Calculous Biliary Disease

Question 1

Which hormone is responsible gallbladder constriction and therefore for biliary colic

Answer 1

CCK - Cholecystokinin
synthesized and secreted by enteroendocrine cells in the duodenum. Its presence causes the release of digestive enzymes and bile from the pancreas and gallbladder, respectively, and also acts as a hunger suppressant.

Question 2

What percentage of patients with asymptomatic gallbladders stones will develop symptoms?
Will develop complications?

Answer 2

20-30% will develop symptoms in 20 years.
About 1% will develop complications.

prophylactic cholecystectomy is not warranted in asymptomatic patient

Question 3

which patients with asymptomatic bile stones can be treated With prophylactic cholecystectomy?
Why?

Answer 3

hemolytic anemias, such as sickle cell anemia.
Patients with a calcified gallbladder wall (known as porcelain gallbladder), those with large (>2.5 cm) gallstones, and those with a long common channel of bile and pancreatic ducts all have a higher risk of gallbladder cancer and should consider cholecystectomy.
In addition, patients with asymptomatic gallstones undergoing bariatric surgery may also benefit from cholecystectomy

Question 4

Why does patients with asymptomatic gallstones undergoing bariatric surgery may also benefit from cholecystectomy?

Answer 4

Not only does rapid weight loss favor stone formation, but also, after gastric bypass, ERCP to remove common bile duct stones in ascending cholangitis is extremely challenging and usually unsuccessful.

Question 5

What is the pathophysiologic mechanism of acute cholecystitis?

Answer 5

the primary pathophysiologic mechanism is unresolved cystic duct obstruction. The obstruction does not resolve, and inflammation ensues, with edema and subserosal hemorrhage. Infection of the stagnant pool of bile is a secondary phenomenon

Question 6

What is acute emphysematous cholecystitis and gangrenous choelcystitis?

Answer 6

Without resolution of the obstruction, the gallbladder will progress to ischemia and necrosis. Eventually, acute cholecystitis becomes acute gangrenous cholecystitis and, when complicated by infection with a gas-forming organism, acute emphysematous cholecystitis

Question 7

What signs on CT scan will suggest of an emphysematous cholecystitis?

Answer 7

Significant pericholecystic inflammatory changes and air in the gallbladder wall

Question 8

Describe the Murphy sign

Answer 8

Arrest of inspiration with gentle pressure under the right costal margin

Question 9

What is the Mirizzi syndrome?

Answer 9

When inflammation or a stone in the gallbladder neck leads to inflammation of the adjoining biliary system, with obstruction of the common hepatic duct.

Question 10

Which type of imaging method has the highest sensitivity for acute cholecystitis?

Answer 10

US - sensitivity of 85% and specificity of 95%

CT - less sensitive than US

Question 11

What are the first steps of treatment for acute cholecystitis

Answer 11

nothing by mouth, (IV) fluids and parenteral antibiotics

Question 12

which types of organisms are common in cholecystitis?

Answer 12

gram-negative aerobes are the most common followed by anaerobes and gram-positive aerobes

Question 13

How many patients with non operative management of cholecystitis will need surgery before the planned one?

Answer 13

20%

Question 14

How should patients with acute cholecystitis and high operative risk be treated?

Answer 14

Some percutaneously placed cholecystostomy tube should be considered.

Question 15

what primary choledocholithiasis is?

Answer 15

stones arise de novo in the bile duct.
generally from brown pigment stones, which are a combination of precipitated bile pigments and cholesterol.
more common in Asian populations
associated with a bacterial infection of the bile duct.

Question 16

what is the name of a stone found in the CBD within 2 years after cholecystectomy?

Answer 16

Retained common duct stones.
Many common duct stones are clinically silent and may be identified only during cholangiography if it is performed routinely during cholecystectomy

Question 17

Without pain or an abnormal liver function panel, cholangiography is usually not performed.
how many patients after cholecystectomy will present with a retained stone?
how many cases of choledocholithiasis will be found if cholangigraphy would have been done routinely?

Answer 17

1% to 2% of patients after cholecystectomy
will present with a retained stone.
When it is performed routinely, intraoperative cholangiography identifies choledocholithiasis in
approximately 10% of asymptomatic patients, suggesting that most choledocholithiasis remains clinically silent.

Question 18

Charcot triad

Reynolds pentad.

Answer 18

Fever,right upper quadrant pain and jaundice - triad.

hypotension and mental status changes- pentad

Question 19

US finding suggestive of choledocholithiasis

Answer 19

dilated bile duct (>8mm) in the presence of gallstones suggests choledocholithiasis, even if common duct stones are not documented ultrasonographically.

Question 20

ndications for preoperative ERCP before cholecystectomy include:

Answer 20

cholangitis, biliary pancreatitis, limited experience of the surgeon with common duct exploration, and patients with multiple comorbidities.

Question 21

what is the sensetivity and specificity of MRCP for the diagnosis of stones in the CBD?
What is it’s drawback compared to ERCP?

Answer 21

sensitive (>90%) almost 100% specificity

it does not provide a therapeutic solution (as in ERCP). A clear cholangiogram by MRCP eliminates the need for ERCP.

Question 22

PTC is an invasive test with a complication rate similar to
that of ERCP (for choledocholithiasis).
when PTC is as effective as ERCP?

Answer 22

in patients with a dilated biliary ductal system

but less effective in the setting of a nondilated biliary tree.

Question 23

how many patients will have recurrent symptoms of biliary tract disease when choledocholithiasis is managed by ERCP and sphincterotomy without cholecystectomy?

Answer 23

almost 50% of all patients will have recurrent symptoms more than one third of these patients eventually require cholecystectomy,
older patients (>70 years) have only a 15% rate of symptom recurrence, so cholecystectomy can be offered selectively to this population of patients.

Question 24

most cases of gallstone pancreatitis are self-limited. If, by clinical assessment, the pancreatitis is severe, what should be the treatment?

Answer 24

early ERCP to remove a stone that may not have passed

Question 25

what is Biliary Dyskinesia?

Answer 25

Dysfunction of the gallbladder that creates classic symptoms of calculous biliary, even in the absence of stones.

Question 26

how billiary dyskinesia is diagnosed?

Answer 26

CCK-stimulated HIDA scan, in which the radiolabeled
iminodiacetic acid will collect in the gallbladder. The
patient is given an IV dose of CCK, and the percentage ejection of the gallbladder in response to CCK is calculated. An ejection fraction less than one third at 20 minutes after CCK administration in patients without stones is considered diagnostic of dyskinesia.

Question 27

what is the management of billiary dyskinesia?

Answer 27

Cholecystectomy.
more than 85% of patients showing improvement or resolution. In nonresponders, ERCP with sphincterotomy may prove useful.

Question 28

When does the diagnosis of sphincter of Oddi dysfunction should be suspected?

Answer 28

biliary pain and a common duct diameter of more than 12 mm

Question 29

Surgery for Calculous Biliary Disease p1498

Answer 29

Surgery for Calculous Biliary Disease p1498