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ABSITE > Ch 32 Biliary > Flashcards

Ch 32 Biliary Flashcards

1
Q

Under which liver segments does the galbladder lie?

A

segments IV and V

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2
Q

Under which liver segments does the galbladder lie?

A

segments IV and V

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3
Q

Cystic artery branches from _____ artery

A

r hepatic

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4
Q

Borders of triangle of calot

A

cystic duct (lateral), common hepatic duct (medial), liver (superior)

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5
Q

Contents of triangle of calot

A

cystic artery, node of mascagni/lunds node (inflamed in cholecystitis or cholangitis)

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6
Q

Blood supply of the hepatic and common bile duct

A

right hepatic (lateral) and retroduodenal branches (medial) of the GDA

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7
Q

cystic veins drain into the _____

A

right branch of the portal vein

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8
Q

lymphatics are on the right/left side of the cbd

A

right

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9
Q

parasympathetic fibers to the gallbladder come from ____

A

left (anterior) vagal trunk

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10
Q

sympathetic fibers to the gallbladder come from ____

A

T7-10 splanchnic and celiac ganglion

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11
Q

Gallbladder mucosa is ____ epithelium

A

columnar

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12
Q

Gallbladder submucosa is ______ cells

A

there is no submucosa on gallbladder

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13
Q

Gallbladder normally fills by contraction of _______ at the ____

A

sphincter of oddi; ampulla of vater

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14
Q

morphine contracts/relaxes sphincter of oddi

A

contracts

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15
Q

glucagon contracts/relaxes sphincter of oddi

A

relaxes

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16
Q

What happens to total bile salt pools after chole

A

down

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17
Q

epithelial invaginations in the gallbladder wall are called _____ and are from ______

A

rokitansky aschoff sinuses; increased gallbladder pressure

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18
Q

epithelial invaginations in the gallbladder wall are called _____ and are from ______

A

rokitansky aschoff sinuses; increased gallbladder pressure

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19
Q

Cystic artery branches from _____ artery

A

r hepatic

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20
Q

Borders of triangle of calot

A

cystic duct (lateral), common hepatic duct (medial), liver (superior)

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21
Q

Contents of triangle of calot

A

cystic artery, node of mascagni/lunds node (inflamed in cholecystitis or cholangitis)

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22
Q

Blood supply of the hepatic and common bile duct

A

right hepatic (lateral) and retroduodenal branches (medial) of the GDA

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23
Q

cystic veins drain into the _____

A

right branch of the portal vein

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24
Q

lymphatics are on the right/left side of the cbd

A

right

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25
Q

3 essential functions of bile

A
  • fat soluble vitamin absorption
  • essential fat absorption
  • bilirubin and cholesterol excretion
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26
Q

sympathetic fibers to the gallbladder come from ____

A

T7-10 splanchnic and celiac ganglion

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27
Q

Gallbladder mucosa is ____ epithelium

A

columnar

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28
Q

Gallbladder submucosa is ______ cells

A

there is no submucosa on gallbladder

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29
Q

Gallbladder normally fills by contraction of _______ at the ____

A

sphincter of oddi; ampulla of vater

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30
Q

morphine contracts/relaxes sphincter of oddi

A

contracts

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31
Q

glucagon contracts/relaxes sphincter of oddi

A

relaxes

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32
Q

What happens to total bile salt pools after chole

A

down

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33
Q

highest concentration of cck and secretin cells are in the _____

A

duodenum

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34
Q

epithelial invaginations in the gallbladder wall are called _____ and are from ______

A

rokitansky aschoff sinuses; increased gallbladder pressure

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35
Q

[cholesterol] hepatic bile vs gall bile

A

50-150 vs 300-700

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36
Q

increase/decrease bile excretion? cck

A

increase

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37
Q

increase/decrease bile excretion? secretin

A

increase

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38
Q

increase/decrease bile excretion? vagal input

A

increase

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39
Q

increase/decrease bile excretion? somatostatin

A

decrease

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40
Q

increase/decrease bile excretion? sympathetic stimulation

A

decrease

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41
Q

____ causes constant, steady, tonic gallbladder contraction

A

cck

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42
Q

3 essential functions of bile

A
  • fat soluble vitamin absorption
  • essential fat absorption
  • bilirubin and cholesterol excretion
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43
Q

4 causes of black gallstones

A

hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic tpn

CHIC

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44
Q

active concentration of conjugated bile salts occurs in the ______ by ___%

A

terminal ileum; 50%

45
Q

passive resorption or nonconjugated bile salts can occur in the ____ with _ %and the _____ with _%

A

small intestine; 45%; colon; 5%

46
Q

Postprandial gallbladder emptying is maximum at ___ hours and is at ___%

A

2 hours; 80%

47
Q

color of bile is mostly due to _____ bilirubin

A

conjugated

48
Q

____ is the breakdown of conjugated bilirubin in gut and gives stool brown color

A

stercobilin

49
Q

conjugated bilirubin is broken down in the gut and reabsorbed; gets converted to ____ and then ___ which is released in urine and provides a yellow color

A

urobilinogen; urobilin

50
Q

How does cholesterol become bile?

A

hmg coa –> cholesterol (hmg coa reductase) –> bile salt acids (7alpha hydroxylase)

51
Q

_____is the rate-limiting step in bile synthesis

A

hmg coa reductase

52
Q

tx of brown stones and success rate

A

almost all patients with primary stones need a biliary drainage procedure –> sphincteroplasty (90% successful)

53
Q

___ and ____ found in the CBD are considered secondary common bile duct stones

A

cholesterol and black

54
Q

[bile salts] hepatic bile vs gall bile

A

1-50 vs 250-350

55
Q

[cholesterol] hepatic bile vs gall bile

A

50-150 vs 300-700

56
Q

gallstones occur in ___% of the population

A

10%

57
Q

_____ and ____ are typically elevated in cholecystitis

A

alk phos and wbc

58
Q

most common type of stone in the US is ____ and is pigmented/nonpigmented

A

cholesterol; nonpigmented

59
Q

What 5 factors cause cholesterol stones

A

stasis, calcium nucleation, increased water reabsorption from gallbladder, reduced lecithin, reduced bile salts

60
Q

MC type of gallstone worldwide is _____

A

pigmented stones

61
Q

_____ stones are caused by solubilization of unconjugated bilirubin with preciptiation

A

calcium bilirubinate

62
Q

what agents do not work on pigmented stones?

A

dissolution (e.g. monooctanoin)

63
Q

4 causes of black gallstones

A

hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic tpn

CHIC

64
Q

elevated bilirubin + reduced hepatic function + bile stasis leads to ______

A

calcium bilirubinate stones

65
Q

where do calcium bilirubinate stones form?

A

in the gallbladder

66
Q

tx of calcium bilirubinate stones

A

cholecystectomy

67
Q

primary CBD stones found largely in asians are _____ stones

A

brown

68
Q

what is the pathophysiology of brown stones

A

MC ecoli infection –> produces beta glucoronidase–> deconjugates bilirubin –> forms calcium bilirubinate

69
Q

most common infection leading to brown stones

A

ecoli

70
Q

___ % of patients undergoing cholecystectomy will have a retained CBD stone —> ___% of these are cleared with ERCP

A

5%; 95%

71
Q

where are brown stones more commonly formed

A

in the bile ducts –> primary cbd stones

72
Q

tx of brown stones and success rate

A

almost all patients with primary stones need a biliary drainage procedure –> sphincteroplasty (90% successful)

73
Q

___ and ____ found in the CBD are considered secondary common bile duct stones

A

cholesterol and black

74
Q

cholecystitis is caused by the obstruction of ____ by a gallstone

A

cystic duct

75
Q

symptoms of cholecystitis

A

ruq pain, referred pain to the right shoulder and scapula, nausea/vomiting, lossof oappetite; post prandial/fatty meal pain

-pain is persistent unlike biliary colic

76
Q

murphy’s sign

A

patient resists deep inspiration with deep palpation to the ruq secondary to pain

77
Q

_____ and ____ are typically elevated in cholecystitis

A

alk phos and wbc

78
Q

_____ is associated with frank purulence in the gallbladder and can lead to sepsis and shock

A

suppurative cholecystitis

79
Q

most common 3 organisms in cholecystitis

A

ecoli (MC) > klebsiella > enterococcus

80
Q

risk factors for gallstones leading to cholecystitis

A

age >40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)

81
Q

dx of gallstones and sensitivity

A

us –> 95% –> hyperechoic focus, posterior shadowing, movement of focus with change in position

82
Q

best initial evaluation for jaundice or RUQ pain

A

ruq us

83
Q

us findings suggestive of acute cholecystitis

A

gallstones, gallbladder wall thickening (>4mm), periocholecystic fluid

84
Q

dilated CBD (> ____ ) suggests cbd stone and obstruction

A

8mm

85
Q

____ scan involves technetium taken up by the liver and excreted in the biliary tract

A

HIDA

86
Q

most sensitive test for acute cholecystitis

A

CCK-CS - cholecystokinin cholescintigraphy (HIDA employed) –> emptying test

87
Q

Indications for cholecystectomy after CCK-CS test

A
  1. gallbladder not seen (cystic duct likely has a stone)
  2. takes >60 minutes to empty (chronic cholecystitis)
  3. ejection fraction
88
Q

Indications for immediate ERCP

A

(signs that a cbd stone is present) –> jaundice, cholangitis, U/S with stone in CBD

89
Q

Indications for pre-op ERCP

A

(any prolonged high value for >24 hours):
AST/ALT>200
bilirubin > 4
amylase or lipase > 1000

90
Q

___ % of patients undergoing cholecystectomy will have a retained CBD stone —> ___% of these are cleared with ERCP

A

5%; 95%

91
Q

Tx cholecystitis

A

cholecystectomy; tube can be placed for patients who are very ill and cannot tolerate surgery

92
Q

best treatment for late common bile duct stone

A

ERCP

-sphincterotomy allows for removal of stone

93
Q

risks of ERCP for late common bile duct stone

A

bleeding, pancreatitis, perforation

94
Q

Transient cystic duct obstruction caused by passage of a gallstone is called _____ and resolves within ____ hours

A

biliary colic; 4-6 hours

95
Q

Differential for air in the biliary system

A
  • MC with previous ERCP or sphincterotomy
  • cholangitis
  • erosion of biliary system into ileum (gallstone ileus)
96
Q

most common route of bacterial infection of bile

A

dissemination from portal system (not retrograde through sphincter of oddi)

97
Q

highest incidence of positive bile cultures occurs with _______

A

postoperative strictures (usually ecoli; often polymicrobial)

98
Q

acalculous cholecystitis usually occurs after ______ (4)

A

severe burns
prolonged tpn
trauma
major surgery

99
Q

primary pathology of acalculous cholecystitis

A 
bile stasis (narcosis, fasting) --> distension and ischemia
increased viscosity (2/2 dehydration, ileus, transfusion)
100
Q

thickened gallbladder wall; ruq pain; increased wbc; no stones

A

acalculous cholecystitis

101
Q

us in acalculous cholecystitis

A

sludge, gallbladder wall thickening, pericholecystic fluid

102
Q

HIDA scan +/- in acalculous cholecystitis

A

+

103
Q

Tx acalculous cholecystitis

A

cholecystectomy; percutaneous drainage if patient is too unstable

104
Q

normal size: pancreatic duct

A

4mm

105
Q

normal size: CBD

A

8mm; 10 after chole

106
Q

normal size: gallbladder wall

A

4mm

107
Q

Mirizzi syndrome

A

compression of common hepatic duct from compression of impacted stone in cystic duct –> associated with choloenteric fistula

108
Q

Bouveret’s syndrome

A

impaction of gallstone in duodenum or pyloric channel leading to gastric outlet obstruction

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