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Surgery > Biliary Tree Surgical Recall > Flashcards

Biliary Tree Surgical Recall Flashcards

1
Q

what is the name of the node in Calot’s triangle

A

Calots Node

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2
Q

what are the small ducts that drain bile directly into the gallbladder from the liver

A

ducts of Luschka

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3
Q

which artery is susceptible to injury during a cholecystectomy? and Why

A

the right hepatic artery because it is close to calots triangle and the cystic artery

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4
Q

where is the infundibulum of the gallbladder?

A

near the cystic duct

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5
Q

where is the fundus of the gallbladder?

A

at the end of the gallbladder

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6
Q

what are the boundaries of the triangle of calot?

A

the 3 C’s

Cystic Duct
Cystic Artery
Common Hepatic Artery

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7
Q

what is the source of alkaline phosphatase?

A

common bile duct epithelium (elevated in common bile duct obstruction)

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8
Q

what is in bile?

A

cholesterol, lecithin, bile acids, bilirubin

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9
Q

what does bile do?

A

emulsify fat

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10
Q

what is the enterohepatic circulation

A

the circulation of bile acids from the liver to the gut and back to the liver

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11
Q

where are most of the bile acids absorbed

A

in the terminal ileum

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12
Q

what stimulates gallbladder emptying

A

cholecystokinin and vagal input

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13
Q

what is the source of cholecystokinin?

A

duodenal mucosal cells

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14
Q

what are the actions of the CCK?

A

gallbladder emptying, opening of the ampulla of water, slowing of gastric emptying, pancreas acing cell growth and release of exocrine products

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15
Q

At what level of serum total bilirubin does one start to get jaundiced?

A

2.5

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16
Q

classically what is thought to be the anatomic location where one first finds evidence of jaundice

A

under the tongue

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17
Q

what are the signs and symptoms of obstructive jaundice?

A

jaundice, dark urine, clay colored stools, pruritus, loss of appetite, nausea

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18
Q

what causes the itching in obstructive jaundice

A

bile salts in the dermis

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19
Q

cholelithiasis

A

gall stones in the gallbladder

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20
Q

choledocholithiasis

A

gallstones in the common bile duct

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21
Q

cholesytitis

A

inflammation of the gallbladder

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22
Q

cholangitis

A

infection of the biliary tract

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23
Q

cholangiocarcinoma

A

adenocarcinoma of the bile ducts

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24
Q

klatskins tumor

A

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

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25
Q

biliary colic

A

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

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26
Q

Biloma

A

intraperitoneal bile fluid collection

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27
Q

choledochojejunostomy

A

anatamosis between the common bile duct and jejunum

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28
Q

hepaticojejunostomy

A

anastomosis of hepatic ducts or common hepatic duct to the jejunum

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29
Q

what is the initial diagnostic study of choice for evaluation of biliary tract/gallbladder/cholelithiasis

A

ultrasound

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30
Q

ERCP

A

endoscopic retrograde cholangiopancreatography

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31
Q

PTC

A

percutaneous transhepatic cholangiogram

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32
Q

IOC

A

intraoperative cholangiogram (done laparoscopically to rule out choledocholitiasis)

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33
Q

HIDA/PRIDA scan?

A

radioisotope study where isotope is concentrated in the liver and secreted into bile and will demonstrate. cholecystitis, bile leak or CBD obstruction

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34
Q

how does the HIDA scan reveal cholecystitis ?

A

nonopacification of the gallbladder from obstruction of the cystic duct

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35
Q

what is a cholecystectomy and lap chole?

A

removal of the call bladder usually laparoscopically or through a standard kosher incision

lap chole- laparoscopic cholecystectomy

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36
Q

what is a sphincterotomy

A

cut through the sphincter of odd to allow passage of gallstones from the common bile duct

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37
Q

how should a postoperative biloma be treated after a lap chole

A

percutaneous drain bile collection

ERCP with placement of biliary stent past leak

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38
Q

what is the treatment of major CBD injury after a lap chole?

A

choledochojejunostomy

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39
Q

what is obstructive jaundice?

A

hyperbilirubinemia greater than 2.5 from obstruction of billow to the duodenum

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40
Q

what lab results are associated with obstructive jaundice?

A

elevated alkaline phosphatase, elevated bilirubin but NO elevated LFTs

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41
Q

cholelithiasis risk factos

A

the big 4

Female
Forty
Fat
Fertile
(fibrates-)

42
Q

what are the types of stones and what are they composed of?

A

Cholesterol

and

Pigmented:
Black stones (calcium bilirubinate)
Brown stones (biliary tract infection)

43
Q

causes of black stones

A

cirrhosis, hemolysis

44
Q

pathogenesis of cholesterol stones

A

secretion of bile supersaturated with cholesterol allows it to precipitate out and form solid crystals then gallstones

45
Q

signs and symptoms of cholelithiasis

A

biliary colic, cholangitis, choledocholitiashs, gallstone, pancreatitis

46
Q

is biliary colic pain really colic

A

no symptoms usually last for hours so it is a misnomer

47
Q

what percentage of patients with cholelithiasis are asymptomatic

A

80%

48
Q

what is thought to cause biliary colic

A

gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction, a stone in the cystic duct or passing though the cystic duct

49
Q

complications of gallstones?

A

acute cholecystitis

choledocholithiasis

gallstone pancreatitis

gallstone ielus

cholangitis

50
Q

how is cholelithiasis diagnosed?

A

history
physical
US

51
Q

how often does US detect choledocholitiasis

A

33%

52
Q

how are symptomatic or complicated cases of cholithiasis treated

A

by cholecystectomy

53
Q

complications of a lap chole

A

common bile duct injury, right hepatic duct injury, cystic duct leak, biloma

54
Q

what are the indications for cholecystectomy in an asymptomatic patient

A

sickle cell disease
calcified gallbladder
patient is a child

55
Q

management of choledocolithiasis

A

ERCP with papillotomy and basket retrieval of stones

56
Q

what medication may dissolve cholesterol gallstones

A

chenodeoxycholic acid/ursodeoxycholic acid

57
Q

major feared complication of ERCP

A

pancreatitis

58
Q

what is the pathogenesis of acute cholecystitis?

A

obstruction of the cystic duct leads to inflammation of the gallbladder

59
Q

risk factors for acute cholecystitis

A

gallstones

60
Q

signs and symptoms of acute cholecystitis

A

unrelenting RUQ pain or tenderness

fever

N/V

postitive Murphys sign

right suscapular pain
epigastric discomfort

61
Q

what is Murphy sign?

A

acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

62
Q

what are the complications of acute cholecystitis

A

abscess, perforation, choledocholithiasis, cholecystenteric fistula, gallstone ileus

63
Q

labs for acute cholecystitis

A

increased WBC, elevated alkaline phosphatase, LFTs, amylase and bilirubin

64
Q

diagnostic test for acute cholecystitis

A

ultrasound

65
Q

what are the signs of acute cholecystitis on US

A

thickened gallbladder wall

pericholecystic fluid

distended gallbladder

gallstones/cystic duct stones

sonographic murphy sign

66
Q

treatment of acute cholecystitis

A

IVFs, antibiotics, cholecystectomy, antibiotics- (pipericillin, tazobactam)

67
Q

risk factors for acute acalculous cholecystitis

A

prolonged fast, TPN, trauma, dehydration, transfusions

68
Q

US findings on acute acaluclous cholecystitis

A

sludge and inflammation

69
Q

HIDA scan findings on HIDA scan

A

non filling of the gallbladder

70
Q

management of acute aclaculous cholecystitis

A

cholecystectomy or cholecystostomy tube

71
Q

causes of cholangitis

A

choledocolithiasis, stricture, neoplasm ,extrinsic compression, ERCP, biliary stent

72
Q

what is the most common cause of cholangitis

A

gallstones in the common bile duct

73
Q

symptoms of cholangitis

A

charcots triad: fever, chills, RUQ pain, jaundice

Reynolds pentad: fever/chills, RUQ pain, jaundice, AMS, shock (hypotension)

74
Q

which organisms are most commonly isolated with cholangitis

A

gram negative organisms (ecoli, klebsiella, pseudomonas, enterobacter, serratia)

75
Q

suppurative cholangitis

A

severe infection with sepsis

76
Q

treatment of cholangitis

A

nonsuppurative: IVF, antibiotics + lap chole

suppurative: IVF, antibiotics, decompression

77
Q

sclerosing cholangitis

A

inflammatory fibrous thickenings of the bile duct walls resulting in strictures

78
Q

history of sclerosing cholangitis

A

progressive obstruction leading to cirrhosis and liver failure

can progress to cholangiocarcinoma (extra hepatic ducts)

79
Q

risk factor for sclerosing cholangitis

A

inflammatory bowel disease

(ulcerative colitis)

80
Q

symptoms of sclerosing cholangitis

A

jaundice, itching, dark urine, clay colored stools, loss of energy, weight loss

81
Q

diagnosis of sclerosing cholangitis

A

elevated alkaline phosphatase, and PTC or ERCP with beads on a string appearance with contrast

82
Q

management options for sclerosing cholangitis

A

hepatoenteric anastomosis and resection of extra hepatic bile ducts

83
Q

gallstone ileus

A

small bowel obstruction from large gallstone that has eroded through the gallbladder into the duodenum/small bowel

84
Q

classic site of obstruction for a gallstone ileus

A

ileocecal valve

85
Q

findings of a gallstone ileus

A

air in the hepatic bile ducts

SBO ( distention, vomiting, RUQ pain, hypovolemia)with air fluid levels

women greater than 70

86
Q

gallstone ileus Abdominal X ray findings

A

radiopaque gallstone in the bowel with air in the biliary tract

87
Q

treatment of gallstone ileus

A

enterotomy with removal of the stone +/- cholecystectomy

88
Q

most common type of gallbladder cancer

A

adenocarcinoma

89
Q

risk factors for gall bladder adenocarcinoma

A

gallstones, porcelain gallbladder, cholecysteneric fistula

90
Q

what is a porcelain gallbladder

A

calcified gallbladder (50% of people with this will get adenocarcinoma of the bladder)

91
Q

symptoms of gallbladder carcinoma

A

biliary colic, weight loss, RUQ mass, jaundice, palpable gallbladder

92
Q

what is the route of spread of gallbladder adenocarcinoma

A

contiguous spread to the liver

93
Q

is gallbladder adenocarcinoma is confined to the mucosa how do you treat?

musclaric/serosa?

A

mucosa: cholecystectomy

musclaris/serosa: radical cholecystectomy (wedge resection)

94
Q

what is cholangiocarcinoma

A

malignancy of the extrahepatic or intrahepatic ducts (primary bile duct cancer)

  • adenocarcinoma
95
Q

most common location for cholangiocarcinoma

A

proxmial bile duct

96
Q

risk factors for cholangiocarcinoma

A

choledochal cysts
ulcerative colitis
thorotrast contrast dye
sclerosing cholangitis
liver fluks (clonorchiasis)

97
Q

klatskin tumor

A

tumor at the junction of the right and left hepatic ducts

98
Q

what is MRCP

A

MRI with visualization of pancreatic and bile ducts

99
Q

what is the management of proximal bile duct cholangiocarcinoma

A

resection with Roux-en-Y hepaticojejunostomy

100
Q

what is the management of distal common bile duct cholangiocarcinoma

A

Whipple procedure

Surgery (3 decks)

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