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*OldSurgery > Biliary Tract Disease > Flashcards

Biliary Tract Disease Flashcards

1
Q

who has a high incidence of cholesterol gallstones?

A 
mexican americans, American indian tribes 
women
multi-parity 
pregnancy
prolonged TPN
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2
Q

what continuously secretes bile?

A

liver

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3
Q

Between meals, _______ ___ ______contracts and diverts bile into gallbladder

A

sphincter of Oddi

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4
Q

______ stimulates contraction of the gallbladder and relaxation of the sphincter of Oddi in response to fats in duodenum

A

CCK

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5
Q

what stores and concentrates bile?

A

gallbladder

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6
Q

what are the most common biliary stones?

A

Mixed

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7
Q

what are stone from infected bile that usually present in the common bile duct (primary- formed w/i common bile duct)

A

brown stones

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8
Q

where do most stone that get in the primary bile duct come from?

A

gallbladder

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9
Q

what normally causes common bile duct stones?

A

stasis or infection

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10
Q

what will you see on US w/ cholecystitis?

A

posterior shadowing

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11
Q

when can you see gallstones on a plain film?

A

cholesterol and calcium

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12
Q

if you suspect GB disease what do you need to get?

A

US

no need for plain film or CT scan

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13
Q

what is the recommended tx for asymptomatic gallstones?

A

observation

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14
Q

what do you do for a person w/ cirrhosis with gallstones?

A

careful observation

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15
Q

when is a cholescystectomy recommended with hemolytic anemia?

A

at time of splenectomy

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16
Q

with somatonstatinoma when is a cholecystectomy recommened?

A

At time of tumor resection

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17
Q

what has a higher risk of gallbladder cancer and needs to be taken out?

A

calcified gallbaldder (porcelain gallbladder)

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18
Q

with obese patients undergoing bariatric surgery when should you remove the gallbladder

A

during the bariatric surgery as it adds minimal M and M

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19
Q

is there any inflammation with biliary colic?

A

none

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20
Q

how long does biliary colic last?

A

1-4 hours

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21
Q

what causes pain with biliary colic

A

pain is from distention of the gallbladder

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22
Q

location of biliary colic

A

RUQ, less likely epigastric. May go to back. May radiate to right shoulder

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23
Q

what are associations of biliary colic?

A

N/V

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24
Q

what will vitals be with for biliary colic?

A

normal

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25
Q

will there be a Murphy’s sign with biliary colic?

A

No, because there is no inflammation

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26
Q

what are precipitating factor for biliary colic?

A

large fatty meals

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27
Q

when do a lot of biliary colic patients present?

A

in between attacks so they will have a normal exam

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28
Q

if a person presents with biliary colic then goes away what should you do?

A

follow up as an outpatient w/ surgeon to have an elective cholecystectomy

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29
Q

what will biliary colic look like on US?

A

gallstones w/o GB wall thickening or pericholocystic fluid and nl CBD

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30
Q

what is gallbladder dysfunction

A

In pts with sx suggestive of biliary colic but no stones

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31
Q

what do you do on patients w/ gallbladder dysfunction?

A

nuclear cholescintigraphy (HIDA, PPIDA< radionuclide biliary scan w/ CCK stimulation) to evaluated GB ejection fraction

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32
Q

what is a normal GB ejection fraction?

A

Normal >35%

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33
Q

what causes acute cholecystitis?

A

Persistent stone impaction in the cystic duct causes the gallbladder to become distended and progressively inflamed

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34
Q

what associations are there with acute cholecystitis?

A

N/V, fever, chills

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35
Q

vitals w/ acute cholecystitis?

A

+/- fever, +/- tachycardia, +/- hypotension

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36
Q

what will LFTS probably look like w/ acute cholecystitis?

A

normal, could have minimal elevation

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37
Q

what will the CBD look like with acute cholecystitis?

A

normal

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38
Q

what will US look like w/ acute cholecystitis?

A

US - gallstones w/ distended GB

GB wall thickening, pericholocystic fluid and US Murphy’s sign

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39
Q

what will acute cholecytitis look like on abdominal exam?

A

tender mass in RUQ
localized guarding or rebound
+ US murphy’s sign

40
Q

TX for acute cholecystitis

A 
NPO
IV fluids
IV abx
IV pain meds
antiemetics
early cholecystectomy (w/i a few days of onset)
41
Q

what can you do for poor surgical canidates who have acute cholecystitis?

A

cholecystectomy tube

42
Q

what levels will differentiate acute cholecystitis and acute pancreatitis?

A

amylase, lipase

43
Q

what differes Perforated peptic ulcer from acute cholecystitis?

A

peritonitis

44
Q

what is the distinction b/w acute biliary colic and acute cholecystitis?

A

time. symptoms will not go away with acute cholecystitis

45
Q

who is acute acalculous cholecytistis common in?

A

patient who is acutely ill for other reasons

common in ICU patients

46
Q

what will you see on US w/ acute acalulous cholecystitis?

A

no stones but other findings of acute cholecystitis

47
Q

what test do you need to get for acute acalculous cholecystitis?

A

Nuclear cholescintigraphy (HIDA, PPIDA, radionuclide biliary scan)

48
Q

Tx for acute acalculous cholecystitis for a patient sick in the ICU

A

cholecystectomy tube

49
Q

Bacterial proliferation in the obstructed GB

A

empyema

50
Q

what is seen in empyema

A

high fever and leukocytosis

need early decompression (tube to drain pus)

51
Q

presentation w/ GB perforation?

A

high, fever, chills, rigors, septic shock

may have a fistula

52
Q

caused by gas forming oragnisms and higher chance of gangrene. More often in older patients, DM.

A

emphysematous cholecystitis

53
Q

Over-distended gallbladder with mucoid or clear and watery content
From gallstone disease
Non-inflammatory
presents similar to biliary colic w/ longer symptoms

A

hydrops (mucocele) of the gallbladder

54
Q

tx for emphysematous cholecystitis

A

emergency cholecystectomy after stabilization

55
Q

what is the gold standard for cholecsystectomy?

A

Laperoscopic cholecystectomy

56
Q

What are reasons you may need to open w/ a cholecystectomy?

A 
Adhesions
poor visualization of critical structures
 hemorrhage
bile duct injury
injury to another organ
57
Q

how is a patient positioning for a cholecystectomy?

A

patient supine w/ arms out

58
Q

where does the surgeon stand for a cholecystectomy?

A

on the left

assistant on right

59
Q

what is a Intraoperative Cholangiogram used for?

A

Used to identify CBD stones and delineate biliary anatomy

60
Q

border of triangle of calot?

A

Common hepatic duct, cystic duct, and edge of the liver

61
Q

complications of lap chole?

A 
CBD injury (serious)
bowel injury
bleeding
infection bile 
bile leak
62
Q

tiny ducts that drain from the liver into the body of the GB or cystic duct stump leak

A

duct of Luschka

63
Q

how do you evaluate a bile leak?

A

Evaluate with labs and PIPIDA +/- other imaging to look for fluid collection

64
Q

Tx for bile leak

A

Treated with perc drainage or ERCP stent placement or combination or surgical drain placement

65
Q

what is post-op cholecystectomy syndrome?

A

Epigastric or RUQ pain after cholecystectomy
40% of patients have minor GI complaints
Gas, bloating, abdominal pain, or diarrhea

66
Q

when does post-op cholecystectomy syndrome resolve?

A

a few weeks

if still have persistent symptoms probably due to a preop dx

67
Q

what is the term for Common bile duct stones

A

Choledocholehiasis

68
Q

where do most stones in the CBD come from?

A

GB

69
Q

symptoms of choledocholehiasis

A

intermittent jaundice

pain in RUQ= dull

70
Q

associated symptoms w/ choledocholethiasis

A

Pruritis, clay colored stools, tea colored urine

71
Q

what labs will be elevated with choledocholethiasis

A

elevated LFTs (alk pos and GGT)
mild elevation so AST and ALT
elevated conjugated bilirubin

72
Q

what will you see on US w/ choledocholethiasis?

A

gallstones +/- CBD stone. Dilated intra- and extra- hepatic ducts. Dilated CBD >6-8mm.

73
Q

the CBD should be how large?

A

a mm per decade

ex- 8 mm if in 80s

74
Q

what special imaging can you get for CBD stones?

A

MRCP- less invasive not therapeutic
ERCP- can grab stone
intraoperative cholangiogram (IOC)

75
Q

TX for CBD stones

A

lap chole to prevent future stones

76
Q

do CBD stones often pass on their own?

A

Yes- usually on a day or 2

look for bilirubin to go down

77
Q

if a stone doesn’t pass through the CBD what can be done?

A

ERCP with sphinterotomy and stone extraction may be performed if pt has lab or imaging finding concerning for CBD stones

78
Q

what is a septic process of the biliary tree?

A

acute ascending cholangitis

79
Q

most common cause of acute ascending cholangitis?

A 
CBD stones or benign strictures
malignancy
pancreatitis
mirizzi's syndrome
viral infection
parasitic infeciton
duodenal ulzer
80
Q

what is mirizzi’s syndrome

A

a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice.

81
Q

pain quality with acute ascending cholangitis

A

parietal, dull, aching

82
Q

what is Charcot’s triad

A

fever, jaundice, RUQ pain

associated w/ acute ascneding cholangitis

83
Q

what is REynold’s Pentad?

A

Charcot’s triad +
Mental status changes (Delirium)
Hypotension (Shock)

84
Q

immediate treatment for acute ascending cholangitis

A

NPO
IVFs
broad-spectrum abx

85
Q

drainage for acute ascendign cholangitis

A

ERCP (GI) or percutaneous transhepatic

- PTC (radiologist)

86
Q

a large gallstone (2 cm) causes a SBO by lodging in the distal ileus

A

gallstone ileus

87
Q

how does a large gallstone get from the gallbaldder into the small intestine?

A

fistula

88
Q

what will you see on imaging w/ a gallstone ileus

A

dilated small bowel
air within biliary tree
stone in terminal ileum

89
Q

Tx for gallstone ileus?

A

NGT
IVF
enterotomy w/ stone extraction +/- cholecystectomy and fistula repair
(often leave gallbladder and fistula alone)

90
Q

risk factors for gallbaldder cancer

A 
cholesterol stones
single large gallstone
porcelain GB
biliary slmonella typhi infection
biliary polyps <1cm
91
Q

symptoms of gallbaldder cancer (advanced)

A

vague RUQ pain
weight loss and malaise
jaundice in 50%
hard mass in RUQ (may be non-tender)

92
Q

what is cancer of the bile duct?

A

Cholangiocarcinoma

93
Q

tumor that Occur at the bifurcation of right and left hepatic ducts

A

Klatskin tumor

94
Q

risk factors for cholangiocarcinoma

A

UC
Sclerosing cholangitis
Choledochal cysts
Parasitic disease

95
Q

what is the most common symptoms of cholangiocarcinoma?

A 
progressive jaundice
pruritis
weight loss
abdominal pain
cholangitis
96
Q

what is curvoisier’s sign?

A

tumor blocks off common bile duct so everythign upstream is dilated
can feel their GB on PE
non-tender palpable GB

97
Q

what will a person with cholangiocarcinoma look like on PE?

A

yellow
hepatomegaly
curvoisier’s sign

*OldSurgery (22 decks)

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