Chapter 32: Gallbladder Flashcards
Where does gallbladder lie?
Beneath segments 4 and 5
Where does gallbladder lie?
Beneath segments 4 and 5
What is the cystic artery a branch of?
The right hepatic artery
Where is the cystic artery found?
Triangle of Calot
Where is the triangle of calot?
Lateral - cystic duct
Medial - Common bile duct
Superior - liver
What is the longitudinal blood supply of the hepatic and common bile duct?
Right hepatic (lateral) and retroduodenal branches of the gastroduodenal artery (medial_
Where do the cystic veins drains?
Right branch of the portal vein
Where are lymphatics in relation to the common bile duct?
Lymphatics are on the right side of the common bile duct
Where do parasympathetic fibers come from to gallbladder?
Parasympathetic fibers come from the left (anterior) trunk of the vagus.
Where do sympathetic fibers come from?
T7-T10 (splanchnic and celiac ganglions)
Mucosa for gallbladder
Gallbladder has no submucosa; mucosa is columnar epithelium
Peristalsis of common bile duct and common hepatic duct
Do not have peristalsis
How does the gallbladder fill?
Gallbladder normally fills by contraction of sphincter of Oddi at the ampulla of Vater
Medication: contracts the sphincter of Oddi
Morphine
Medication: relaxes the sphincter of Oddi
Glucagon
Normal size: common bile duct (CBD)
Normal size: gallbladder wall
What happens to total bile salt pools after cholecystectomy?
Total bile salt pools decrease
What happens to total bile salt pools after cholecystectomy?
Total bile salt pools decrease
What is the cystic artery a branch of?
The right hepatic artery
Biliary ducts that can leak after a cholecystectomy, lie in the gallbladder fossa
Ducts of Luschka
Where is the triangle of calot?
Lateral - cystic duct
Medial - Common bile duct
Superior - liver
What is the longitudinal blood supply of the hepatic and common bile duct?
Right hepatic (lateral) and retroduodenal branches of the gastroduodenal artery (medial_
Where do the cystic veins drains?
Right branch of the portal vein
Where are lymphatics in relation to the common bile duct?
Lymphatics are on the right side of the common bile duct
Where do parasympathetic fibers come from to gallbladder?
Parasympathetic fibers come from the left (anterior) trunk of the vagus.
Where do sympathetic fibers come from?
T7-T10 (splanchnic and celiac ganglions)
Mucosa for gallbladder
Gallbladder has no submucosa; mucosa is columnar epithelium
Peristalsis of common bile duct and common hepatic duct
Do not have peristalsis
How does the gallbladder fill?
Gallbladder normally fills by contraction of sphincter of Oddi at the ampulla of Vater
Medication: contracts the sphincter of Oddi
Morphine
Medication: relaxes the sphincter of Oddi
Glucagon
Normal size: common bile duct (CBD)
Normal size: gallbladder wall
Rate limiting step in cholesterol synthesis
HMG CoA reductase
What happens to total bile salt pools after cholecystectomy?
Total bile salt pools decrease
Where are the highest concentration of CCK and secretin cells?
Duodenum
Epithelial invaginations in the gallbladder wall; formed from increased gallbladder pressure
Rokitansky-Aschoff sinuses
Biliary ducts that can leak after a cholecystectomy, lie in the gallbladder fossa
Ducts of Luschka
Increases bile excretion
CCK, secretin, and vagal input
Decreases bile excretion
Somatostatin, sympathetic stimulation
What causes gallbladder contraction?
CCK causes constant, steady, tonic contraction
Essential functions of bile
Fat-soluble vitamin absorption, essential fat absorption, bilirubin and cholesterol excretion
How does gallbladder form concentrated bile?
Active resorption of NaCl and water
Where does active resorption of conjugated bile salts occur?
Terminal ileum (50%)
Where does passive resorption of non conjugated bile salts occur?
Small intestine (45%) and colon (5%)
Time: postprandial gallbladder emptying
Maximum at 2 hours (80%)
What secretes bile?
Hepatocytes (80%) and bile canalicular cells (20%)
What causes color of bile?
Mostly due to conjugated bilirubin
Breakdown product of conjugated bilirubin in gut; gives stool brown color
Stercobilin
Conjugated bilirubin is broken down in the gut and reabsorbed; gets converted to urobilinogen and eventually urobilin, which is released in the urine (yellow color)
Urobilinogen
Pathway of bile salts (acids) formation
HMG CoA -> (HMG CoA reductase) -> cholesterol -> (7-alpha hydroxylase) -> bile salts (acids)
Rate limiting step in cholesterol synthesis
HMG CoA reductase
occurs in 10% of the population; vast majority are asymptomatic
- only 10% of gallstones are radiopague
gallstones
What causes cholesterol stones?
Stasis, calcium nucleation, and increased water reabsorption form gallbladder. Also caused by decreased lecithin and bile salts
- found almost exclusively in the gallbladder
- most common type of stone found in the united state (75%)
Nonpigmented stones - cholesterol stones
- most common type of stone found in the united states
- most common type of stone found worldwide
- US: nonpigmented (cholesterol)
- World: pigmented (calcium bilirubinate, black, brown)
Caused by solubilization of unconjugated bilirubin with precipitation
Calcium bilirubinate stones (pigmented stones)
Do not work on pigmented stones
Dissolution agents (monoctanoin)
What causes black stones?
Hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN
Factors for development of black stones
Increased bilirubin load.
Decreased hepatic function.
Bile stasis -> all get calcium bilirubinate stones.
Can be caused by hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN.
- Almost always form in gallbladder.
- Tx: cholecystectomy if symptomatic
Black stones (pigmented stones)
- primary CBD stones, formed in ducts, Asians
- Infection causing deconjugation of bilirbuin
Brown stones
Most common organism causing brown stones
E coli
How does E coli cause brown stones?
Produces beta-glucuronidase, which deconjugates bilirubin with formation of calcium bilirubinate
What do you need to check for with brown stones?
Ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi
Where are brown stones most commonly formed?
Most commonly form in the bile ducts (are primary common bile duct stones)
Tx: brown stones
Almost all patients with primary stones need a biliary drainage procedure - sphincteroplasty (90% successful)
What are considered secondary common bile duct stones?
Cholesterol stones and black stones found in the CBD
- Primary common bile duct stones
- Secondary common bile duct stones
- Primary: brown stones
- Secondary: cholesterol and black stones
- Caused by obstruction of the cystic duct by a gallstone
- Results in gallbladder wall distention and wall inflammation
- RUQ pain, referred pain to the right shoulder and scapula, n/v, loss of appetite.
- attacks frequently occur after a fatty meal; pain is persistent (unlike biliary colic)
Cholecystitis
Patient resists deep inspiration with deep palpation to the RUQ secondary to pain
Murphy’s sign
Lab tests likely to be elevated in cholecystitits
Alkaline phosphatase and WBCs
Associated with frank purulence in the gallbladder -> can be associated with sepsis and shock
Suppurative cholecystitis
Most common organisms in cholecystitis
E. coli (#1), Klebsiella, Enterococcus
Risk factors for stone development
Age > 40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)
Is ultrasound effective in cholecystitis?
95% sensitive for picking up stones.
- Hyperechoic focus, posterior shadowing, movement of focus with changes in position.
Best initial evaluation test for jaundice of RUQ pain.
Ultrasound
What are ultrasound findings suggestive of acute cholecystitis?
Gallstones, gall bladder wall thickening (>4mm), pericholecystic fluid
Size of common bile duct suggesting CBD stone and obstruction
> 8 mm
Technetium taken up by liver and excreted in the biliary tract
HIDA scan
Most sensitive test for cholecystitis (also uses HIDA)
CCK-CS test (cholecystokinin cholescntigraphy)
Indications for cholecystectomy after CCK-CS test
- If gallbladder not seen (the cystic duct likely has a stone in it)
- Takes > 60 minutes to empty (chronic cholecystitis)
- Ejection fraction
Indications for immediate ERCP
Signs that a common bile duct stone is present -> jaundice, cholangitis, US shows stones in CBD
Indications for pre-op ERCP
Any of the following needs to be persistently high for > 24 hours to justify pre-op ERCP
- AST or ALT ( > 200)
- Bilirubin > 4
- Amylase or lipase (> 1000)
How many patients undergoing cholecystectomy will have a retained CBD stone?
Treatment for cholecystitis
Cholecystectomy; cholecystostomy tube can be placed in patients who are very ill and cannot tolerate surgery
Best treatment for late common bile duct stone
ERCP. Spincterotomy allows for removal of stone.
Risks: ERCP
bleeding, pancreatitis, perforation
Transient cystic duct obstruction caused by passage of a gallstone
Biliary colic; resolves within 4-6 hours
When does air in the biliary system occur?
Most commonly occurs with previous ERCP and sphincterotomy
- Can also occur with cholangitis or erosion of the biliary system into the duodenum (i.e. gallstone ileus)
How does bacterial infection of bile occur?
Dissemination form portal system is the most common route (not retrograde through sphincter of Oddi)
Highest incidence of positive bile cultures
Occurs with postoperative strictures (usually E. coli, often polymicrobial)
thickened wall, RUQ pain, increased WBCs, no stones
Acalculous cholecystitis
What causes acalculous cholecystitis?
Severe burns, prolonged TPN, trauma, or major surgery
Primary pathology: acalculous cholecystitis
Bile stasis (narcotic fasting), leading to distention and ischemia - Also have increased viscosity secondary to dehydration, ileus, transfusions
Ultrasound/HIDA: acalculous cholecystitis
- US: Sludge, gallbladder wall thickening, and pericholecystic fluid
- HIDA: positive
Tx: acalculous cholecystitis
Cholecystectomy; percutaneous drainage if patient too unstable
- Gas in the gallbladder wall -> can see on plain film
- Symptoms: severe, rapid-onset abdominal pina, nausea, vomiting, and sepsis
- perforation more common in these patients
Emphysematous gallbladder disease
Patient population associated with emphysematous gallbladder disease
Increased in diabetes; usually secondary to Clostridium perfringens
Tx: emphysematous gallbladder disease
Emergent cholecystectomy; percutaneous drainage if patient is too unstable
Fistula between gallbladder and duodenum that releases stone, causing small bowel obstruction; elderly.
- can see pneumobilia (air in the biliary system) on plain film
Gallstone ileus
Most common site of obstruction in gallstone ileus
Terminal ileum
Tx: gallstone ileus
Remove stone through enterotomy proximal to obstruction
- perform cholecystectomy and fistula resection if patient can tolerate it (if old and frail, just leave the fistula)
When do common bile duct injuries most commonly occur?
After laparoscopic cholecystectomy
Management of intraoperative CBD injury
If
Persistent nausea and vomiting or jaundice following lap chole..
Get ultrasound to look for fluid collection
Ultrasound shows fluid collection after lap chole
May be bile leak -> percutaneous drain into the collection.
- bilious fluid: get ERCP -> sphincterotomy & stent if due to cystic duct remnant leak, small injuries to hepatic or CBD, leak of DOL
- Large lesions: hepaticojejunostomy or choledochojejunostomy
N/V/jaundice s/p lap chole:
- US shows fluid collection with dilated hepatic ducts
Likely have a completely transected common bile duct (PTC tube initially, then hepaticojejunostomy or choledochojejunostomy)
- Early symptoms (7d): hepaticojejunostomy 6-8wks after injury (tissue too friably for surgery after 7 days)
Management: sepsis following lap chole
Fluid resuscitation and stabilize. May be due to complete transection of the CBD and cholangitis -> get U/S to look for dilated intrahepatic ducts or fluid collections
Management of anastomotic leaks following transplantation or hepaticojejunostomy
Usually handled with percutaneous drainage of fluid collection followed by ERCP with temporary stent (leak will heal)
Lap chole: most important cause of late postoperative bile duct strictures
Ischemia
Causes of bile duct strictures
Ischemia following lap chole, chronic pancreatitis, gallbladder CA, bile duct CA
Symptoms: bile duct strictures
Sepsis, cholangitis, jaundice
Dx: bile duct strictures without a history of pancreatitis or biliary surgery
CA until proven otherwise
Dx: Bile duct strictures
MRCP defines anatomy, look for mass -> if CA not rule out with MRCP, need ERCP with brush biopsies
Tx: bile duct strictures
If due to ischemia or chronic pancreatitis -> choledochojejunostomy (best long-term solution).
- If due to cancer, follow appropriate workup
Pathophys: hemobilia
Fistula between bile duct and hepatic arterial system (most commonly)
UGIB, jaundice, RUQ pain
Hemobilia
What is the insult causing hemobilia?
Trauma or percutaneous instrumentation to liver (eg, PTC tube)
Dx: hemobilia
Angiogram
Tx: hemobilia
Angioembolization; operation if that fails.
Rare, although MC CA of the biliary tract
Gallbladder adenocarcinoma
- Four times more common than bile duct CA; most have stones
Most common site of metastasis of gallbladder adenocarcinoma
liver
Risk of gallbladder CA in porcelain gallbladder
15%
Tx: porcelain gallbladder
Cholecystectomy
How does gallbladder adenocarcinoma spread?
1st spreads to segments 4 and 5; 1st nodes are the cystic duct nodes (right side)
Symptoms: jaundice 1st (bile duct invasion with obstruction) then RUQ pain
Gallbladder adenocarcinoma
Tx: gallbladder adenocarcinoma
If muscle not involved -> cholecystectomy sufficient
- If in muscle but not beyond -> need wedge resection of segments 4b and 5
- if beyond muscle and still resectable -> need formal resection of segments IVb and V
Why is the laparoscopic approach contraindicated for gallbladder cancer?
High incidence of tumor implants in trocar sites when discovered after laparoscopic cholecystectomy
Overall 5 year survival in bladder adenocarcinoma
5%
- Occurs in elderly; males
- risk factors: C sinensis infection, ulcerative colitis, choledochal cysts, primary sclerosing cholangitis, chronic bile duct infection
Bile duct cancer (cholangiocarcinoma)
Symptoms:
early - painless jaundice;
late - weight loss, pruritus
Bile duct cancer (cholangiocarcioma)
Persistent increase in bilirubin and alkaline phosphatase
- Dx: MRCP (defines anatomy, looks for mass)
- Invades contiguous structures early
Bile duct cancer (cholangiocarcinoma)
What is highly suggestive of bile duct cancer?
Discovery of a focal bile duct stenosis in patients without a history of biliary surgery or pancreatitis
Tx: bile duct cancer (cholangiocarcinoma)
- Upper 1/3 (Klatskin tumors): can try lobectomy and stenting of contralateral bile duct if localized to either the right or left lobes
- Middle 1/3: hepaticojejunostomy
- Lower 1/3: Whipple
Treatment: unresectable bile duct cancer (cholangiocarcinoma)
Palliative stenting for unresectable disease
5-year survival rate bile duct cancer (cholangiocarcinoma)
20%
- Female gender; Asians; 90% are extrahepatic; 15% CA risk (cholangiocarcinoma)
- older patients have episodic pain, fever, jaundice, cholangitis
Choledochal cysts
How do choledochal cysts present in children?
Infants can have symptoms similar to biliary atresia
Most common types of choledochal cysts
Most are type I: fusiform or saccular dilatation of extra hepatic ducts (very dilated)
What causes choledochal cysts?
Caused by abnormal reflux of pancreatic enzymes during uterine development
Tx: choledochal cysts
Cyst excision with hepaticojejunostomy and cholecystectomy usual
Choledochal cysts: partially intrahepatic
Type 4 cysts
Choledochal cysts: totally intrahepatic
Type 5 (Caroli’s disease)
Management: type 4 and type 5 choledochal cysts
Will need partial liver resection or liver TXP
- Men in 4th-5th decade
- Can be associated with ulcerative colitis, pancreatitis, diabetes
- Symptoms: jaundice, fatigue, pruritus (from bile acids), weight loss, RUQ pain
Primary sclerosing cholangitis
Pathophysiology: primary sclerosing cholangitis
- Get multiple strictures throughout the hepatic ducts
- Leads to portal HTN and hepatic failure (progressive fibrosis of intrahepatic and extra hepatic ducts)
Relationship of primary sclerosing cholangitis to colon resection for ulcerative colitis
Does not get better after colon resection for ulcerative colitis
Complications: primary sclerosing cholangitis
Cirrhosis, cholangiocarcinoma
Tx: primary sclerosing cholangitis
- Liver TXP needed long term for most; PTC tube drainage, choledochojejunostomy or balloon dilatation of dominant strictures may provide symptomatic relief
- Cholestyramine: can decrease pruritus symptoms (decrease bile acids)
- UDCA (ursodeoxycholic acid) - can decrease symptoms (decrease bile acids) and improve liver enzymes
- women; medium-sized hepatic ducts
- cholestasis -> cirrhosis -> portal hypertension
- Symptoms: jaundice, fatigue, pruritus, xanthomas
Primary biliary cirrhosis
Antibodies for primary biliary cirrhosis
Antimitochrondrial antibiodies
Risk for cancer in primary sclerosing cholangitis
No increased risk for cancer
Tx: primary biliary cirrhosis
Liver TXP
- usually caused by obstruction of the bile duct (most commonly due to gallstones)
- can also be caused by indwelling tubes (Eg PTC tube)
Cholangitis
RUQ pain.
Fever.
Jaundice.
Charcot’s triad - cholangitis
Charcot’s triad plus mental status changes and shock (suggests sepsis)
Reynold’s pentad - cholangitis
MC organisms causing cholangitis
E. coli (#1) and Klebsiella
What causes colovenous reflux?
> 200 mmHg pressure -> systemic bacteremia
Dx: cholangitis
Increased AST/ALT, bilirubin, alkaline phosphatase, and WBCs.
- US: dilated CBD (>8 mm, > 10mm after cholecystectomy) if due to obstruction of the biliary system
Late complications of cholangitis
Stricture and hepatic abscess
1 serious complication cholangitis; related to sepsis
Renal failure
Causes of cholangitis
Infection, biliary strictures, neoplasm, choledochal cysts, duodenal diverticula
Tx: cholangitis
Fluid resuscitation and antibiotics intially.
- Emergent ERCP with sphincterotomy and stone extraction; if ERCP fails, place PTC tube to decompress the biliary system.
- If the patient has cholangitis due to infected PTC tube, change the PTC tube
Cause of shock following lap chole: early (1st 24 hours)
Hemorrhagic shock from clip that fell off cystic artery
Cause of shock following lap chole: late (after 1st 24 hours)
Septic shock from accidental clip on CBD with subsequent cholangitis
Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus
- Not premalignant; does not cause stones, can cause RUQ pain
- Tx: cholecystectomy
Adenomyomatosis
Benign neuroectoderm tumor of gallbladder
- Can occur in biliary tract with signs of cholecystitis
- Tx: cholecystectomy
Granular cell myoblastoma
Speckled cholesterol deposits on the gallbladder wall
Cholesterolosis
if > 1 cm, need to worry about malignancy
- polyps in patients > 60 years more likely malignant
- TX: cholecystectomy
Gallbladder polyps
Bound to albumin covalently, half-life of 18 days; may take a while to clear after long-standing jaundice
Delta bilirubin
Compression of the common hepatic duct
- Tx: cholecystectomy; may need hepaticojejunostomy for hepatic duct stricture
Mirrizzi syndrome
What causes Mirizzi syndrome (compression of the common hepatic duct)?
1) stone in the gallbladder infundibulum
2) inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causes common hepatic duct stricture
Antibiotic: can cause gallbladder slugging and cholestatic jaundice
Ceftriaxone
Indications for asymptomatic cholecystectomy
In patients undergoing liver TXP or gastric bypass procedure (if stones are present)
