Biliary Tree Surgical Recall Flashcards
what is the name of the node in Calot’s triangle
Calots Node
what are the small ducts that drain bile directly into the gallbladder from the liver
ducts of Luschka
which artery is susceptible to injury during a cholecystectomy? and Why
the right hepatic artery because it is close to calots triangle and the cystic artery
where is the infundibulum of the gallbladder?
near the cystic duct
where is the fundus of the gallbladder?
at the end of the gallbladder
what are the boundaries of the triangle of calot?
the 3 C’s
Cystic Duct
Cystic Artery
Common Hepatic Artery
what is the source of alkaline phosphatase?
common bile duct epithelium (elevated in common bile duct obstruction)
what is in bile?
cholesterol, lecithin, bile acids, bilirubin
what does bile do?
emulsify fat
what is the enterohepatic circulation
the circulation of bile acids from the liver to the gut and back to the liver
where are most of the bile acids absorbed
in the terminal ileum
what stimulates gallbladder emptying
cholecystokinin and vagal input
what is the source of cholecystokinin?
duodenal mucosal cells
what are the actions of the CCK?
gallbladder emptying, opening of the ampulla of water, slowing of gastric emptying, pancreas acing cell growth and release of exocrine products
At what level of serum total bilirubin does one start to get jaundiced?
2.5
classically what is thought to be the anatomic location where one first finds evidence of jaundice
under the tongue
what are the signs and symptoms of obstructive jaundice?
jaundice, dark urine, clay colored stools, pruritus, loss of appetite, nausea
what causes the itching in obstructive jaundice
bile salts in the dermis
cholelithiasis
gall stones in the gallbladder
choledocholithiasis
gallstones in the common bile duct
cholesytitis
inflammation of the gallbladder
cholangitis
infection of the biliary tract
cholangiocarcinoma
adenocarcinoma of the bile ducts
klatskins tumor
cholangiocarcinoma of bile duct at the junction of the right and left hepatic ducts
biliary colic
pain from gallstones from a stone in the cystic duct usually
pain is in the RUQ, epigastrium, or right sub scapular region go the back
usually postprandial especially after a fatty meal
lasts minutes to hours but eventually goes away
Biloma
intraperitoneal bile fluid collection
choledochojejunostomy
anatamosis between the common bile duct and jejunum
hepaticojejunostomy
anastomosis of hepatic ducts or common hepatic duct to the jejunum
what is the initial diagnostic study of choice for evaluation of biliary tract/gallbladder/cholelithiasis
ultrasound
ERCP
endoscopic retrograde cholangiopancreatography
PTC
percutaneous transhepatic cholangiogram
IOC
intraoperative cholangiogram (done laparoscopically to rule out choledocholitiasis)
HIDA/PRIDA scan?
radioisotope study where isotope is concentrated in the liver and secreted into bile and will demonstrate. cholecystitis, bile leak or CBD obstruction
how does the HIDA scan reveal cholecystitis ?
nonopacification of the gallbladder from obstruction of the cystic duct
what is a cholecystectomy and lap chole?
removal of the call bladder usually laparoscopically or through a standard kosher incision
lap chole- laparoscopic cholecystectomy
what is a sphincterotomy
cut through the sphincter of odd to allow passage of gallstones from the common bile duct
how should a postoperative biloma be treated after a lap chole
percutaneous drain bile collection
ERCP with placement of biliary stent past leak
what is the treatment of major CBD injury after a lap chole?
choledochojejunostomy
what is obstructive jaundice?
hyperbilirubinemia greater than 2.5 from obstruction of billow to the duodenum
what lab results are associated with obstructive jaundice?
elevated alkaline phosphatase, elevated bilirubin but NO elevated LFTs
cholelithiasis risk factos
the big 4
Female
Forty
Fat
Fertile
(fibrates-)
what are the types of stones and what are they composed of?
Cholesterol
and
Pigmented:
Black stones (calcium bilirubinate)
Brown stones (biliary tract infection)
causes of black stones
cirrhosis, hemolysis
pathogenesis of cholesterol stones
secretion of bile supersaturated with cholesterol allows it to precipitate out and form solid crystals then gallstones
signs and symptoms of cholelithiasis
biliary colic, cholangitis, choledocholitiashs, gallstone, pancreatitis
is biliary colic pain really colic
no symptoms usually last for hours so it is a misnomer
what percentage of patients with cholelithiasis are asymptomatic
80%
what is thought to cause biliary colic
gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction, a stone in the cystic duct or passing though the cystic duct
complications of gallstones?
acute cholecystitis
choledocholithiasis
gallstone pancreatitis
gallstone ielus
cholangitis
how is cholelithiasis diagnosed?
history
physical
US
how often does US detect choledocholitiasis
33%
how are symptomatic or complicated cases of cholithiasis treated
by cholecystectomy
complications of a lap chole
common bile duct injury, right hepatic duct injury, cystic duct leak, biloma
what are the indications for cholecystectomy in an asymptomatic patient
sickle cell disease
calcified gallbladder
patient is a child
management of choledocolithiasis
ERCP with papillotomy and basket retrieval of stones
what medication may dissolve cholesterol gallstones
chenodeoxycholic acid/ursodeoxycholic acid
major feared complication of ERCP
pancreatitis
what is the pathogenesis of acute cholecystitis?
obstruction of the cystic duct leads to inflammation of the gallbladder
risk factors for acute cholecystitis
gallstones
signs and symptoms of acute cholecystitis
unrelenting RUQ pain or tenderness
fever
N/V
postitive Murphys sign
right suscapular pain
epigastric discomfort
what is Murphy sign?
acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration
what are the complications of acute cholecystitis
abscess, perforation, choledocholithiasis, cholecystenteric fistula, gallstone ileus
labs for acute cholecystitis
increased WBC, elevated alkaline phosphatase, LFTs, amylase and bilirubin
diagnostic test for acute cholecystitis
ultrasound
what are the signs of acute cholecystitis on US
thickened gallbladder wall
pericholecystic fluid
distended gallbladder
gallstones/cystic duct stones
sonographic murphy sign
treatment of acute cholecystitis
IVFs, antibiotics, cholecystectomy, antibiotics- (pipericillin, tazobactam)
risk factors for acute acalculous cholecystitis
prolonged fast, TPN, trauma, dehydration, transfusions
US findings on acute acaluclous cholecystitis
sludge and inflammation
HIDA scan findings on HIDA scan
non filling of the gallbladder
management of acute aclaculous cholecystitis
cholecystectomy or cholecystostomy tube
causes of cholangitis
choledocolithiasis, stricture, neoplasm ,extrinsic compression, ERCP, biliary stent
what is the most common cause of cholangitis
gallstones in the common bile duct
symptoms of cholangitis
charcots triad: fever, chills, RUQ pain, jaundice
Reynolds pentad: fever/chills, RUQ pain, jaundice, AMS, shock (hypotension)
which organisms are most commonly isolated with cholangitis
gram negative organisms (ecoli, klebsiella, pseudomonas, enterobacter, serratia)
suppurative cholangitis
severe infection with sepsis
treatment of cholangitis
nonsuppurative: IVF, antibiotics + lap chole
suppurative: IVF, antibiotics, decompression
sclerosing cholangitis
inflammatory fibrous thickenings of the bile duct walls resulting in strictures
history of sclerosing cholangitis
progressive obstruction leading to cirrhosis and liver failure
can progress to cholangiocarcinoma (extra hepatic ducts)
risk factor for sclerosing cholangitis
inflammatory bowel disease
(ulcerative colitis)
symptoms of sclerosing cholangitis
jaundice, itching, dark urine, clay colored stools, loss of energy, weight loss
diagnosis of sclerosing cholangitis
elevated alkaline phosphatase, and PTC or ERCP with beads on a string appearance with contrast
management options for sclerosing cholangitis
hepatoenteric anastomosis and resection of extra hepatic bile ducts
gallstone ileus
small bowel obstruction from large gallstone that has eroded through the gallbladder into the duodenum/small bowel
classic site of obstruction for a gallstone ileus
ileocecal valve
findings of a gallstone ileus
air in the hepatic bile ducts
SBO ( distention, vomiting, RUQ pain, hypovolemia)with air fluid levels
women greater than 70
gallstone ileus Abdominal X ray findings
radiopaque gallstone in the bowel with air in the biliary tract
treatment of gallstone ileus
enterotomy with removal of the stone +/- cholecystectomy
most common type of gallbladder cancer
adenocarcinoma
risk factors for gall bladder adenocarcinoma
gallstones, porcelain gallbladder, cholecysteneric fistula
what is a porcelain gallbladder
calcified gallbladder (50% of people with this will get adenocarcinoma of the bladder)
symptoms of gallbladder carcinoma
biliary colic, weight loss, RUQ mass, jaundice, palpable gallbladder
what is the route of spread of gallbladder adenocarcinoma
contiguous spread to the liver
is gallbladder adenocarcinoma is confined to the mucosa how do you treat?
musclaric/serosa?
mucosa: cholecystectomy
musclaris/serosa: radical cholecystectomy (wedge resection)
what is cholangiocarcinoma
malignancy of the extrahepatic or intrahepatic ducts (primary bile duct cancer)
- adenocarcinoma
most common location for cholangiocarcinoma
proxmial bile duct
risk factors for cholangiocarcinoma
choledochal cysts
ulcerative colitis
thorotrast contrast dye
sclerosing cholangitis
liver fluks (clonorchiasis)
klatskin tumor
tumor at the junction of the right and left hepatic ducts
what is MRCP
MRI with visualization of pancreatic and bile ducts
what is the management of proximal bile duct cholangiocarcinoma
resection with Roux-en-Y hepaticojejunostomy
what is the management of distal common bile duct cholangiocarcinoma
Whipple procedure
