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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
``` PATHOPHYSIOLOGY What are the signs and symptoms of obstructive jaundice? P366 ```
``` Jaundice Dark urine Clay-colored stools (acholic stools) Pruritus (itching) Loss of appetite Nausea ```
26
PATHOPHYSIOLOGY What causes the itching in obstructive jaundice? P366
Bile salts in the dermis (not bilirubin!)
27
PATHOPHYSIOLOGY Define the following terms: Cholelithiasis P366 (picture)
Gallstones in gallbladder
28
PATHOPHYSIOLOGY Define the following terms: Choledocholithiasis P367 (picture)
Gallstone in common bile duct
29
PATHOPHYSIOLOGY Define the following terms: Cholecystitis P367 (picture)
Inflammation of gallbladder
30
PATHOPHYSIOLOGY Define the following terms: Cholangitis P367
Infection of biliary tract
31
PATHOPHYSIOLOGY Define the following terms: Cholangiocarcinoma P367
Adenocarcinoma of bile ducts
32
PATHOPHYSIOLOGY Define the following terms: Klatskin’s tumor P367
Cholangiocarcinoma of bile duct at the junction of the right and left hepatic ducts
33
PATHOPHYSIOLOGY Define the following terms: Biliary colic P367
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
34
PATHOPHYSIOLOGY Define the following terms: Biloma P368
Intraperitoneal bile fluid collection
35
PATHOPHYSIOLOGY Define the following terms: Choledochojejunostomy P368
Anastomosis between common bile duct | and jejunum
36
PATHOPHYSIOLOGY Define the following terms: Hepaticojejunostomy P368
Anastomosis of hepatic ducts or common | hepatic duct to jejunum
37
``` DIAGNOSTIC STUDIES What is the initial diagnostic study of choice for evaluation of the biliary tract/gallbladder/ cholelithiasis? P368 ```
Ultrasound!
38
DIAGNOSTIC STUDIES Define the following diagnostic studies: ERCP P368
Endoscopic Retrograde | CholangioPancreatography
39
DIAGNOSTIC STUDIES Define the following diagnostic studies: PTC P368
Percutaneous Transhepatic | Cholangiogram
40
DIAGNOSTIC STUDIES Define the following diagnostic studies: IOC P368
``` IntraOperative Cholangiogram (done laparoscopically or open to rule out choledocholithiasis) ```
41
DIAGNOSTIC STUDIES Define the following diagnostic studies: HIDA/PRIDA scan P368
Radioisotope study; isotope concentrated in liver and secreted into bile; will demonstrate cholecystitis, bile leak, or CBD obstruction
42
DIAGNOSTIC STUDIES How does the HIDA scan reveal cholecystitis? P368
Non-opacification of the gallbladder from | obstruction of the cystic duct
43
DIAGNOSTIC STUDIES How often will plain x-ray films see gallstones? P368
10% to 15%
44
BILIARY SURGERY What is a cholecystectomy? P368
Removal of the gallbladder laparoscopically or through a standard Kocher incision
45
BILIARY SURGERY What is a “lap chole”? P369 (picture)
LAParoscopic CHOLEcystectomy
46
BILIARY SURGERY What is the Kocher incision? P369
Right subcostal incision
47
BILIARY SURGERY What is a sphincterotomy? P369
Cut through sphincter of Oddi to allow passage of gallstones from the common bile duct; most often done at ERCP; also known as papillotomy
48
``` BILIARY SURGERY How should postoperative biloma be treated after a lap chole? P369 ```
1. Percutaneous drain bile collection 2. ERCP with placement of biliary stent past leak (usually cystic duct remnant leak)
49
``` BILIARY SURGERY What is the treatment of major CBD injury after a lap chole? P369 ```
Choledochojejunostomy
50
BILIARY SURGERY What is it? P369
Jaundice (hyperbilirubinemia >2.5) from | obstruction of bile flow to the duodenum
51
``` BILIARY SURGERY What is the differential diagnosis of proximal bile duct obstruction? P369 ```
``` Cholangiocarcinoma Lymphadenopathy Metastatic tumor Gallbladder carcinoma Sclerosing cholangitis Gallstones Tumor embolus Parasites Postsurgical stricture Hepatoma Benign bile duct tumor ```
52
``` BILIARY SURGERY What is the differential diagnosis of distal bile duct obstruction? P370 ```
``` Choledocholithiasis (gallstones) Pancreatic carcinoma Pancreatitis Ampullary carcinoma Lymphadenopathy Pseudocyst Postsurgical stricture Ampulla of Vater dysfunction/stricture Lymphoma Benign bile duct tumor Parasites ```
53
``` BILIARY SURGERY What is the initial study of choice for obstructive jaundice? P370 ```
Ultrasound
54
BILIARY SURGERY What lab results are associated with obstructive jaundice? P370
Elevated alkaline phosphatase, elevated | bilirubin with or without elevated LFTs
55
CHOLELITHIASIS What is it? P370
Formation of gallstones
56
CHOLELITHIASIS What is the incidence? P370
≈10% of U.S. population will develop | gallstones
57
CHOLELITHIASIS What are the “Big 4” risk factors? P370
``` The “four Fs”: Female Fat Forty Fertile (multiparity) ```
58
CHOLELITHIASIS What are other less common risk factors for gallstones? P370
``` 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 ```
59
CHOLELITHIASIS What are the types of stones? P371
``` Cholesterol stones (75%) Pigment stones (25%) ```
60
CHOLELITHIASIS What are the types of pigmented stones? P371
``` Black stones (contain calcium bilirubinate) Brown stones (associated with biliary tract infection) ```
61
CHOLELITHIASIS What are the causes of black-pigmented stones? P371
Cirrhosis, hemolysis
62
CHOLELITHIASIS What is the pathogenesis of cholesterol stones? P371
Secretion of bile supersaturated with cholesterol (relatively decreased amounts of lecithin and bile salts); then, cholesterol precipitates out and forms solid crystals, then gallstones
63
CHOLELITHIASIS Is hypercholesterolemia a risk factor for gallstone formation? P371
No (but hyperlipidemia is)
64
CHOLELITHIASIS What are the signs and symptoms? P371
Symptoms of: biliary colic, cholangitis, | choledocholithiasis, gallstone, pancreatitis
65
CHOLELITHIASIS Is biliary colic pain really “colic”? P371
No, symptoms usually last for hours; | therefore, colic is a misnomer
66
``` CHOLELITHIASIS What percentage of patients with gallstones are asymptomatic? P371 ```
80% of patients with cholelithiasis are | asymptomatic!
67
CHOLELITHIASIS What is thought to cause biliary colic? P371
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
CHOLELITHIASIS What is Boas’ sign? P371
Referred right subscapular pain of biliary | colic
69
CHOLELITHIASIS What are the five major complications of gallstones? P371
1. Acute cholecystitis 2. Choledocholithiasis 3. Gallstone pancreatitis 4. Gallstone ileus 5. Cholangitis
70
CHOLELITHIASIS How is cholelithiasis diagnosed? P372
History Physical examination Ultrasound
71
CHOLELITHIASIS How often does ultrasound detect cholelithiasis? P372
> 98% of the time!
72
CHOLELITHIASIS How often does ultrasound detect choledocholithiasis? P372
About 33% of the time . . . not a very | good study for choledocholithiasis!
73
``` CHOLELITHIASIS How are symptomatic or complicated cases of cholelithiasis treated? P372 ```
By cholecystectomy
74
CHOLELITHIASIS What are the possible complications of a lap chole? P372
Common bile duct injury; right hepatic duct/artery injury; cystic duct leak; biloma (collection of bile)
75
``` CHOLELITHIASIS What are the indications for cholecystectomy in the asymptomatic patient? P372 ```
Sickle-cell disease Calcified gallbladder (porcelain gallbladder) Patient is a child
76
CHOLELITHIASIS Define IOC. P372
IntraOperative Cholangiogram (dye in bile duct by way of the cystic duct with fluoro/x-ray)
77
CHOLELITHIASIS What are the indications for an IOC (6)? P372
1. Jaundice 2. Hyperbilirubinemia 3. Gallstone pancreatitis (resolved) 4. Elevated alkaline phosphatase 5. Choledocholithiasis on ultrasound 6. To define anatomy
78
CHOLELITHIASIS What is choledocholithiasis? P372
Gallstones in the common bile duct
79
CHOLELITHIASIS What is the management of choledocholithiasis? P372
``` 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
``` CHOLELITHIASIS What medication may dissolve a cholesterol gallstone? P372 ```
Chenodeoxycholic acid, ursodeoxycholic acid (Actigall®); but if medication is stopped, gallstones often recur
81
CHOLELITHIASIS What is the major feared complication of ERCP? P373
Pancreatitis
82
ACUTE CHOLECYSTITIS What is the pathogenesis of acute cholecystitis? P373
Obstruction of cystic duct leads to inflammation of the gallbladder; ≈95% of cases result from calculi, and ≈5% from acalculous obstruction
83
ACUTE CHOLECYSTITIS What are the risk factors? P373
What are the risk factors?
84
ACUTE CHOLECYSTITIS What are the signs and symptoms? P373
``` 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
ACUTE CHOLECYSTITIS What is Murphy’s sign? P373
Acute pain and inspiratory arrest elicited | by palpation of the RUQ during inspiration
86
ACUTE CHOLECYSTITIS What are the complications of acute cholecystitis? P373
``` Abscess Perforation Choledocholithiasis Cholecystenteric fistula formation Gallstone ileus ```
87
ACUTE CHOLECYSTITIS What lab results are associated with acute cholecystitis? P373
Increased WBC; may have: Slight elevation in alkaline phosphatase, LFTs Slight elevation in amylase, T. Bili
88
``` ACUTE CHOLECYSTITIS What is the diagnostic test of choice for acute cholecystitis? P373 ```
Ultrasound
89
ACUTE CHOLECYSTITIS What are the signs of acute cholecystitis on ultrasound? P373
``` 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
``` ACUTE CHOLECYSTITIS What is the difference between acute cholecystitis and biliary colic? P374 ```
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
ACUTE CHOLECYSTITIS What is the treatment of acute cholecystitis? P374
IVFs, antibiotics, and cholecystectomy | early
92
ACUTE CHOLECYSTITIS What are the steps in lap chole (6)? P374
``` 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
ACUTE CHOLECYSTITIS How is an IOC performed? P374
``` 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
``` ACUTE CHOLECYSTITIS What percentage of patients has an accessory cystic artery? P374 ```
10%
95
``` ACUTE CHOLECYSTITIS Why should the gallbladder specimen be opened in the operating room? P374 ```
Looking for gallbladder cancer, anatomy
96
ACUTE ACALCULOUS CHOLECYSTITIS What is it? P374
Acute cholecystitis without evidence of | stones
97
ACUTE ACALCULOUS CHOLECYSTITIS What is the pathogenesis? P374
``` 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
ACUTE ACALCULOUS CHOLECYSTITIS What are the risk factors? P375
``` Prolonged fasting TPN Trauma Multiple transfusions Dehydration Often occurs in prolonged postoperative or ICU setting ```
99
ACUTE ACALCULOUS CHOLECYSTITIS What are the diagnostic tests of choice? P375
1. Ultrasound; sludge and inflammation usually present with acute acalculous cholecystitis 2. HIDA scan
100
ACUTE ACALCULOUS CHOLECYSTITIS What are the findings on HIDA scan? P375
Nonfilling of the gallbladder
101
``` ACUTE ACALCULOUS CHOLECYSTITIS What is the management of acute acalculous cholecystitis? P375 ```
Cholecystectomy, or cholecystostomy tube if the patient is unstable (placed percutaneously by radiology or open surgery)
102
CHOLANGITIS What is it? P375
Bacterial infection of the biliary tract from obstruction (either partial or complete); potentially life-threatening
103
CHOLANGITIS What are the common causes? P375
``` 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
CHOLANGITIS What is the most common cause of cholangitis? P375
Gallstones in common bile duct | choledocholithiasis
105
CHOLANGITIS What are the signs and symptoms? P375
Charcot’s triad: fever/chills, RUQ pain, and jaundice Reynold’s pentad: Charcot’s triad plus altered mental status and shock
106
CHOLANGITIS What lab results are associated with cholangitis? P375
Increased WBCs, bilirubin, and alkaline | phosphatase, positive blood cultures
107
``` CHOLANGITIS Which organisms are most commonly isolated with cholangitis? P376 ```
``` 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
CHOLANGITIS What are the diagnostic tests of choice? P376
Ultrasound and contrast study (e.g., ERCP or IOC) after patient has “cooled off” with IV antibiotics
109
CHOLANGITIS What is suppurative cholangitis? P376
Severe infection with sepsis—“pus under | pressure”
110
CHOLANGITIS What is the management of cholangitis? P376
``` 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
SCLEROSING CHOLANGITIS What is it? P376
Multiple inflammatory fibrous thickenings of bile duct walls resulting in biliary strictures
112
SCLEROSING CHOLANGITIS What is its natural history? P376
Progressive obstruction possibly leading to cirrhosis and liver failure; 10% of patients will develop cholangiocarcinoma
113
SCLEROSING CHOLANGITIS What is the etiology? P376
Unknown, but probably autoimmune
114
SCLEROSING CHOLANGITIS What is the major risk factor? P376
Inflammatory bowel disease
115
SCLEROSING CHOLANGITIS What type of IBD is the most common risk factor? P376
Ulcerative colitis (≈66%)
116
``` SCLEROSING CHOLANGITIS What are the signs and symptoms of sclerosing cholangitis? P377 ```
``` Same as those for obstructive jaundice: Jaundice Itching (pruritus) Dark urine Clay-colored stools Loss of energy Weight loss (Many patients are asymptomatic) ```
117
SCLEROSING CHOLANGITIS What are the complications? P377
Cirrhosis Cholangiocarcinoma (10%) Cholangitis Obstructive jaundice
118
SCLEROSING CHOLANGITIS How is it diagnosed? P377
Elevated alkaline phosphatase, and PTC or ERCP revealing “beads on a string” appearance on contrast study
119
SCLEROSING CHOLANGITIS What are the management options? P377
``` 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
``` SCLEROSING CHOLANGITIS What percentage of patients with IBD develops sclerosing cholangitis? P377 ```
< 5%
121
GALLSTONE ILEUS What is it? P377
Small bowel obstruction from a large gallstone ( >2.5 cm) that has eroded through the gallbladder and into the duodenum/small bowel
122
GALLSTONE ILEUS What is the classic site of obstruction? P377
``` Ileocecal valve (but may cause obstruction in the duodenum, sigmoid colon) ```
123
GALLSTONE ILEUS What are the classic findings of gallstone ileus? P378 (picture)
(see Picture)
124
GALLSTONE ILEUS What is the population at risk? P378
Gallstone ileus is most commonly seen in | women older than 70 years
125
GALLSTONE ILEUS What are the signs/ symptoms? P378
Symptoms of SBO: distention, vomiting, | hypovolemia, RUQ pain
126
GALLSTONE ILEUS Gallstone ileus causes what percentage of cases of SBO? P378
< 1%
127
GALLSTONE ILEUS What are the diagnostic tests of choice? P378
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
GALLSTONE ILEUS What is the management? P378
Surgery: enterotomy with removal of the | stone ± interval cholecystectomy (intervaldelayed)
129
CARCINOMA OF THE GALLBLADDER What is it? P378
Malignant neoplasm arising in the gallbladder, vast majority are adenocarcinoma (90%)
130
CARCINOMA OF THE GALLBLADDER What are the risk factors? P379
Gallstones, porcelain gallbladder, | cholecystenteric fistula
131
CARCINOMA OF THE GALLBLADDER What is the female:male ratio? P379
4:1
132
``` CARCINOMA OF THE GALLBLADDER What is the most common site of gallbladder cancer in the gallbladder? P379 ```
60% in fundus
133
CARCINOMA OF THE GALLBLADDER What is a porcelain gallbladder? P379
Calcified gallbladder
134
``` CARCINOMA OF THE GALLBLADDER What percentage of patients with a porcelain gallbladder will have gallbladder cancer? P379 ```
≈50% (20%–60%)
135
CARCINOMA OF THE GALLBLADDER What is the incidence? P379
≈1% of all gallbladder specimens
136
CARCINOMA OF THE GALLBLADDER What are the symptoms? P379
Biliary colic, weight loss, anorexia; many patients are asymptomatic until late; may present as acute cholecystitis
137
CARCINOMA OF THE GALLBLADDER What are the signs? P379
Jaundice (from invasion of the common duct or compression by involved pericholedochal lymph nodes), RUQ mass, palpable gallbladder (advanced disease)
138
CARCINOMA OF THE GALLBLADDER What are the diagnostic tests of choice? P379
Ultrasound, abdominal CT, ERCP
139
CARCINOMA OF THE GALLBLADDER What is the route of spread? P379
Contiguous spread to the liver is most | common
140
``` CARCINOMA OF THE GALLBLADDER What is the management under the following conditions? Confined to mucosa P379 ```
Cholecystectomy
141
``` CARCINOMA OF THE GALLBLADDER What is the management under the following conditions? Confined to muscularis/ serosa P379 ```
Radical cholecystectomy: cholecystectomy and wedge resection of overlying liver, and lymph node dissection  ± chemotherapy/XRT
142
``` CARCINOMA OF THE GALLBLADDER What is the main complication of a lap chole for gallbladder cancer? P379 ```
Trocar site tumor implants (Note: if known preoperatively, perform open cholecystectomy)
143
CARCINOMA OF THE GALLBLADDER What is the prognosis for gallbladder cancer? P380
Dismal overall: 5% 5-year survival as most are unresectable at diagnosis T1 with cholecystectomy: 95% 5-year survival
144
CHOLANGIOCARCINOMA What is it? P380
Malignancy of the extrahepatic or intrahepatic ducts—primary bile duct cancer
145
CHOLANGIOCARCINOMA What is the histology? P380
Almost all are adenocarcinomas
146
CHOLANGIOCARCINOMA Average age at diagnosis? P380
≈65 years, equally affects male/female
147
CHOLANGIOCARCINOMA What are the signs and symptoms? P380
Those of biliary obstruction: jaundice, pruritus, dark urine, clay-colored stools, cholangitis
148
CHOLANGIOCARCINOMA What is the most common location? P380
Proximal bile duct
149
CHOLANGIOCARCINOMA What are the risk factors? P380
``` Choledochal cysts Ulcerative colitis Thorotrast contrast dye (used in 1950s) Sclerosing cholangitis Liver flukes (clonorchiasis) Toxin exposures (e.g., Agent Orange) ```
150
CHOLANGIOCARCINOMA What is a Klatskin tumor? P380 (picture)
Tumor that involves the junction of the | right and left hepatic ducts
151
CHOLANGIOCARCINOMA What are the diagnostic tests of choice? P381
Ultrasound, CT scan, ERCP/PTC with | biopsy/brushings for cytology, MRCP
152
CHOLANGIOCARCINOMA What is an MRCP? P381
MRI with visualization of pancreatic and | bile ducts
153
``` CHOLANGIOCARCINOMA What is the management of proximal bile duct cholangiocarcinoma? P381 ```
Resection with Roux-en-Y hepaticojejunostomy (anastomose bile ducts to jejunum) ± unilateral hepatic lobectomy
154
``` CHOLANGIOCARCINOMA What is the management of distal common bile duct cholangiocarcinoma? P381 ```
Whipple procedure
155
MISCELLANEOUS CONDITIONS What is a porcelain gallbladder? P381
``` 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
MISCELLANEOUS CONDITIONS What is hydrops of the gallbladder? P381
Complete obstruction of the cystic duct by a gallstone, with filling of the gallbladder with fluid (not bile) from the gallbladder mucosa
157
MISCELLANEOUS CONDITIONS What is Gilbert’s syndrome? P381
Inborn error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia (Think: Gilbert’s = Glucuronyl)
158
MISCELLANEOUS CONDITIONS What is Courvoisier’s gallbladder? P381
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
MISCELLANEOUS CONDITIONS What is Mirizzi’s syndrome? P381
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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