANATOMY
“Dr. Blackbourne, are you
absolutely sure that the Triangle
of Calot includes the cystic
artery and not the liver edge?”
P365
A

Yes, look up Gastroenterology, 2002;

123(5):1440

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12
Q

PHYSIOLOGY
What is the source of
alkaline phosphatase?
P365

A

Bile duct epithelium; expect alkaline
phosphatase to be elevated in bile duct
obstruction

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13
Q

PHYSIOLOGY
What is in bile?
P365

A

Cholesterol, lecithin (phospholipid), bile

acids, and bilirubin

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14
Q

PHYSIOLOGY
What does bile do?
P365

A

Emulsifies fats

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15
Q

PHYSIOLOGY
What is the enterohepatic
circulation?
P365

A

Circulation of bile acids from liver to gut

and back to the liver

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16
Q

PHYSIOLOGY
Where are most of the bile
acids absorbed?
P365

A

In the terminal ileum

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17
Q

PHYSIOLOGY
What stimulates gallbladder
emptying?
P365

A

Cholecystokinin and vagal input

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18
Q

PHYSIOLOGY
What is the source of
cholecystokinin?
P365

A

Duodenal mucosal cells

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19
Q

PHYSIOLOGY
What stimulates the release
of cholecystokinin?
P365

A

Fat, protein, amino acids, and HCl

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20
Q

PHYSIOLOGY
What inhibits its release?
P366

A

Trypsin and chymotrypsin

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21
Q

PHYSIOLOGY
What are its actions?
P366

A 
Gallbladder emptying
Opening of ampulla of Vater
Slowing of gastric emptying
Pancreas acinar cell growth and release
    of exocrine products
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22
Q 
PATHOPHYSIOLOGY
At what level of serum total
bilirubin does one start to
get jaundiced?
P366
A

> 2.5

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23
Q 
PATHOPHYSIOLOGY
Classically, what is thought
to be the anatomic location
where one first finds
evidence of jaundice?
P366
A

Under the tongue

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24
Q 
PATHOPHYSIOLOGY
With good renal function,
how high can the serum
total bilirubin go?
P366
A

Very rarely, >20

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25
Q 
PATHOPHYSIOLOGY
What are the signs and
symptoms of obstructive
jaundice?
P366
A 
Jaundice
Dark urine
Clay-colored stools (acholic stools)
Pruritus (itching)
Loss of appetite
Nausea
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26
Q

PATHOPHYSIOLOGY
What causes the itching in
obstructive jaundice?
P366

A

Bile salts in the dermis (not bilirubin!)

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27
Q

PATHOPHYSIOLOGY
Define the following terms:
Cholelithiasis
P366 (picture)

A

Gallstones in gallbladder

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28
Q

PATHOPHYSIOLOGY
Define the following terms:
Choledocholithiasis
P367 (picture)

A

Gallstone in common bile duct

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29
Q

PATHOPHYSIOLOGY
Define the following terms:
Cholecystitis
P367 (picture)

A

Inflammation of gallbladder

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30
Q

PATHOPHYSIOLOGY
Define the following terms:
Cholangitis
P367

A

Infection of biliary tract

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31
Q

PATHOPHYSIOLOGY
Define the following terms:
Cholangiocarcinoma
P367

A

Adenocarcinoma of bile ducts

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32
Q

PATHOPHYSIOLOGY
Define the following terms:
Klatskin’s tumor
P367

A

Cholangiocarcinoma of bile duct at the
junction of the right and left hepatic
ducts

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33
Q

PATHOPHYSIOLOGY
Define the following terms:
Biliary colic
P367

A

Pain from gallstones, usually from a stone
at cystic duct: The pain is located in the
RUQ, epigastrium, or right subscapular
region of the back; it usually lasts minutes
to hours but eventually goes away; it
is often postprandial, especially after
fatty foods

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34
Q

PATHOPHYSIOLOGY
Define the following terms:
Biloma
P368

A

Intraperitoneal bile fluid collection

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35
Q

PATHOPHYSIOLOGY
Define the following terms:
Choledochojejunostomy
P368

A

Anastomosis between common bile duct

and jejunum

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36
Q

PATHOPHYSIOLOGY
Define the following terms:
Hepaticojejunostomy
P368

A

Anastomosis of hepatic ducts or common

hepatic duct to jejunum

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37
Q 
DIAGNOSTIC STUDIES
What is the initial diagnostic
study of choice for evaluation
of the biliary tract/gallbladder/
cholelithiasis?
P368
A

Ultrasound!

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38
Q

DIAGNOSTIC STUDIES
Define the following diagnostic studies:
ERCP
P368

A

Endoscopic Retrograde

CholangioPancreatography

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39
Q

DIAGNOSTIC STUDIES
Define the following diagnostic studies:
PTC
P368

A

Percutaneous Transhepatic

Cholangiogram

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40
Q

DIAGNOSTIC STUDIES
Define the following diagnostic studies:
IOC
P368

A 
IntraOperative Cholangiogram (done
laparoscopically or open to rule out
choledocholithiasis)
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41
Q

DIAGNOSTIC STUDIES
Define the following diagnostic studies:
HIDA/PRIDA scan
P368

A

Radioisotope study; isotope concentrated
in liver and secreted into bile; will
demonstrate cholecystitis, bile leak, or
CBD obstruction

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42
Q

DIAGNOSTIC STUDIES
How does the HIDA scan
reveal cholecystitis?
P368

A

Non-opacification of the gallbladder from

obstruction of the cystic duct

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43
Q

DIAGNOSTIC STUDIES
How often will plain x-ray
films see gallstones?
P368

A

10% to 15%

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44
Q

BILIARY SURGERY
What is a cholecystectomy?
P368

A

Removal of the gallbladder
laparoscopically or through a standard
Kocher incision

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45
Q

BILIARY SURGERY
What is a “lap chole”?
P369 (picture)

A

LAParoscopic CHOLEcystectomy

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46
Q

BILIARY SURGERY
What is the Kocher incision?
P369

A

Right subcostal incision

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47
Q

BILIARY SURGERY
What is a sphincterotomy?
P369

A

Cut through sphincter of Oddi to allow
passage of gallstones from the common
bile duct; most often done at ERCP; also
known as papillotomy

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48
Q 
BILIARY SURGERY
How should postoperative
biloma be treated after a lap
chole?
P369
A
  1. Percutaneous drain bile collection
  2. ERCP with placement of biliary stent
    past leak (usually cystic duct remnant
    leak)
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49
Q 
BILIARY SURGERY
What is the treatment of
major CBD injury after a
lap chole?
P369
A

Choledochojejunostomy

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50
Q

BILIARY SURGERY
What is it?
P369

A

Jaundice (hyperbilirubinemia >2.5) from

obstruction of bile flow to the duodenum

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51
Q 
BILIARY SURGERY
What is the differential
diagnosis of proximal bile
duct obstruction?
P369
A 
Cholangiocarcinoma
Lymphadenopathy
Metastatic tumor
Gallbladder carcinoma
Sclerosing cholangitis
Gallstones
Tumor embolus
Parasites
Postsurgical stricture
Hepatoma
Benign bile duct tumor
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52
Q 
BILIARY SURGERY
What is the differential
diagnosis of distal bile duct
obstruction?
P370
A 
Choledocholithiasis (gallstones)
Pancreatic carcinoma
Pancreatitis
Ampullary carcinoma
Lymphadenopathy
Pseudocyst
Postsurgical stricture
Ampulla of Vater dysfunction/stricture
Lymphoma
Benign bile duct tumor
Parasites
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53
Q 
BILIARY SURGERY
What is the initial study
of choice for obstructive
jaundice?
P370
A

Ultrasound

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54
Q

BILIARY SURGERY
What lab results are associated
with obstructive jaundice?
P370

A

Elevated alkaline phosphatase, elevated

bilirubin with or without elevated LFTs

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55
Q

CHOLELITHIASIS
What is it?
P370

A

Formation of gallstones

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56
Q

CHOLELITHIASIS
What is the incidence?
P370

A

≈10% of U.S. population will develop

gallstones

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57
Q

CHOLELITHIASIS
What are the “Big 4” risk
factors?
P370

A 
The “four Fs”:
    Female
    Fat
    Forty
    Fertile (multiparity)
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58
Q

CHOLELITHIASIS
What are other less common
risk factors for gallstones?
P370

A 
Oral contraceptives
Bile stasis
Chronic hemolysis (pigment stones)
Cirrhosis
Infection
Native American heritage
Rapid weight loss/gastric bypass
Obesity
Inflammatory bowel disease (IBD)
Terminal ileal resection
Total parenteral nutrition (TPN)
Vagotomy
Advanced age
Hyperlipidemia
Somatostatin therapy
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59
Q

CHOLELITHIASIS
What are the types of
stones?
P371

A 
Cholesterol stones (75%)
Pigment stones (25%)
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60
Q

CHOLELITHIASIS
What are the types of
pigmented stones?
P371

A 
Black stones (contain calcium bilirubinate)
Brown stones (associated with biliary
tract infection)
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61
Q

CHOLELITHIASIS
What are the causes of
black-pigmented stones?
P371

A

Cirrhosis, hemolysis

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62
Q

CHOLELITHIASIS
What is the pathogenesis of
cholesterol stones?
P371

A

Secretion of bile supersaturated with
cholesterol (relatively decreased amounts
of lecithin and bile salts); then, cholesterol
precipitates out and forms solid crystals,
then gallstones

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63
Q

CHOLELITHIASIS
Is hypercholesterolemia a risk
factor for gallstone formation?
P371

A

No (but hyperlipidemia is)

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64
Q

CHOLELITHIASIS
What are the signs and
symptoms?
P371

A

Symptoms of: biliary colic, cholangitis,

choledocholithiasis, gallstone, pancreatitis

65
Q

CHOLELITHIASIS
Is biliary colic pain really
“colic”?
P371

A

No, symptoms usually last for hours;

therefore, colic is a misnomer

66
Q 
CHOLELITHIASIS
What percentage of
patients with gallstones are
asymptomatic?
P371
A

80% of patients with cholelithiasis are

asymptomatic!

67
Q

CHOLELITHIASIS
What is thought to cause
biliary colic?
P371

A

Gallbladder contraction against a stone
temporarily at the gallbladder/cystic duct
junction; a stone in the cystic duct; or a
stone passing through the cystic duct

68
Q

CHOLELITHIASIS
What is Boas’ sign?
P371

A

Referred right subscapular pain of biliary

colic

69
Q

CHOLELITHIASIS
What are the five major
complications of gallstones?
P371

A
  1. Acute cholecystitis
  2. Choledocholithiasis
  3. Gallstone pancreatitis
  4. Gallstone ileus
  5. Cholangitis
70
Q

CHOLELITHIASIS
How is cholelithiasis
diagnosed?
P372

A

History
Physical examination
Ultrasound

71
Q

CHOLELITHIASIS
How often does ultrasound
detect cholelithiasis?
P372

A

> 98% of the time!

72
Q

CHOLELITHIASIS
How often does ultrasound
detect choledocholithiasis?
P372

A

About 33% of the time . . . not a very

good study for choledocholithiasis!

73
Q 
CHOLELITHIASIS
How are symptomatic or
complicated cases of
cholelithiasis treated?
P372
A

By cholecystectomy

74
Q

CHOLELITHIASIS
What are the possible
complications of a lap chole?
P372

A

Common bile duct injury; right hepatic
duct/artery injury; cystic duct leak;
biloma (collection of bile)

75
Q 
CHOLELITHIASIS
What are the indications for
cholecystectomy in the
asymptomatic patient?
P372
A

Sickle-cell disease
Calcified gallbladder (porcelain
gallbladder)
Patient is a child

76
Q

CHOLELITHIASIS
Define IOC.
P372

A

IntraOperative Cholangiogram (dye in
bile duct by way of the cystic duct with
fluoro/x-ray)

77
Q

CHOLELITHIASIS
What are the indications for
an IOC (6)?
P372

A
  1. Jaundice
  2. Hyperbilirubinemia
  3. Gallstone pancreatitis (resolved)
  4. Elevated alkaline phosphatase
  5. Choledocholithiasis on ultrasound
  6. To define anatomy
78
Q

CHOLELITHIASIS
What is choledocholithiasis?
P372

A

Gallstones in the common bile duct

79
Q

CHOLELITHIASIS
What is the management of
choledocholithiasis?
P372

A 
1. ERCP with papillotomy and
    basket/balloon retrieval of stones
    (pre- or postoperatively)
2. Laparoscopic transcystic duct or trans
    common bile duct retrieval
3. Open common bile duct exploration
80
Q 
CHOLELITHIASIS
What medication may
dissolve a cholesterol
gallstone?
P372
A

Chenodeoxycholic acid, ursodeoxycholic
acid (Actigall®); but if medication is
stopped, gallstones often recur

81
Q

CHOLELITHIASIS
What is the major feared
complication of ERCP?
P373

A

Pancreatitis

82
Q

ACUTE CHOLECYSTITIS
What is the pathogenesis of
acute cholecystitis?
P373

A

Obstruction of cystic duct leads to
inflammation of the gallbladder; ≈95%
of cases result from calculi, and ≈5%
from acalculous obstruction

83
Q

ACUTE CHOLECYSTITIS
What are the risk factors?
P373

A

What are the risk factors?

84
Q

ACUTE CHOLECYSTITIS
What are the signs and
symptoms?
P373

A 
Unrelenting RUQ pain or tenderness
Fever
Nausea/vomiting
Painful palpable gallbladder in 33%
Positive Murphy’s sign
Right subscapular pain (referred)
Epigastric discomfort (referred)
85
Q

ACUTE CHOLECYSTITIS
What is Murphy’s sign?
P373

A

Acute pain and inspiratory arrest elicited

by palpation of the RUQ during inspiration

86
Q

ACUTE CHOLECYSTITIS
What are the complications
of acute cholecystitis?
P373

A 
Abscess
Perforation
Choledocholithiasis
Cholecystenteric fistula formation
Gallstone ileus
87
Q

ACUTE CHOLECYSTITIS
What lab results are
associated with acute cholecystitis?
P373

A

Increased WBC; may have:
Slight elevation in alkaline
phosphatase, LFTs
Slight elevation in amylase, T. Bili

88
Q 
ACUTE CHOLECYSTITIS
What is the diagnostic
test of choice for acute
cholecystitis?
P373
A

Ultrasound

89
Q

ACUTE CHOLECYSTITIS
What are the signs of acute
cholecystitis on ultrasound?
P373

A 
Thickened gallbladder wall (3 mm)
Pericholecystic fluid
Distended gallbladder
Gallstones present/cystic duct stone
Sonographic Murphy’s sign (pain on
    inspiration after placement of
    ultrasound probe over gallbladder)
90
Q 
ACUTE CHOLECYSTITIS
What is the difference
between acute cholecystitis
and biliary colic?
P374
A

Biliary colic has temporary pain; acute
cholecystitis has pain that does not resolve,
usually with elevated WBCs, fever, and
signs of acute inflammation on U/S

91
Q

ACUTE CHOLECYSTITIS
What is the treatment of
acute cholecystitis?
P374

A

IVFs, antibiotics, and cholecystectomy

early

92
Q

ACUTE CHOLECYSTITIS
What are the steps in lap
chole (6)?
P374

A 
1. Dissection of peritoneum overlying
    the cystic duct and artery
2. Clipping of cystic artery and transect
3. Division of cystic duct between clips
4. Dissection of gallbladder from the
    liver bed
5. Cauterization; irrigation; suction, to
    obtain hemostasis of the liver bed
6. Removal of the gallbladder through
    the umbilical trocar site
93
Q

ACUTE CHOLECYSTITIS
How is an IOC performed?
P374

A 
1. Place a clip on the cystic duct–
    gallbladder junction
2. Cut a small hole in the distal cystic
    duct to cannulate
3. Inject half-strength contrast and
    take an x-ray or fluoro
94
Q 
ACUTE CHOLECYSTITIS
What percentage of patients
has an accessory cystic
artery?
P374
95
Q 
ACUTE CHOLECYSTITIS
Why should the gallbladder
specimen be opened in the
operating room?
P374
A

Looking for gallbladder cancer, anatomy

96
Q

ACUTE ACALCULOUS CHOLECYSTITIS
What is it?
P374

A

Acute cholecystitis without evidence of

stones

97
Q

ACUTE ACALCULOUS CHOLECYSTITIS
What is the pathogenesis?
P374

A 
It is believed to result from sludge and
gallbladder disuse and biliary stasis,
perhaps secondary to absence of
cholecystokinin stimulation (decreased
contraction of gallbladder)
98
Q

ACUTE ACALCULOUS CHOLECYSTITIS
What are the risk factors?
P375

A 
Prolonged fasting
TPN
Trauma
Multiple transfusions
Dehydration
Often occurs in prolonged postoperative
    or ICU setting
99
Q

ACUTE ACALCULOUS CHOLECYSTITIS
What are the diagnostic tests
of choice?
P375

A
  1. Ultrasound; sludge and inflammation
    usually present with acute acalculous
    cholecystitis
  2. HIDA scan
100
Q

ACUTE ACALCULOUS CHOLECYSTITIS
What are the findings on
HIDA scan?
P375

A

Nonfilling of the gallbladder

101
Q 
ACUTE ACALCULOUS CHOLECYSTITIS
What is the management
of acute acalculous
cholecystitis?
P375
A

Cholecystectomy, or cholecystostomy
tube if the patient is unstable (placed
percutaneously by radiology or open
surgery)

102
Q

CHOLANGITIS
What is it?
P375

A

Bacterial infection of the biliary tract
from obstruction (either partial or
complete); potentially life-threatening

103
Q

CHOLANGITIS
What are the common
causes?
P375

A 
Choledocholithiasis
Stricture (usually postoperative)
Neoplasm (usually ampullary carcinoma)
Extrinsic compression (pancreatic
    pseudocyst/pancreatitis)
Instrumentation of the bile ducts (e.g.,
    PTC/ERCP)
Biliary stent
104
Q

CHOLANGITIS
What is the most common
cause of cholangitis?
P375

A

Gallstones in common bile duct

choledocholithiasis

105
Q

CHOLANGITIS
What are the signs and
symptoms?
P375

A

Charcot’s triad: fever/chills, RUQ pain,
and jaundice
Reynold’s pentad: Charcot’s triad plus
altered mental status and shock

106
Q

CHOLANGITIS
What lab results are associated
with cholangitis?
P375

A

Increased WBCs, bilirubin, and alkaline

phosphatase, positive blood cultures

107
Q 
CHOLANGITIS
Which organisms are most
commonly isolated with
cholangitis?
P376
A 
Gram-negative organisms (E. coli,
    Klebsiella, Pseudomonas, Enterobacter,
    Proteus, Serratia) are the most common
Enterococci are the most common
    gram-positive bacteria
Anaerobes are less common (B. fragilis
    most frequent)
Fungi are even less common (Candida)
108
Q

CHOLANGITIS
What are the diagnostic tests
of choice?
P376

A

Ultrasound and contrast study (e.g., ERCP
or IOC) after patient has “cooled off” with
IV antibiotics

109
Q

CHOLANGITIS
What is suppurative
cholangitis?
P376

A

Severe infection with sepsis—“pus under

pressure”

110
Q

CHOLANGITIS
What is the management of
cholangitis?
P376

A 
Nonsuppurative: IVF and antibiotics,
    with definitive treatment later (e.g.,
    lap chole +/– ERCP)
Suppurative: IVF, antibiotics, and
    decompression; decompression can be
    obtained by ERCP with papillotomy,
    PTC with catheter drainage, or
    laparotomy with T-tube placement
111
Q

SCLEROSING CHOLANGITIS
What is it?
P376

A

Multiple inflammatory fibrous
thickenings of bile duct walls resulting in
biliary strictures

112
Q

SCLEROSING CHOLANGITIS
What is its natural history?
P376

A

Progressive obstruction possibly leading
to cirrhosis and liver failure; 10% of
patients will develop cholangiocarcinoma

113
Q

SCLEROSING CHOLANGITIS
What is the etiology?
P376

A

Unknown, but probably autoimmune

114
Q

SCLEROSING CHOLANGITIS
What is the major risk
factor?
P376

A

Inflammatory bowel disease

115
Q

SCLEROSING CHOLANGITIS
What type of IBD is the
most common risk factor?
P376

A

Ulcerative colitis (≈66%)

116
Q 
SCLEROSING CHOLANGITIS
What are the signs and
symptoms of sclerosing
cholangitis?
P377
A 
Same as those for obstructive jaundice:
    Jaundice
    Itching (pruritus)
    Dark urine
    Clay-colored stools
    Loss of energy
    Weight loss
    (Many patients are asymptomatic)
117
Q

SCLEROSING CHOLANGITIS
What are the complications?
P377

A

Cirrhosis
Cholangiocarcinoma (10%)
Cholangitis
Obstructive jaundice

118
Q

SCLEROSING CHOLANGITIS
How is it diagnosed?
P377

A

Elevated alkaline phosphatase, and PTC
or ERCP revealing “beads on a string”
appearance on contrast study

119
Q

SCLEROSING CHOLANGITIS
What are the management
options?
P377

A 
Hepatoenteric anastomosis (if primarily
    extrahepatic ducts are involved)
    and resection of extrahepatic
    bile ducts because of the risk of
    cholangiocarcinoma
Transplant (if primarily intrahepatic
    disease or cirrhosis)
Endoscopic balloon dilations
120
Q 
SCLEROSING CHOLANGITIS
What percentage of patients
with IBD develops sclerosing
cholangitis?
P377
121
Q

GALLSTONE ILEUS
What is it?
P377

A

Small bowel obstruction from a large
gallstone ( >2.5 cm) that has eroded
through the gallbladder and into the
duodenum/small bowel

122
Q

GALLSTONE ILEUS
What is the classic site of
obstruction?
P377

A 
Ileocecal valve (but may cause
obstruction in the duodenum, sigmoid
colon)
123
Q

GALLSTONE ILEUS
What are the classic findings
of gallstone ileus?
P378 (picture)

A

(see Picture)

124
Q

GALLSTONE ILEUS
What is the population at
risk?
P378

A

Gallstone ileus is most commonly seen in

women older than 70 years

125
Q

GALLSTONE ILEUS
What are the signs/
symptoms?
P378

A

Symptoms of SBO: distention, vomiting,

hypovolemia, RUQ pain

126
Q

GALLSTONE ILEUS
Gallstone ileus causes what
percentage of cases of SBO?
P378

127
Q

GALLSTONE ILEUS
What are the diagnostic tests
of choice?
P378

A

Abdominal x-ray: occasionally reveals
radiopaque gallstone in the bowel;
40% of patients show air in the
biliary tract, small bowel distention,
and air fluid levels secondary to ileus
UGI: used if diagnosis is in question; will
show cholecystenteric fistula and the
obstruction
Abdominal CT: reveals air in biliary
tract, SBO +/– gallstone in intestine

128
Q

GALLSTONE ILEUS
What is the management?
P378

A

Surgery: enterotomy with removal of the

stone ± interval cholecystectomy (intervaldelayed)

129
Q

CARCINOMA OF THE GALLBLADDER
What is it?
P378

A

Malignant neoplasm arising in the
gallbladder, vast majority are
adenocarcinoma (90%)

130
Q

CARCINOMA OF THE GALLBLADDER
What are the risk factors?
P379

A

Gallstones, porcelain gallbladder,

cholecystenteric fistula

131
Q

CARCINOMA OF THE GALLBLADDER
What is the female:male ratio?
P379

132
Q 
CARCINOMA OF THE GALLBLADDER
What is the most common
site of gallbladder cancer in
the gallbladder?
P379
A

60% in fundus

133
Q

CARCINOMA OF THE GALLBLADDER
What is a porcelain
gallbladder?
P379

A

Calcified gallbladder

134
Q 
CARCINOMA OF THE GALLBLADDER
What percentage of patients
with a porcelain gallbladder
will have gallbladder cancer?
P379
A

≈50% (20%–60%)

135
Q

CARCINOMA OF THE GALLBLADDER
What is the incidence?
P379

A

≈1% of all gallbladder specimens

136
Q

CARCINOMA OF THE GALLBLADDER
What are the symptoms?
P379

A

Biliary colic, weight loss, anorexia; many
patients are asymptomatic until late; may
present as acute cholecystitis

137
Q

CARCINOMA OF THE GALLBLADDER
What are the signs?
P379

A

Jaundice (from invasion of the common duct
or compression by involved pericholedochal
lymph nodes), RUQ mass, palpable
gallbladder (advanced disease)

138
Q

CARCINOMA OF THE GALLBLADDER
What are the diagnostic tests
of choice?
P379

A

Ultrasound, abdominal CT, ERCP

139
Q

CARCINOMA OF THE GALLBLADDER
What is the route of spread?
P379

A

Contiguous spread to the liver is most

common

140
Q 
CARCINOMA OF THE GALLBLADDER
What is the management
under the following conditions?
Confined to mucosa
P379
A

Cholecystectomy

141
Q 
CARCINOMA OF THE GALLBLADDER
What is the management
under the following conditions?
Confined to muscularis/
serosa
P379
A

Radical cholecystectomy:
cholecystectomy and wedge resection
of overlying liver, and lymph node dissection
± chemotherapy/XRT

142
Q 
CARCINOMA OF THE GALLBLADDER
What is the main
complication of a lap chole
for gallbladder cancer?
P379
A

Trocar site tumor implants (Note: if
known preoperatively, perform open
cholecystectomy)

143
Q

CARCINOMA OF THE GALLBLADDER
What is the prognosis for
gallbladder cancer?
P380

A

Dismal overall: 5% 5-year survival as
most are unresectable at diagnosis
T1 with cholecystectomy: 95% 5-year
survival

144
Q

CHOLANGIOCARCINOMA
What is it?
P380

A

Malignancy of the extrahepatic or
intrahepatic ducts—primary bile duct
cancer

145
Q

CHOLANGIOCARCINOMA
What is the histology?
P380

A

Almost all are adenocarcinomas

146
Q

CHOLANGIOCARCINOMA
Average age at diagnosis?
P380

A

≈65 years, equally affects male/female

147
Q

CHOLANGIOCARCINOMA
What are the signs and
symptoms?
P380

A

Those of biliary obstruction: jaundice,
pruritus, dark urine, clay-colored
stools, cholangitis

148
Q

CHOLANGIOCARCINOMA
What is the most common
location?
P380

A

Proximal bile duct

149
Q

CHOLANGIOCARCINOMA
What are the risk factors?
P380

A 
Choledochal cysts
Ulcerative colitis
Thorotrast contrast dye (used in 1950s)
Sclerosing cholangitis
Liver flukes (clonorchiasis)
Toxin exposures (e.g., Agent Orange)
150
Q

CHOLANGIOCARCINOMA
What is a Klatskin tumor?
P380 (picture)

A

Tumor that involves the junction of the

right and left hepatic ducts

151
Q

CHOLANGIOCARCINOMA
What are the diagnostic tests
of choice?
P381

A

Ultrasound, CT scan, ERCP/PTC with

biopsy/brushings for cytology, MRCP

152
Q

CHOLANGIOCARCINOMA
What is an MRCP?
P381

A

MRI with visualization of pancreatic and

bile ducts

153
Q 
CHOLANGIOCARCINOMA
What is the management
of proximal bile duct
cholangiocarcinoma?
P381
A

Resection with Roux-en-Y hepaticojejunostomy
(anastomose bile ducts to
jejunum) ± unilateral hepatic lobectomy

154
Q 
CHOLANGIOCARCINOMA
What is the management of
distal common bile duct
cholangiocarcinoma?
P381
A

Whipple procedure

155
Q

MISCELLANEOUS CONDITIONS
What is a porcelain
gallbladder?
P381

A 
Calcified gallbladder seen on
abdominal x-ray; results from chronic
cholelithiasis/cholecystitis with
calcified scar tissue in gallbladder wall;
cholecystectomy required because of
the strong association of gallbladder
carcinoma with this condition
156
Q

MISCELLANEOUS CONDITIONS
What is hydrops of the
gallbladder?
P381

A

Complete obstruction of the cystic
duct by a gallstone, with filling of the
gallbladder with fluid (not bile) from the
gallbladder mucosa

157
Q

MISCELLANEOUS CONDITIONS
What is Gilbert’s syndrome?
P381

A

Inborn error in liver bilirubin uptake
and glucuronyl transferase resulting in
hyperbilirubinemia (Think: Gilbert’s =
Glucuronyl)

158
Q

MISCELLANEOUS CONDITIONS
What is Courvoisier’s
gallbladder?
P381

A

Palpable, nontender gallbladder (unlike
gallstone disease) associated with cancer
of the head of the pancreas; able to distend
because it has not been “scarred down”
by gallstones

159
Q

MISCELLANEOUS CONDITIONS
What is Mirizzi’s syndrome?
P381

A

Common hepatic duct obstruction as a
result of extrinsic compression from a
gallstone impacted in the cystic duct

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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