Ch 32 Biliary Flashcards
Under which liver segments does the galbladder lie?
segments IV and V
Under which liver segments does the galbladder lie?
segments IV and V
Cystic artery branches from _____ artery
r hepatic
Borders of triangle of calot
cystic duct (lateral), common hepatic duct (medial), liver (superior)
Contents of triangle of calot
cystic artery, node of mascagni/lunds node (inflamed in cholecystitis or cholangitis)
Blood supply of the hepatic and common bile duct
right hepatic (lateral) and retroduodenal branches (medial) of the GDA
cystic veins drain into the _____
right branch of the portal vein
lymphatics are on the right/left side of the cbd
right
parasympathetic fibers to the gallbladder come from ____
left (anterior) vagal trunk
sympathetic fibers to the gallbladder come from ____
T7-10 splanchnic and celiac ganglion
Gallbladder mucosa is ____ epithelium
columnar
Gallbladder submucosa is ______ cells
there is no submucosa on gallbladder
Gallbladder normally fills by contraction of _______ at the ____
sphincter of oddi; ampulla of vater
morphine contracts/relaxes sphincter of oddi
contracts
glucagon contracts/relaxes sphincter of oddi
relaxes
What happens to total bile salt pools after chole
down
epithelial invaginations in the gallbladder wall are called _____ and are from ______
rokitansky aschoff sinuses; increased gallbladder pressure
epithelial invaginations in the gallbladder wall are called _____ and are from ______
rokitansky aschoff sinuses; increased gallbladder pressure
Cystic artery branches from _____ artery
r hepatic
Borders of triangle of calot
cystic duct (lateral), common hepatic duct (medial), liver (superior)
Contents of triangle of calot
cystic artery, node of mascagni/lunds node (inflamed in cholecystitis or cholangitis)
Blood supply of the hepatic and common bile duct
right hepatic (lateral) and retroduodenal branches (medial) of the GDA
cystic veins drain into the _____
right branch of the portal vein
lymphatics are on the right/left side of the cbd
right
3 essential functions of bile
- fat soluble vitamin absorption
- essential fat absorption
- bilirubin and cholesterol excretion
sympathetic fibers to the gallbladder come from ____
T7-10 splanchnic and celiac ganglion
Gallbladder mucosa is ____ epithelium
columnar
Gallbladder submucosa is ______ cells
there is no submucosa on gallbladder
Gallbladder normally fills by contraction of _______ at the ____
sphincter of oddi; ampulla of vater
morphine contracts/relaxes sphincter of oddi
contracts
glucagon contracts/relaxes sphincter of oddi
relaxes
What happens to total bile salt pools after chole
down
highest concentration of cck and secretin cells are in the _____
duodenum
epithelial invaginations in the gallbladder wall are called _____ and are from ______
rokitansky aschoff sinuses; increased gallbladder pressure
[cholesterol] hepatic bile vs gall bile
50-150 vs 300-700
increase/decrease bile excretion? cck
increase
increase/decrease bile excretion? secretin
increase
increase/decrease bile excretion? vagal input
increase
increase/decrease bile excretion? somatostatin
decrease
increase/decrease bile excretion? sympathetic stimulation
decrease
____ causes constant, steady, tonic gallbladder contraction
cck
3 essential functions of bile
- fat soluble vitamin absorption
- essential fat absorption
- bilirubin and cholesterol excretion
4 causes of black gallstones
hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic tpn
CHIC
active concentration of conjugated bile salts occurs in the ______ by ___%
terminal ileum; 50%
passive resorption or nonconjugated bile salts can occur in the ____ with _ %and the _____ with _%
small intestine; 45%; colon; 5%
Postprandial gallbladder emptying is maximum at ___ hours and is at ___%
2 hours; 80%
color of bile is mostly due to _____ bilirubin
conjugated
____ is the breakdown of conjugated bilirubin in gut and gives stool brown color
stercobilin
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
urobilinogen; urobilin
How does cholesterol become bile?
hmg coa –> cholesterol (hmg coa reductase) –> bile salt acids (7alpha hydroxylase)
_____is the rate-limiting step in bile synthesis
hmg coa reductase
tx of brown stones and success rate
almost all patients with primary stones need a biliary drainage procedure –> sphincteroplasty (90% successful)
___ and ____ found in the CBD are considered secondary common bile duct stones
cholesterol and black
[bile salts] hepatic bile vs gall bile
1-50 vs 250-350
[cholesterol] hepatic bile vs gall bile
50-150 vs 300-700
gallstones occur in ___% of the population
10%
_____ and ____ are typically elevated in cholecystitis
alk phos and wbc
most common type of stone in the US is ____ and is pigmented/nonpigmented
cholesterol; nonpigmented
What 5 factors cause cholesterol stones
stasis, calcium nucleation, increased water reabsorption from gallbladder, reduced lecithin, reduced bile salts
MC type of gallstone worldwide is _____
pigmented stones
_____ stones are caused by solubilization of unconjugated bilirubin with preciptiation
calcium bilirubinate
what agents do not work on pigmented stones?
dissolution (e.g. monooctanoin)
4 causes of black gallstones
hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic tpn
CHIC
elevated bilirubin + reduced hepatic function + bile stasis leads to ______
calcium bilirubinate stones
where do calcium bilirubinate stones form?
in the gallbladder
tx of calcium bilirubinate stones
cholecystectomy
primary CBD stones found largely in asians are _____ stones
brown
what is the pathophysiology of brown stones
MC ecoli infection –> produces beta glucoronidase–> deconjugates bilirubin –> forms calcium bilirubinate
most common infection leading to brown stones
ecoli
___ % of patients undergoing cholecystectomy will have a retained CBD stone —> ___% of these are cleared with ERCP
5%; 95%
where are brown stones more commonly formed
in the bile ducts –> primary cbd stones
tx of brown stones and success rate
almost all patients with primary stones need a biliary drainage procedure –> sphincteroplasty (90% successful)
___ and ____ found in the CBD are considered secondary common bile duct stones
cholesterol and black
cholecystitis is caused by the obstruction of ____ by a gallstone
cystic duct
symptoms of cholecystitis
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
murphy’s sign
patient resists deep inspiration with deep palpation to the ruq secondary to pain
_____ and ____ are typically elevated in cholecystitis
alk phos and wbc
_____ is associated with frank purulence in the gallbladder and can lead to sepsis and shock
suppurative cholecystitis
most common 3 organisms in cholecystitis
ecoli (MC) > klebsiella > enterococcus
risk factors for gallstones leading to cholecystitis
age >40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)
dx of gallstones and sensitivity
us –> 95% –> hyperechoic focus, posterior shadowing, movement of focus with change in position
best initial evaluation for jaundice or RUQ pain
ruq us
us findings suggestive of acute cholecystitis
gallstones, gallbladder wall thickening (>4mm), periocholecystic fluid
dilated CBD (> ____ ) suggests cbd stone and obstruction
8mm
____ scan involves technetium taken up by the liver and excreted in the biliary tract
HIDA
most sensitive test for acute cholecystitis
CCK-CS - cholecystokinin cholescintigraphy (HIDA employed) –> emptying test
Indications for cholecystectomy after CCK-CS test
- gallbladder not seen (cystic duct likely has a stone)
- takes >60 minutes to empty (chronic cholecystitis)
- ejection fraction
Indications for immediate ERCP
(signs that a cbd stone is present) –> jaundice, cholangitis, U/S with stone in CBD
Indications for pre-op ERCP
(any prolonged high value for >24 hours):
AST/ALT>200
bilirubin > 4
amylase or lipase > 1000
___ % of patients undergoing cholecystectomy will have a retained CBD stone —> ___% of these are cleared with ERCP
5%; 95%
Tx cholecystitis
cholecystectomy; tube can be placed for patients who are very ill and cannot tolerate surgery
best treatment for late common bile duct stone
ERCP
-sphincterotomy allows for removal of stone
risks of ERCP for late common bile duct stone
bleeding, pancreatitis, perforation
Transient cystic duct obstruction caused by passage of a gallstone is called _____ and resolves within ____ hours
biliary colic; 4-6 hours
Differential for air in the biliary system
- MC with previous ERCP or sphincterotomy
- cholangitis
- erosion of biliary system into ileum (gallstone ileus)
most common route of bacterial infection of bile
dissemination from portal system (not retrograde through sphincter of oddi)
highest incidence of positive bile cultures occurs with _______
postoperative strictures (usually ecoli; often polymicrobial)
acalculous cholecystitis usually occurs after ______ (4)
severe burns
prolonged tpn
trauma
major surgery
primary pathology of acalculous cholecystitis
bile stasis (narcosis, fasting) --> distension and ischemia increased viscosity (2/2 dehydration, ileus, transfusion)
thickened gallbladder wall; ruq pain; increased wbc; no stones
acalculous cholecystitis
us in acalculous cholecystitis
sludge, gallbladder wall thickening, pericholecystic fluid
HIDA scan +/- in acalculous cholecystitis
+
Tx acalculous cholecystitis
cholecystectomy; percutaneous drainage if patient is too unstable
normal size: pancreatic duct
4mm
normal size: CBD
8mm; 10 after chole
normal size: gallbladder wall
4mm
Mirizzi syndrome
compression of common hepatic duct from compression of impacted stone in cystic duct –> associated with choloenteric fistula
Bouveret’s syndrome
impaction of gallstone in duodenum or pyloric channel leading to gastric outlet obstruction
