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Comprehensive Prep > Chapter 32: Biliary System > Flashcards

Chapter 32: Biliary System Flashcards

1
Q

What is the triangle of Calot?

A

Cystic duct, CBD, liver

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2
Q

What blood vessels supply the hepatic and CBD?

A

Right hepatic and retroduodenal branches of the GDA

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3
Q

What side of the CBD are the lymphatics on?

A

Right

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4
Q

What is the mucosal of the gallbladder? Submucosa?

A

Columnar epithelium; NO submucosa

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5
Q

What will contract the sphincter of Oddi?

A

Morphine

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6
Q

What will relax the sphincter of Oddi?

A

Glucagon

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7
Q

What is the normal size of the GB wall? Pancreatic duct? CBD?

A

GB wall: 2-4mm Pancreatic duct: <10mm s/p chole

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8
Q

Where is the highest concentration of CCK and secretin cells?

A

Duodenum

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9
Q

What are Rokitansky-Aschoff sinuses?

A

Invagination of the epithelium of the wall of the gallbladder; formed from increased gallbladder pressure

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10
Q

What are the ducts of Luschka?

A

Biliary ducts that can leak after chole

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11
Q

What stimulates increased bile excretion?

A

CCK, secretin, vagal input

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12
Q

What causes decreased bile excretion?

A

VIP, somatostatin, sympathetic stimulation

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13
Q

What are the 3 essential functions of bile?

A

Fat-soluble vitamin absorption, bilirubin excretion, cholesterol excretion

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14
Q

How does the gallbladder form concentrated bile?

A

Active resorption of Na and H20

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15
Q

How many times a day does the bile salt pool cycle?

A

4-8 times/day

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16
Q

Where does active resorption of conjugated bile acids occur? Passive resorption of nonconjugated bile acids?

A

Active: terminal ileum (50%), passive: small intestine and colon

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17
Q

Where is bile secreted from?

A

Bile canalicular cells (20%), hepatocytes (80%)

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18
Q

What is the breakdown product of conjugated bilirubin that gives stool brown colon?

A

Stercobilin

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19
Q

What is the breakdown product of conjugated bilirubin that gets reabsorbed and released in urine?

A

Urobilin

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20
Q

Pathway of cholesterol and bile acid synthesis?

A

HMG CoA –> (HMG CoA reductase) –> cholesterol –> (7-alpha-hydroxylase) –> bile acids

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21
Q

What is the rate-limiting step in cholesterol synthesis?

A

HMG CoA reductase

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22
Q

What causes stones in obese people? In thin people?

A

Obese: overactive HMG CoA reductase, thin: underactive 7-alpha-hydroxylase

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23
Q

What % of the population has gallstones?

A

10%

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24
Q

What % of gallstones are radiopaque?

A

10%

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25
Q

What causes nonpigmented stones?

A

Increase cholesterol insolubilization; caused by stasis, calcium nucleation by mucin glycoproteins, increased water reabsorption from gallbladder; decreased lecithin and bile acids

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26
Q

What is the most common type of stone found in the US?

A

Nonpigmented (75%)

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27
Q

What is the most common type of stone found worldwide?

A

Pigmented

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28
Q

What causes pigmented stones?

A

Solubilization of unconjugated bilirubin with precipitation of calcium bilirubinate and insoluble salts

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29
Q

What causes black stones?

A

Hemolytic disorders or cirrhosis; also in pts with chronic TPN, ileal resection; increased bilirubin load, decreased hepatic function and bile stasis

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30
Q

What causes brown stones? Where are they found?

A

Infection causing deconjugation of bilirubin; found in CBD, formed in ducts

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31
Q

Most common bacteria causing brown stones?

A

E. coli

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32
Q

What needs to be checked for in a patient with brown stones?

A

Ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi

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33
Q

Cholecystitis is caused by what?

A

Obstruction of the cystic duct by gallstone

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34
Q

What is suppurative cholecystitis?

A

Associated with frank purulence in the GB, can be associated with sepsis and shock

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35
Q

Most common organisms in acute cholecystitis?

A

E. coli, klebsiella, enterococcus

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36
Q

Risk factors for stone formation?

A

Age >40, female, obesity, pregnancy, rapid wt loss, vagotomy, TPN, ileal resection

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37
Q

Sensitivity of US in picking up stones?

A

95%

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38
Q

What is the definition of biliary dyskinesia?

A

<40% of gallbladder volume excreted after CCK over 1 hour

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39
Q

Causes of air in the biliary system?

A

Previous ERCP and sphincterotomy, cholangitis, erosion of the biliary system into duodenum (gallstone ileus)

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40
Q

What are signs of acalculous cholecystitis? Pathology?

A

Thickened wall, RUQ pain, elevated WBCs; bile stasis leading to distention and ischemia

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41
Q

When does acalculous cholecystitis occur?

A

After burns, prolonged TPN, trauma, other major surgery

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42
Q

Diagnosis of acalculous cholecystitis?

A

US shows sludge, GB wall thickening, pericholecystic fluid; HIDA (+)

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43
Q

What is the common organism causing emphysematous gallbladder disease?

A

C. perfringens

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44
Q

What is gallstone ileus?

A

Fistula between GB and duodenum that releases stone, causing SBO; elderly, can see pneumobilia on plain film

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45
Q

Most common site of obstruction in gallstone ileus?

A

Terminal ileum

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46
Q

Treatment for gallstone ileus?

A

Remove stone with enterotomy proximal to obstruction; perform chole and fistula resection

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47
Q

What is the benefit of interoperative cholangiography?

A

Does not prevent injuries; may limit severity, increases early diagnosis of injury to CBD

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48
Q

In what % of patients does the right posterior duct enter the CBD separately? What segment is it from?

A

10%, segment 6 or 7

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49
Q

What is the treatment if the right posterior duct is injured during lap chole?

A

If >2mm, need to open and perform hepaticoj

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50
Q

Treatment for intraop CBD injury?

A

If <50% of the circumference, can perform primary repair; in all other cases need hepaticoj or choledochoj

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51
Q

What is the workup for persistent nausea and vomiting or jaundice following lap chole?

A

US to look for fluid collection: if collection, perc drain - bilious: ERCP and stent vs repair; no fluid collection, dilated hepatic ducts - concern for transected bile duct

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52
Q

Treatment for anastamotic leaks following transplant or hepaticoj?

A

ERCP and stents

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53
Q

Treatment for sepsis following lap chole?

A

Fluid resuscitation, stabilize; concern for complete transection of CBD and cholangitis

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54
Q

Most common situation in which CBD or hepatic duct strictures occur?

A

After lap chole

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55
Q

What is the most important cause of late postoperative biliary strictures?

A

Ischemia; can also be caused by chronic pancreatitis, stricture of biliary enteric anastomosis

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56
Q

Diagnosis of CBD or hepatic duct stricture?

A

ERCP; US will show dilated ducts

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57
Q

Treatment of CBD or hepatic duct strictures?

A

ERCP with sphincterotomy and possible stent placement; PTC tube if that fails; 7d post injury: hepaticoj 6-8wks after injury

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58
Q

What causes hemobilia?

A

Fistula between bile duct and hepatic arterial system; most commonly occurs with trauma, also infections, primary gallstones, aneurysms, tumors

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59
Q

Presentation of hemobilia?

A

UGI bleed, jaundice, RUQP

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60
Q

Diagnosis of hemobilia? Treatment?

A

Angiogram; resuscitation, angio and embolization, operation if that fails

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61
Q

What is the most common cancer of the biliary tract?

A

Gallbladder adenocarcinoma

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62
Q

What is the most common site of mets from gallbladder adenocarcinoma?

A

Liver

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63
Q

Risk of cancer with porcelain gallbladder?

A

10-20%, need chole

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64
Q

What % of patients present with stage IV disease?

A

90%

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65
Q

Symptoms of gallbladder CA?

A

Jaundice 1st, then RUQ pain

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66
Q

Treatment based on stage of GB CA?

A

Stage I (mucosa): chole; stage II+ (into muscle): wide resection around liver bed - 2-3cm margins, regional lymphadenectomy, may need Whipple, lobectomy or resection of CBD

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67
Q

Contraindication for lap chole?

A

Gallbladder CA; high incidence of tumor implants in trocar sites

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68
Q

5-yr survival of gallbladder CA?

A

5%

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69
Q

Risk factors for bile duct cancer (cholangiocarcinoma)?

A

C. sinensis infection, typhoid, UC, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection

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70
Q

Symptoms of cholangiocarcinoma?

A

Early: painless jaundice, can also get cholangitis; late: wt loss, anemia, pruritis; persistent increase in alk phos and bilirubin

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71
Q

Diagnosis of cholangio?

A

ERCP 1st, MRI may help define the lesion

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72
Q

What does the discovery of a focal bile duct stenosis in pts without h/o biliary surgery or pancreatitis suggest?

A

Bile duct ca

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73
Q

Where are Klatskin tumors?

A

In upper 1/3 of bile duct; most common type, worst prognosis

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74
Q

Treatment for Klatskin tumor?

A

Lobectomy and stenting of contralateral bile duct if localized to right or left lobe; usually unresectable

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75
Q

Treatment for cholangio in middle 1/3? Lower 1/3?

A

Middle: hepaticoj, lower: Whipple

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76
Q

5-yr survival for cholangio?

A

20%

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77
Q

What % of choledochal cysts are extrahepatic?

A

90%

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78
Q

What is the cancer risk with choledochal cysts?

A

15%

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79
Q

Symptoms of choledochal cyst?

A

Episodic pain, fever, jaundice, cholangitis

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80
Q

Presentation in infants?

A

Similar to biliary atresia

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81
Q

Possible cause of choledochal cysts?

A

Abnormal reflux of pancreatic enzymes during development secondary to bad angle of insertion

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82
Q

Most common type of choledochal cyst?

A

Type I: saccular or fusiform dilation of extrahepatic ducts

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83
Q

Treatment for choldochal cyst?

A

Excision with hepaticoj and chole; type IV partially intrahepatic/type V totally intrahepatic will need liver resection

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84
Q

What patients have primary sclerosing cholangitis?

A

Men in 4-5th decade; associated with retroperitoneal fibrosis, Riedel’s thyroiditis, pancreatitis, UC, DM

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85
Q

Symptoms of PSC?

A

Fatigue, fluctuating jaundice, pruritus, wt loss, RUQ pain

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86
Q

Does PSC get better after cholon resection for UC?

A

NO

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87
Q

Consequences and complications of PSC?

A

Portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intra/extrahepatic ducts); chirrhosis, cholangio

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88
Q

Diagnosis of PSC? Treatment?

A

ERCP showing multiple strictures and dilations; transplant needed long term, PTC drainage/choledochoj may be effective, balloon dilation for symptomatic relief

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89
Q

Treatment for pruritus symptoms?

A

Cholestyramine

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90
Q

Primary biliary cirrhosis occurs in what size ducts?

A

Medium-sized hepatic ducts

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91
Q

Consequences of PBC?

A

Cholestasis –> cirrhosis –> portal HTN

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92
Q

Symptoms of PBC?

A

Fatigue, pruritus, jaundice, xanthomas

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93
Q

What type of antibodies are associated with PBC?

A

Antimitochondrial antibodies

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94
Q

Cancer risk with PBC?

A

No increased risk of cancer

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95
Q

Treatment for PBC?

A

Transplant

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96
Q

What is Charcot’s triad?

A

RUQ pain, jaundice, fever - indicates cholangitis

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97
Q

What is Reynold’s pentad

A

RUQ pain, jaundice, fever, altered mental status, shock - suggests sepsis from cholangitis

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98
Q

Most common organisms in cholangitis?

A

E. coli and Klebsiella

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99
Q

Late complications of cholangitis?

A

Stricture and hepatic abscess

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100
Q

1 serious complication of cholangitis?

A

Renal failure; related to sepsis

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101
Q

Most common etiology of cholangitis? Other causes?

A

Gallstones; also biliary strictures, neoplasm, chronic pancreatitis, congenital choledochal cysts, duodenal diverticula

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102
Q

What is the cause of systemic bacteremia from cholangitis?

A

At >20mmHg, cholovenous reflux occurs –> systemic bacteremia

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103
Q

Treatment for cholangitis?

A

Fluid resus, abx, ERCP with sphincterotomy nd stone extraction, if fails - PTC

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104
Q

What is oriental cholangiohepatitis?

A

Recurrent cholangitis from primary CBD stones; in Asia; caused by C. sinensis, A. lumbricoides, T. trichiuria, E. coli

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105
Q

Treatment for oriental cholangiohepatitis?

A

Hepaticoj and antiparasitic medications

106
Q

What is the most common cause of shock following lap chole early (1st 24h)? Late (after 1st 24h)?

A

Early: hemorrhagic shock from clip that fell off cystic artery; late: septic shock from accidental clip on CBD with subsequent cholangitis

107
Q

What is adenomyomatosis?

A

Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus; not premalignant, does not cause stones; tx: chole

108
Q

What is granular cell myoblastoma?

A

Benign neuroectoderm tumor of the GB; can occur in biliary tract with signs of cholecystitis; tx: chole

109
Q

What is cholesterolosis?

A

Speckled cholesterol deposits on GB wall

110
Q

What size GB polyp more likely to be malignant?

A

>1cm

111
Q

What is delta bilirubin?

A

Bound to albumin covalently, half-life 18d, may take a while to clear after long-standing jaundice

112
Q

What is Mirizzi syndrome?

A

Compression of the common hepatic duct by a stone in the infundibulum of the GB or inflammation arising from the GB or cystic duct; causing stricture and hepatic duct obstruction

113
Q

What abx can cause gallbladder sludging and cholestatic jaundice?

A

Ceftriaxone

114
Q

What are indications for asymptomatic cholecystectomy?

A

Pts undergoing liver TXP or gastric bypass

115
Q

Which stones, if found in the common bile duct, are considered secondary common bile duct stones?

A

Cholesterol stones and black stones

116
Q

What is the treatment for gallbladder adenocarcinoma if there is involvement beyond muscle but it is still resectable?

A

Formal resection of segments IVb and V

[UpToDate: For patients with gallbladder that extends beyond the mucosa, >T1a, the benefit of more radical surgery has been controversial. Randomized trials comparing simple cholecystectomy with radical surgery for gallbladder cancer have not been performed; all available studies are retrospective series. Some of these series, but not all, link better outcomes with more radical surgery.

In another Japanese series of 1686 resected gallbladder cancers from 172 major hospitals, survival rates were significantly better for patients undergoing radical resection compared with patients with simple cholecystectomy (three-year survival: 66% vs 14%, 5-year survival: 51% vs 6%).

At the Mayo Clinic, 22 of 40 patients undergoing potentially curative resection had a simple cholecystectomy, while the remainder had a radical procedure. Although 5-year overall survival rates were similar (33% vs 32%), median survival in patients undergoing radical resection was significantly better (3.6 vs 0.8 years), and for those with transmural extension or nodal metastasis, the only 5-year survivors were those who had undergone extended cholecystectomy.

On the other hand, in a series of 104 patients treated at Memorial Sloan-Kettering over a 12-year period, major hepatectomy, resection of adjacent organs other than the liver, and common bile duct excision increased perioperative morbidity and were not associated with better survival. The authors concluded that major hepatic resection (including excision of the common bile duct) was appropriate, when necessary, to clear disease, but not mandatory in all cases.

Recommendation - Patients with a preoperative diagnosis of potentially resectable, localized gallbladder cancer should be offered definitive resection which involves en bloc resection of the gallbladder and a margin of underlying liver (nonanatomic or anatomic resection), and resection of the regional lymph nodes or extrahepatic biliary ducts depending upon the extent of disease identified intraoperatively. A right hepatic lobectomy may be appropriate in selected patients (eg, tumor of the gallbladder neck, tumor involving the right portal triad).]

117
Q

What is the treatment for cholangitis?

A
  • Fluid resuscitation
  • Antibiotics
  • Emergent ERCP with sphincterotomy and stone extraction (if applicable)
  • If ERCP fails, place PTC tube to decompress the biliary system

[If the cause is an infected PTC tube, change the tube]

118
Q

Cystic veins drain into which vein?

A

The right branch of the portal vein

119
Q

What is caused by abnormal reflux of pancreatic enzymes during uterine development?

A

Choledochal cysts

120
Q

What percent of gallstones are radiopaque?

A

Only 10%

[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.

Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.

Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]

121
Q

What is the approach to intraoperative common bile duct injury that is greater than 50% of the circumference of the bile duct and cannot be primarily repaired?

A

Hepaticojejunostomy or choledocojejunostomy

122
Q

What is the treatment for granular cell myoblastoma of the gallbladder?

A

Cholecystectomy

[Granular cell myoblastoma = A benign neuroectoderm tumor of the gallbladder]

123
Q

What is the first symptom of gallbladder adenocarcinoma?

A

Jaundice (bile duct invasion with obstruction)

[RUQ pain after that]

124
Q

What is the treatment for Mirizzi syndrome?

A

Cholecystectomy

[May need hepaticojejunostomy for hepatic duct stricture]

125
Q

What type of choledochal cyst is partially intrahepatic?

A

Type IV

126
Q

The cystic artery branches off of which artery?

A

Right hepatic artery

127
Q

What is the most sensitive test for cholecystitis?

A

Cholecystokinin cholescintigraphy (CCK-CS test)

[Cholescinitgraphy is a HIDA scan. It is 97% sensitive for acute cholecystitis (U/S is 95% sensitive).]

128
Q

What is the treatment for cholangiocarcinoma in the lower 1/3 of the biliary system?

A

Whipple

129
Q

What is the treatment for choledochal cysts?

A

Cyst excision with hepaticojejunostomy and cholecystectomy

[UpToDate: Patients with type I, II, or IV cysts usually undergo surgical resection of the cysts due to the significant risk of malignancy, provided they are good surgical candidates. Type I and IV cysts should be completely resected with creation of a Roux-en-Y hepatojejunostomy. Serial sections from the cyst wall should be examined by the pathologist to look for any malignant changes. Type II cysts can be treated with simple cyst excision. Type III cysts (choledochoceles) require treatment if they are symptomatic and may be managed with sphincterotomy or endoscopic resection. Treatment for type V cysts is largely supportive and is aimed at dealing with problems such as recurrent cholangitis and sepsis. Type V cysts can be difficult to manage, and some patients with type V cysts eventually require liver transplantation.]

130
Q

What is the overall 5-year survival of gallbladder adenocarcinoma?

A

5%

[UpToDate: Gallbladder cancer (GBC) is an uncommon but highly fatal malignancy; fewer than 5000 new cases are diagnosed each year in the United States. The majority are found incidentally in patients undergoing exploration for cholelithiasis; a tumor will be found in 1% to 2% of such cases. The poor prognosis associated with GBC is thought to be related to advanced stage at diagnosis, which is due both to the anatomic position of the gallbladder, and the vagueness and nonspecificity of symptoms.

Surgery is the only potentially curative treatment for gallbladder cancer. Surgical series report long-term survival rates of 85% to 100% for patients with early-stage (T1) disease. Unfortunately, fewer than 10% of symptomatic patients and only approximately 20% of patients with incidentally diagnosed gallbladder cancer have early-stage disease. The poor prognosis associated with GBC is related to the often advanced stage at diagnosis.]

131
Q

What are 2 late complications of cholangitis?

A
  1. Stricture
  2. Hepatic abscess
132
Q

What are 3 risks of ERCP?

A
  1. Bleeding
  2. Pancreatitis
  3. Perforation
133
Q

What is the overall 5-year survival rate of cholangiocarcinoma?

A

20%

134
Q

What is the treatment for gallbladder adenocarcinoma if muscle is involved but nothing beyond?

A

Wedge resection of segments IVb and V

[UpToDate: Patients with stage T1b disease may benefit from a more radical approach, given that T1b tumors are associated with a higher incidence of lymph node metastases compared with T1a tumors (15% versus 2.5%). Some investigators have shown a median survival advantage of over three years for extended versus cholecystectomy alone for T1b cancers (9.85 vs 6.42 years, respectively). Extended cholecystectomy (cholecystectomy including a rim of liver tissue) should be performed for medically-fit patients who have tumors that invade the muscular layer (T1b).

The optimal approach to T1b disease is more controversial. If there is no contraindication to surgery, extended resection is reasonable for T1b gallbladder cancer. At least two retrospective studies comparing cholecystectomy alone versus extended cholecystectomy for T1b tumors found no significant difference in overall survival (with up to 87% 10-year survival). Others have reported improved survival with re-resection. Furthermore, a number of studies describe high rates of residual disease upon re-resection, with lymph node metastases in 12% to 20% and 0% to 13% with liver involvement. Two reports describe up to a 50% to 60% locoregional recurrence rate after cholecystectomy alone for T1b disease. The authors of both reports concluded that gallbladder cancer is a locally aggressive disease and even early-stage disease warrants extended resection. Finally, as noted above, decision analysis showed a median survival advantage of over three years for extended versus simple cholecystectomy (9.85 vs 6.42 years).

135
Q

What type of choledochal cyst is totally intrahepatic?

A

Type V

[Known as Caroli’s disease]

136
Q

What are 5 risk factors for cholangiocarcinoma?

A
  1. C. sinensis infection
  2. Ulcerative colitis
  3. Choledochal cysts
  4. Primary sclerosing cholangitis
  5. Chronic bile duct infection
137
Q

Which bacteria produces beta-glucuronidase, deconjugating bilirubin and forming calcium bilirubinate?

A

E. Coli

138
Q

What are the 4 main causes of pigmented (black) gallstones?

A
  1. Hemolytic disorders
  2. Cirrhosis
  3. Ileal resection (loss of bile salts)
  4. Chronic TPN

[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.

Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.

Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]

139
Q

How is hemobilia diagnosed?

A

Angiogram

140
Q

What is the treatment for biliary strictures that are due to ischemia or pancreatitis?

A

Choledochojejunostomy

[Best long-term solution]

141
Q

What anatomical structures form the lateral, medial, and superior borders of the Triangle of Calot (Hepatobiliary triangle)?

A
  • Lateral border: Cystic duct
  • Medial border: Common hepatic duct
  • Superior border: Liver
142
Q

Do dissolution agents such as monoctanoin work on pigmented stones?

A

No

[Monoctanoin is a monoglyceride used to dissolve gallstones that are caused by cholesterol.]

143
Q

What is the risk of gallbladder cancer in a patient with porcelain gallbladder?

A

15%

[These patients need a cholecystectomy]

144
Q

Thickened nodules of mucosa and muscle associated with Rokitansky-Aschoff sinuses in the gallbladder are called what?

A

Adenomyomatosis

[Not premalignant and does not cause stones but can cause RUQ pain]

[UpToDate: Adenomyomatosis is an abnormality of the gallbladder characterized by overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula. Despite the name, this condition does not involve any adenomatous changes in the gallbladder epithelium. While generally not considered to be a premalignant condition, adenomyomatosis is sometimes encountered in gallbladders resected for cancer, which has led to the suggestion that it is a premalignant condition. However, the association and its magnitude remain unclear. There is, however, a clear association of adenomyomatosis with cholelithiasis, particularly with the segmental type, which was reported in 89% of patients with segmental adenomyomatosis in one series.

Adenomyomatosis of the gallbladder is less common than cholesterolosis in most reports, with some exceptions. In one report, for example, only 103 cases of adenomyomatosis were found in over 10,000 cholecystectomies (1%). This is compared with the much higher prevalence of cholesterolosis (9% to 26%). Adenomyomatosis is more common in women.]

145
Q

What is the treatment for brown (pigmented) gallstones which are primarily formed in the common bile duct?

A

Almost all patients with primary stones need a biliary drainage procedure

[Sphincteroplasty is 90% successful]

146
Q

How does the gallbladder form concentrated bile?

A

Active resorption of NaCl and water

147
Q

What is the most common rout of bacterial infection of bile?

A

Dissemination from portal system

[Not retrograde through sphincter of oddi]

148
Q

What is the treatment of acalculous cholecystitis?

A

Cholecystectomy

149
Q

What are 3 indications for immediate ERCP?

A
  1. Jaundice
  2. Cholangitis
  3. U/S shows stone in common bile duct

[Signs that a common bile duct stone is present]

150
Q

What kind of bilirubin is bound to albumin covalently, has a half-life of 18 days, and may take a while to clear after long-standing jaundice?

A

Delta bilirubin

151
Q

Which antibiotic can cause gallbladder sludging and cholestatic jaundice?

A

Ceftriaxone

152
Q

How does the gallbladder normally fill?

A

Contraction of the sphincter of Oddi at the the Ampulla of Vader

153
Q

Parasympathetic fibers to the biliary system come from where?

A

The left trunk (anterior trunk) of the vagus nerve

154
Q

What is the name of the breakdown product of conjugated bilirubin in the gut that gives stool its brown color?

A

Stercobilin

155
Q

What is the treatment for hemobilia?

A

Angioembolization

[Operation if that fails]

156
Q

What is the approach to treating a patient with an anastomotic leak following transplantation or hepaticojejunostomy

A

Percutaneous drainage of fluid collection followed by ERCP with temporary stent

[Leak will heal]

157
Q

Is this hepatic bile or gallbladder bile?

  • Na (mEq/L): 140-170
  • Cl (mEq/L): 50-120
  • Bile Salts (mEq/dL): 1-50
  • Cholesterol (mEq/dL): 50-150
A

Hepatic bile

158
Q

Which hormone causes constant, steady, tonic contraction of the gallbladder?

A

CCK

159
Q

What are the components of Reynolds’ Pentad seen in patients with cholangitis?

A
  • Charcot’s Triad (RUQ pain, fever, jaundice)
  • Mental status change
  • Shock

[Suggests sepsis]

160
Q

What is the only treatment that can alter the outcome for a patient with primary sclerosing cholangitis?

A

Liver transplant

161
Q

Can a laparoscopic approach be used for the resection of gallbladder adenocarcinoma?

A

No

[High incidence of tumor implants in trocar sites when cancer is discovered after laparoscopic cholecystectomy]

162
Q

How is cholangiocarcinoma diagnosed?

A

Magnetic resonance cholangiopancreatography (MRCP) defines the anatomy and looks for a mass

163
Q

A gallbladder polyp of what size would be worrisome for malignancy?

A

Greater than 1 cm

164
Q

What is the approach to a patient with evidence of an injury to the biliary system more than 7 days after laparoscopic cholecystectomy?

A

Hepaticojejunostomy 6-8 weeks after injury

[Tissue too friable for surgery after 7 days]

165
Q

Patients undergoing which 2 procedures should have an asymptomatic cholecystectomy?

A
  1. Patient undergoing liver transplant
  2. Patient undergoing gastric bypass

[Also Whipple procedures should include a cholecystectomy.]

166
Q

What are 3 non-iatrogenic causes of biliary strictures?

A
  1. Chronic pancreatitis
  2. Gallbladder cancer
  3. Bile duct cancer
167
Q

What is the treatment for gallbladder adenocarcinoma if muscle is not involved?

A

Cholecystectomy

[UpToDate: Simple cholecystectomy alone is felt to be adequate for patients with tumors that are limited to the lamina propria (T1a). Cure rates following simple cholecystectomy range from 73% to 100% in case series. Patients found to have incidental T1a tumors with negative margins are generally felt to be curable with the cholecystectomy that has already been performed. Re-resection for T1a tumors does not appear to provide an overall survival benefit.]

168
Q

What percent of patients undergoing cholecystectomy will have a retained common bile duct stone?

A

5%

[95% of these are cleared with ERCP]

169
Q

Which medication or hormone causes the sphincter of Oddi to relax?

A

Glucagon

170
Q

What are 3 findings on cholecystokinin-cholescintigraphy that are indications for cholecystectomy?

A
  1. Gallbladder not seen (cystic duct likely has a stone)
  2. Takes greater than 60 minutes to empty (chronic cholecystitis)
  3. Ejection fraction less than 40% (biliary dyskinesia)
171
Q

Men in which decade of life typically get primary sclerosing cholangitis?

A

4th-5th decade

[UpToDate: The incidence is higher in males and the median age at diagnosis was 41.]

172
Q

What is the best initial test for evaluation of jaundice or RUQ pain?

A

Ultrasound

173
Q

Common bile duct injuries most commonly occur after which operation?

A

After laparoscopic cholecystectomy

174
Q

What is the approach to a patient with nausea, vomiting, or jaundice and an ultrasound showing fluid collection following laparoscopic cholecystectomy?

A
  • Percutaneous drain into the collection (Might be a bile leak)
  • If fluid is bilious, get ERCP

Sphincterotomy and stent if due to:

  1. Cystic duct remnant leak
  2. Small injuries to the hepatic or common bile duct
  3. Leak from a duct of Luschka

[Larger lesions (ie complete duct transection) will require hepaticojejunostomy or choledochojejunostomy]

175
Q

What is the treatment for cholangiocarcinoma in the middle 1/3 of the biliary system?

A

Hepaticojejunostomy

176
Q

What are 4 ways to treat the symptoms of primary sclerosing cholangitis?

A
  1. PTC tube drainage
  2. Choledochojejunostomy or balloon dilatation of dominant strictures may provide some symptomatic relief
  3. Cholestyramine can help with pruritus
  4. Ursodeoxycholic acid can improve liver enzymes and decrease symptoms
177
Q

What kind of gallbladder stone is caused by solubilization of unconjugated bilirubin with precipitation?

A

Pigmented (Calcium bilirubinate) stones

178
Q

What kind of epithelium is the mucosa of the gallbladder?

A

Columnar epithelium

179
Q

What is the most important cause of late postoperative biliary strictures following laparoscopic cholecystectomy?

A

Ischemia

180
Q

What are the 2 most common organisms responsible for cholangitis?

A
  1. E. Coli (most common)
  2. Klebsiella
181
Q

What is a normal size for the common bile duct?

A

<8mm (<10mm after cholecystectomy)

[UpToDate: Measurements of components of the hepatobiliary tree depend upon the skill of the ultrasonographer obtaining the measurements, and there is variability in terms of what is considered “normal.” However, some general estimates are available regarding the expected sizes of structures in the hepatobiliary tree:

  • Gallbladder: The gallbladder wall should be less than or equal to 2 mm (in a distended or fasting gallbladder). Collapsed gallbladders, seen when the subject has eaten, typically appear slightly more thickened. Typically, the maximum “normal” dimension of the gallbladder is 5 X 10 cm.
  • Common hepatic duct: The common hepatic duct (inner wall to inner wall) is usually measured at the level of the hepatic artery. In the normal fasting state, it should be <7 mm in patients <60 years, and <10 mm in patients older than 60.
  • Common bile duct (CBD): The normal CBD diameter increases with age and in patients who have had a cholecystectomy. In patients in their 40s, the normal mean diameter is 4 mm. The normal mean diameter then increases by 1 mm every decade, and authors have proposed that in older patients the normal upper limit of normal be set at 8.5 mm. The CBD is commonly up to 10 mm in patients who have undergone a cholecystectomy.
  • Liver: The span of the liver in the right midclavicular line should be less than 16 cm.]
182
Q

Which kind of gallstones are formed in the ducts and are more common in Asians?

A

Brown (pigmented stones)

[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.

Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.

Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]

183
Q

What are the 3 most common organisms in cholecystitis?

A
  1. E. Coli (#1)
  2. Klebsiella
  3. Enterococcus
184
Q

What are the 3 main causes of non-pigmented (cholesterol) gallstones?

A
  1. Stasis
  2. Calcium nucleation
  3. Increased water reabsorption from the gallbladder

[Other causes are decreased lecithin and bile salts]

[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.

Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.

Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]

185
Q

What is the treatment for primary biliary cirrhosis?

A

Liver transplant

186
Q

Discovery of focal bile duct stenosis in patients without a history of biliary surgery or pancreatitis is highly suggestive of what?

A

Bile duct cancer (cholangiocarcinoma)

187
Q

What is the rate-limiting enzyme in the conversion of HMG CoA to Cholesterol?

A

HMG CoA reductase

[HMG-CoA (or 3-hydroxy-3-methylglutaryl-coenzyme A) is an intermediate in the mevalonate and ketogenesis pathways. It is formed from acetyl CoA and acetoacetyl CoA by HMG-CoA synthase]

188
Q

Which 2 lab values are frequently elevated in cholecystitis?

A
  1. Alkaline phosphatase
  2. WBCs
189
Q

Emphysematous gallbladder disease is most commonly secondary to which bacteria?

A

Clostridium perfringens

190
Q

What is the rate-limiting enzyme in the conversion of Cholesterol into bile salts (acids)?

A

7-alpha-hydroxylase

191
Q

What is the most common type of gallstone found in the United States?

A

Non-pigmented (cholesterol) gallstones

[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.

Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.

Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]

192
Q

A benign neuroectoderm tumor of the gallbladder is called what?

A

Granular cell myoblastoma

193
Q

Which 2 lab values are persistently elevated in cholangiocarcinoma?

A
  1. Bilirubin
  2. Alkaline phosphatase
194
Q

The color of bile is mostly due to what?

A

Conjugated bilirubin

195
Q

What is the most common type of gallstone found worldwide?

A

Pigmented stones

[Wikipedia: Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese- classification system). Between 35% and 90% of stones are cholesterol stones.

Bilirubin (“pigment”, “black pigment”) stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.

Mixed (“Brown Pigment”) stones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.]

196
Q

Hemobilia is most commonly caused by a fistula between which 2 structures?

A

Bile duct and hepatic arterial system

197
Q

Gallbladder polyps in which age group are more likely malignant?

A

People over 60 years old

198
Q

Gallstones occur in what percent of the general population?

A

10%

[Vast majority are asymptomatic]

[UpToDate: In the United States, the age standardized prevalence of gallbladder disease was estimated based upon a sample of more than 14,000 persons aged 20 to 74 in whom gallbladder disease was detected by the presence of gallstones or cholecystectomy on ultrasonography. The following prevalence rates were observed:

  • 8.6% and 16.6% among non-Hispanic white men and women, respectively
  • 8.9% and 26.7% among Mexican American men and women, respectively
  • 5.3% and 13.9% among non-Hispanic black men and women, respectively]
199
Q

When do symptoms of cholecystitis typically occur?

A

After a fatty meal

200
Q

Cholangitis is usually caused by what?

A

Obstruction of the bile duct

[Can also be caused by indwelling tubes, biliary strictures, neoplasm, choledochal cysts, duodenal diverticula]

201
Q

What is the treatment for gallbladder polyps?

A

Cholecystectomy

202
Q

Do the common bile duct and common hepatic duct have peristalsis?

A

No

203
Q

Which segment(s) of the liver does gallbladder adenocarcinoma invade first?

A

Segments IV and V

[First nodes are the cystic duct nodes on the right side]

204
Q

Which cells secrete 20% of bile?

A

Bile canalicular cells

[Other 80% is secreted by the hepatocytes.]

205
Q

Where does active resorption of conjugated bile salts occur?

A

Terminal ileum

[50% of resorption occurs here]

206
Q

What is the treatment for cholangiocarcinoma in the upper 1/3 of the biliary system (Klatskin tumor which occur at the confluence of the right and left hepatic bile ducts)?

A

Lobectomy and stenting of contralateral bile duct if localized to either the right or left lobe Palliative stenting if unresectable disease

[Upper 1/3 has worst prognosis and is usually unresectable]

207
Q

What is the treatment for a type V choledochal cyst?

A

Partial liver resection or liver transplant

[Type V cyst is totally intrahepatic]

208
Q

Which 3 medical conditions are associated with primary sclerosing cholangitis?

A
  1. Ulcerative colitis
  2. Pancreatitis
  3. Diabetes

[UpToDate: Ulcerative colitis has been reported in 25% to 90% of patients with PSC.]

209
Q

What type of choledochal cyst is characterized by fusiform or saccular dilatation of extrahepatic ducts?

A

Type I

[Most common type]

210
Q

What is Mirizzi syndrome?

A

Compression of the common hepatic duct by a stone in the gallbladder infundibulum or from inflammation arising from the gallbladder or cystic duct and causing common hepatic duct stricture

211
Q

What is characterized by multiple strictures throughout the hepatic ducts?

A

Primary Sclerosing Cholangitis

212
Q

Fistula formation between the gallbladder and duodenum can result in what?

A

Gallstone ileus

[More common in elderly]

213
Q

What percent of choledochal cysts are extrahepatic?

A

90%

214
Q

How does one work up a suspected biliary stricture?

A
  • Magnetic resonance cholangiopancreatography (MRCP) defines the anatomy and looks for a mass (cancer)
  • If cancer is not ruled out with MRCP, need ERCP with brush biopsies
215
Q

Biliary stricture without a history of pancreatitis or biliary surgery is what until proven otherwise?

A

Cancer

216
Q

What is the treatment for adenomyomatosis?

A

Cholecystectomy

[Adenomyomatosis = A thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus]

[UpToDate: Adenomyomatosis is an abnormality of the gallbladder characterized by overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula. Despite the name, this condition does not involve any adenomatous changes in the gallbladder epithelium. While generally not considered to be a premalignant condition, adenomyomatosis is sometimes encountered in gallbladders resected for cancer, which has led to the suggestion that it is a premalignant condition. However, the association and its magnitude remain unclear. There is, however, a clear association of adenomyomatosis with cholelithiasis, particularly with the segmental type, which was reported in 89% of patients with segmental adenomyomatosis in one series.

Adenomyomatosis of the gallbladder is less common than cholesterolosis in most reports, with some exceptions. In one report, for example, only 103 cases of adenomyomatosis were found in over 10,000 cholecystectomies (1%). This is compared with the much higher prevalence of cholesterolosis (9% to 26%). Adenomyomatosis is more common in women.]

217
Q

What is suppurative cholecystitis?

A

Frank purulence in the gallbladder that can be associated with sepsis and shock

218
Q

Will HIDA scan be positive in acalculous cholecystitis?

A

Yes

219
Q

What are 8 risk factors for gallstones?

A
  1. Age greater than 40
  2. Female
  3. Obesity
  4. Pregnancy
  5. Rapid weight loss
  6. Vagotomy
  7. TPN (pigmented stones)
  8. Ileal resection (pigmented stones)
220
Q

What are speckled cholesterol deposits on the gallbladder wall called?

A

Cholesterolosis

221
Q

What is the most common site of metastasis of gallbladder adenocarcinoma?

A

Liver

222
Q

Is this hepatic bile or gallbladder bile?

  • Na (mEq/L): 225-350
  • Cl (mEq/L): 1-10
  • Bile Salts (mEq/dL): 250-350
  • Cholesterol (mEq/dL): 300-700
A

Gallbladder bile

223
Q

What is the associated risk of cholangiocarcinoma in a patient with a choledochal cyst?

A

15% cancer risk

224
Q

What is the most common site of obstruction in gallstone ileus?

A

Terminal ileum

225
Q

Epithelial invaginations in the gallbladder wall that are formed from increased gallbladder pressures are called what?

A

Rokitansky-Aschoff sinuses

226
Q

What test should be performed to work up a patient with nausea, vomiting, or jaundice following laparoscopic cholecystectomy?

A

Ultrasound to look for fluid collection

[If fluid collection is present, may be bile leak -> percutaneous drain into the collection -> If fluid is bilious, get ERCP]

227
Q

What is the approach to a patient with nausea, vomiting, or jaundice, an ultrasound showing fluid collection, and percutaneous drainage of bilious fluid following laparoscopic cholecystectomy?

A

ERCP

Sphincterotomy and stent if due to:

  1. Leak from a duct of Luschka
  2. Small injuries to the hepatic or common bile duct
  3. Cystic duct remnant leak

[Larger lesions (ie complete duct transection) will require hepaticojejunostomy or choledochojejunostomy]

228
Q

Where does cholecystitis frequently cause referred pain?

A

Right shoulder and scapula

[UpToDate: Visceral pain can be caused by obstruction of any hollow viscus or injury to another pain-sensitive visceral structure such as the visceral pleura, hepatic capsule, or peritoneum. These syndromes are particularly common in patients with gastrointestinal and gynecologic malignancies.

Hepatic distention syndrome — Pain-sensitive structures in the region of the liver include the hepatic capsule, vessels, and biliary tract. Stretching of the hepatic capsule by a primary hepatoma or intrahepatic metastases can cause chronic cancer pain, which is commonly described as dull, right sided subcostal pain. If the superior aspect of the capsule is involved, diaphragmatic irritation may lead to referred pain to the top of the ipsilateral shoulder.

Pain also may result from injury or invasion of the porta hepatis, with or without biliary duct obstruction. This pain may be referred to the ipsilateral scapular region.]

229
Q

What is the normal size of the pancreatic duct?

A

Less than 4mm

[UpToDate: Several studies have evaluated the pancreas with EUS in populations of patients without clinical features or obvious risk factors for chronic pancreatitis such as those undergoing nonpancreatic tumor staging, evaluation of submucosal tumors or portal hypertension. However, whether these studies truly reflected findings in a population of patients with a “normal” pancreas is unclear.

In a report of 20 patients, the pancreatic parenchyma was described as having a homogeneous, fine, granular appearance with smooth margins. The pancreatic duct diameter was 1.9 mm on average (range 1.5-2.4 mm).

In another series of 25 patients, the pancreatic parenchyma was described as being homogeneous and finely reticulated without evidence of side branch ectasia. A ventral anlage (echogenic difference between the ventral and dorsal pancreas) was seen in 68% of patients. No cysts or stones were described. The main pancreatic duct was uniformly tubular in shape with anechoic walls and a mean diameter (in the pancreatic body at the portal vein confluence) of 1.7 mm (range 1-3 mm). Only two patients had a duct diameter of 3 mm. Side branches were visible in 8 of 25 patients.

A third report focused on a group of healthy volunteers without a prior history of abdominal pain or alcohol abuse. The pancreatic parenchyma was described as being uniform and more echogenic than liver. A ventral anlage was detected in 45%. No cysts were seen. The main pancreatic duct diameter was 2.4 mm (range 0.8-3.6) in the head, 1.8 mm (0.9-3.0) in the body, and 1.2 mm (range, 0.5-2.0) in the tail. Side branches were visible but narrow (mean diameter 0.8 mm, head; 0.5 mm, body; 0.3 mm, tail).]

230
Q

Lymphatics are on which side of the common bile duct?

A

Right side

231
Q

What are the early and late symptoms of cholangiocarcinoma?

A
  • Early: Painless jaundice
  • Late: Weight loss, pruritus
232
Q

What is the name of the breakdown product of conjugated bilirubin that gets released in the urine and gives urine its yellow color?

A

Urobilin

[Conjugated bilirubin is broken down in gut -> Reabsorbed -> Converted to urobilinogen -> converted to urobilin]

233
Q

What is the treatment for emphysematous gallbladder disease?

A

Emergent cholecystectomy

234
Q

Which cells secrete 80% of bile?

A

Hepatocytes

[Other 20% is secreted by the bile canalicular cells.]

235
Q

What is the primary pathophysiology of acalculous cholecystitis?

A

Bile stasis (from narcotics and fasting) leading to distention and ischemia

[Also have increased viscosity from dehydration, ileus, transfusions]

236
Q

What is the likely cause of shock that occurs within the first 24 hours after laparoscopic cholecystectomy?

A

Hemorrhagic shock from clip that fell off cystic artery

237
Q

When is postprandial gallbladder emptying at its maximum?

A

2 hours after meals

238
Q

Which tissue layer is absent in the gallbladder?

A

Submucosa

239
Q

What is the treatment for gallstone ileus?

A
  1. Remove stone through enterotomy proximal to obstruction
  2. Cholecystectomy and fistula resection if patient can tolerate it (leave fistula if patient is old and frail)
240
Q

What is the sensitivity of ultrasound for detecting gallstones?

A

95%

241
Q

Which 3 signals increase bile excretion?

A
  1. CCK
  2. Secretin
  3. Acetylcholine (vagal input)
242
Q

Where are the highest concentrations of CCK and secretin cells located?

A

Duodenum

243
Q

Which 2 signals decrease bile excretion?

A
  1. Somatostatin
  2. Sympathetic stimulation
244
Q

What are the 2 most common causes of hemobilia?

A
  1. Trauma
  2. Percutaneous instrumentation to liver
245
Q

Do patients with primary biliary cirrhosis have an increased risk of cancer?

A

No

246
Q

Where does passive resorption of nonconjugated bile salts occur?

A
  1. Small intestine (45% of resorption)
  2. Colon (5% of resorption)

[The other 50% of resorption is actively resorbed in the terminal ileum.]

247
Q

What are the components of Charcot’s Triad seen in patients with cholangitis?

A
  1. RUQ pain
  2. Fever
  3. Jaundice
248
Q

Sympathetic fibers to the biliary system come from where?

A

T7-T10 (splanchnic and celiac ganglions)

249
Q

Which anatomical triangle contains the cystic artery?

A

The triangle of Calot (Hepatobiliary triangle)

250
Q

Progressive fibrosis of intrahepatic and extrahepatic bile ducts in a patient with primary sclerosing cholangitis eventually results in what?

A

Portal hypertension and hepatic failure

251
Q

Intraoperative common bile duct injury can be primarily repaired if the injury is less than what percent of the circumference of the common bile duct?

A

Less than 50%

[In all other cases, will likely need hepaticojejunostomy or choledocojejunostomy]

252
Q

Which 3 lab values, if persistently high for greater than 24 hours, is an indication for pre-op ERCP?

A
  1. AST or ALT (greater than 200)
  2. Bilirubin (greater than 4)
  3. Amylase or lipase (greater than 1,000)
253
Q

What is the likely cause of shock that occurs more than 24 hours after laparoscopic cholecystectomy?

A

Septic shock from accidental clip on common bile duct with subsequent cholangitis

254
Q

Air in the biliary system most commonly occurs after what?

A

ERCP and sphincterotomy

[Can also occur with cholangitis or erosion of the biliary system into the duodenum]

255
Q

In which portion of the biliary system does cholangiocarcinoma most commonly occur?

A

Upper 1/3

[Worst prognosis and usually unresectable]

[UpToDate: Biliary tract cancers were traditionally divided into cancers of the gallbladder, the extrahepatic ducts, and the ampulla of Vater, while intrahepatic tumors of the bile system were classified as primary liver cancers. More recently, the term cholangiocarcinoma has been used to refer to bile duct cancers arising in the intrahepatic, perihilar, or distal (extrahepatic) biliary tree, exclusive of the gallbladder or ampulla of Vater.

Intrahepatic cholangiocarcinomas originate from small intrahepatic ductules (termed peripheral cholangiocarcinomas) or large intrahepatic ducts proximal to the bifurcation of the right and left hepatic ducts. The extrahepatic bile ducts are divided into perihilar (including the confluence itself) and distal segments, with the transition occurring at the point where the common bile duct lies posterior to the duodenum distal to the insertion of the cystic duct into the common bile duct.

In general, perihilar disease represents about 50%; distal disease, 40%; and intrahepatic disease, less than 10% of cholangiocarcinoma cases.]

256
Q

Patients with primary biliary cirrhosis test positive for which antibody?

A

Antimitochondrial antibodies

[UpToDate: Antimitochondrial antibodies (AMA) are the serologic hallmark of PBC. They are present in approximately 95% of patients with PBC. Occasionally, AMA are detected in patients with no other features suggestive of PBC. Many of these patients will eventually go on to develop features of PBC.

Antinuclear antibodies (ANA) are found in up to 70% of patients with PBC. A variety of staining patterns may be present. Two immunofluorescence patterns are considered “PBC-specific”: the multiple nuclear dots pattern (target antigen, Sp100) and the rim-like/membranous pattern (target antigens, gp210, nucleoporin p62, and the lamin B receptor). Other antibodies such as anticentromere, anti-SSA/Ro, and anti-dsDNA antibodies can be also found in PBC.

ANA have clinical significance in PBC for two reasons. First, their presence can cause confusion with autoimmune hepatitis or autoimmune hepatitis/PBC overlap. Second, some suggest that ANA may be associated with more rapid progression of disease and a poorer prognosis. However, the strength of this association and the implications for management are uncertain. For example, patients with PBC who are AMA-negative and have a positive ANA, a disease often called autoimmune cholangitis but more appropriately AMA-negative PBC, have the same outcomes as those who are AMA-positive and ANA-negative.]

257
Q

What is the normal thickness of the gallbladder wall?

A

Less than 4mm

[UpToDate: Gallbladder wall thickening (greater than 4 to 5 mm) is indicative of cholecystitis.

Measurements of components of the hepatobiliary tree depend upon the skill of the ultrasonographer obtaining the measurements, and there is variability in terms of what is considered “normal.” However, some general estimates are available regarding the expected sizes of structures in the hepatobiliary tree:

Gallbladder: The gallbladder wall should be less than or equal to 2 mm (in a distended or fasting gallbladder). Collapsed gallbladders, seen when the subject has eaten, typically appear slightly more thickened. Typically, the maximum “normal” dimension of the gallbladder is 5 X 10 cm.

Common hepatic duct: The common hepatic duct (inner wall to inner wall) is usually measured at the level of the hepatic artery. In the normal fasting state, it should be <7 mm in patients <60 years, and <10 mm in patients older than 60.

Common bile duct (CBD): The normal CBD diameter increases with age and in patients who have had a cholecystectomy. In patients in their 40s, the normal mean diameter is 4 mm. The normal mean diameter then increases by 1 mm every decade, and authors have proposed that in older patients the normal upper limit of normal be set at 8.5 mm. The CBD is commonly up to 10 mm in patients who have undergone a cholecystectomy.

Liver: The span of the liver in the right midclavicular line should be less than 16 cm.]

258
Q

What is the approach to a patient with evidence of an injury to the biliary system within 7 days of laparoscopic cholecystectomy?

A

Take back to the OR for hepaticojejunostomy

[After 7 days, must wait 6-8 weeks before takeback for hepaticojejunostomy.]

259
Q

Biliary ducts that lie in the gallbladder fossa and can leak after cholecystectomy are called what?

A

Ducts of Luschka

260
Q

What is Murphy’s sign?

A

Patient resists deep inspiration with deep palpation to the RUQ because of pain

261
Q

What is the most common cancer of the biliary tract?

A

Gallbladder adenocarcinoma

[4x more common than bile duct cancer, but still rare]

262
Q

Which medication or hormone causes the sphincter of Oddi to contract?

A

Morphine

Comprehensive Prep (45 decks)

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